• Service Connection Statement

    Service Connection Statement

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    How to Complete This Form

    Please complete a separate statement form for each claim you intend to pursue.

    ⏳This form tells us how your condition is connected to your service. Your answers, in your own words, become part of your claim. Answer each question as completely and honestly as possible. Your responses will help us understand how your condition could be linked to your active duty service, trace your symptoms over time, and explain how each condition affects you today.

    🛑 You can stop at any time. Click Save My Progress at the bottom of any page. We'll email you a link to pick up right where you left off when you have time. 

    ❓If you have any questions or are unsure how to answer something, please contact your Client Coordinator for assistance. That's what we're here for! 

  • Format: (000) 000-0000.

  • THIS STATEMENT IS ABOUT ...

  • Is your condition listed below?*

  • If your statement is about a mental health condition, please click here. 

  • Unless otherwise instructed, please complete a separate statement for EACH medical condition or disability in your case.

  • Is this statement about one of the following conditions: back, shoulders, elbows, wrists, hips, knees, ankles, or feet?*
  • Does your {whichMedical} condition change the way you walk — for example, does it cause you to limp, walk unevenly, or favor one side of your body?*
    • Chronic Fatigue Syndrome 
    • Are you so tired that you've had to give up or cut back on daily activities — chores, errands, hobbies, or work?
    • Did the tiredness start suddenly?
    • How long has this been going on for?
    • Do you experience any of the following additional symptoms? Select ALL that apply.
    • Sleep Apnea 

    • 0% Rating — No Compensation


      What it means: A sleep study confirms you have sleep apnea, but you don’t have symptoms that affect your daily life or require treatment.


      Why it matters: You get recognition of the condition, but no monthly payments. Still useful if the condition worsens later or for secondary service-connection purposes.

    • 30% Rating — Daytime Hypersomnolence


      What it means: You’re constantly tired or sleepy during the day (hypersomnolence), even if you sleep a full night. This is typically before CPAP is prescribed or if CPAP doesn’t resolve the daytime sleepiness.


      Evidence needed: Documented complaints of sleepiness, fatigue, or impaired functioning due to poor sleep, but you are not prescribed a CPAP. 

    • 50% Rating — CPAP Requirement

      What it means: You need a CPAP or similar machine to manage your sleep apnea. This is the most common rating for veterans with diagnosed obstructive sleep apnea.


      Key evidence: A prescription or statement from your doctor confirming regular use of a CPAP machine.

    • 100% Rating — Severe Respiratory Complications


      What it means: Your sleep apnea is so severe that it causes:

      • Chronic respiratory failure with CO₂ retention, or
      • Cor pulmonale (a serious heart complication from lung issues), or
      • You’ve had a tracheostomy (surgical opening in the neck to help you breathe)

      VERY RARE: Reserved for the most serious and life-threatening cases.

    • Are you already service-connected or receiving disability compensation for any of the following conditions? Select ALL that apply.

    • Why are we asking?


      If the VA has already service-connected you for one of the conditions listed above, we may be able to show that the condition caused your sleep apnea or made it worse. This could support a claim for sleep apnea as a secondary condition.

    • Hearing Loss and/or Tinnitus 

    • Your answers will help the VA understand when your hearing loss and/or tinnitus began, what caused it, how it is connected to your active duty service, and how it affects your daily life.

      Please provide clear, specific, and honest details. The information you give can help support your claim and may affect whether the VA grants your claim. 

    • What types of loud noises were you exposed to in service? Select ALL that apply

  • HOW IS THIS CONDITION RELATED TO YOUR MILITARY SERVICE?

  • YOU MUST ANSWER YES TO AT LEAST ONE OF THE FOUR QUESTIONS BELOW.

    If you answer NO to ALL questions below, you will not be able to complete a statement for this condition.

  • Please answer the following questions about your claim for 

    {whichMedical}

     

    What is service-connection? 
    Click for more information on what service-connection means and how the VA determines whether a condition is related to service.

  • This means that you suffered an injury while you were in service that caused this condition.

    Examples:

    • hit with a blunt object
    • fell down and twisted joint
    • broke a bone
    • piece of equipment fell on top of me
    • fell off of repair tank

     

  • This means that this condition was caused by the constant wear and tear of your job while you were in service. 

    Examples:

    • picking up 50LB boxes everyday caused back or knee problems
    • marching long distances with heavy equipment caused foot or ankle conditions

    This is a common cause of many orthopedic conditions.

     

  • This means that this condition was caused by an exposure to a toxin or chemical during service:

    Examples:

    • migraines due to exposure to jet fuel
    • heart condition due to exposure to asbestos
    • diabetes mellitus due to exposure to firefighting foam
    • Sinius Condition due to burn pits

     

  • This means that this condition was caused by another medical condition.

    Examples:

    • knee condition due to a back injury
    • peripheral neuropathies due to diabetes mellitus II
    • migraines due to tinnitus
    • depression due to an orthopedic condition

  • ERROR:

    At least ONE of the questions above must be YES in order to proceed.

  • DIRECT INJURY IN SERVICE

  • Please answer the following questions about your claim for {whichMedical}.

  • Why didn’t you receive treatment in service at the time of your direct injury (whether by a medic, military treatment facility/hospital, etc.)? Select ALL that apply*

  • *Please note that this question is NOT designed to judge you or your choices or make you second guess them, but to provide the VA with a reason as to WHY you did not receive treatment at the time of the injury.

     

    The above answers are very common, and knowing which specific ones apply to your case helps us be able to fill in any potential gaps or lack of treatment when putting together your specific timeline.

  • CHRONIC SYMPTOMS OVER TIME

    A chronic condition is a condition that develops over an extended period of time. Imagine if you had a headache that lasted for weeks or even months. It's not like a cold that you get better from in a few days. Instead, it's something that stays with you for a long time, sometimes even for your whole life. For example, some people have asthma, which means they might have trouble breathing sometimes, and they have to manage it all the time.

  • Please answer the following questions about your claim for {whichMedical}.

  • How long did you serve on active duty?*
  • If you were in the National Guard or Reserves, your active duty time is when you were in: (1) basic training, (2) advanced individual training (AIT) or specialized training, and/or (3) all deployments or overseas service.

    *If you are not sure how much of your service was considered active duty, please contact {whoAsked} for clarification.

  • What types of physical activities did you perform regularly while you were in service? Please only select the activates that impacted this specific condition.*
    • Did you lift/push/pull heavy items?
      • How heavy were these things?
      • How often did you have to do this?
    • How far would you need to walk with them?
      • On your back?
      • On your shoulders?
    • Were you constantly bending over?
      • On your knees?
      • Under trucks?
      • Were you constantly using your arms?
      • Lifting things onto your shoulders?
      • Above your head?
      • Were you constantly bending?
      • Working in awkward positions?
    • Did you complete strenuous exercises and workouts? How often did you do this while you were in service?
  • During your time in the military, did your job require you to drive, ride in, or work on any vehicles most days? (Select ALL)
  • How often did you have to jump down or climb out of a military vehicle from more than 2 feet off the ground? (Choose one)

  • Potential Exposures

    Please answer the following questions about potential exposures to toxins while you were in service.
  • State (if National Guard)
  • Were you exposed to any harmful substances, chemicals, or environmental hazards during your military service? SELECT ALL THAT APPLY.

  • For more information on potential exposures during service, click here.

     

    For examples of good quality statements on exposures we've seen in the past, click here.

  • Agent Orange

    Herbicide used in Vietnam, Korea DMZ, and some Thailand bases. Exposure to Agent Orange has been known to cause diabetes, ischemic heart disease, prostate cancer, Parkinson’s, peripheral neuropathy
  • Agent Orange - Did you serve in any of the following locations?
  • AO - WHERE were you exposed?
  • To what extent were you exposed to these toxins? Select ALL that apply.

  • Burn Pits

    Open-air burning of trash, fuel, plastics, and waste in Iraq, Afghanistan, etc. Exposure to burn pits or fine particulate matter has been known to cause asthma, bronchitis, lung disease, cancers, chronic sinusitis
  • Burn Pits - Did you serve in any of the following locations?
  • BP - WHERE were you exposed?
  • To what extent were you exposed to these toxins? Select ALL that apply.

  • Camp Lejeune

    TCE, benzene, and other chemicals in base water (1953–1987). Exposure to contaminated water has been known to cause kidney cancer, liver cancer, leukemia, Parkinson’s, infertility, birth defects
  • Camp Lejeune - Did you serve in any of the following locations for 30+ days? (does not need to be consecutively)
  • Image field 357
  • CL - WHERE were you exposed?
  • To what extent were you exposed to these toxins? Select ALL that apply.

  • Other Potential Exposures

  • Please answer the following questions about your exposure to toxins other than Agent Orange, Burn Pits, or Camp Lejeune answered in previous questions: 

     

    {wereYou337}

     

     

  • OE - WHERE were you exposed?
  • To what extent were you exposed to these toxins? Select ALL that apply.

  • SECONDARY

    Complete this section if you believe your {whichMedical} was caused or aggravated by another service-connected condition.

  • Please answer the following questions about your claim for {whichMedical}.

  • Is your {whatOther} condition service-connected or are you receiving disability compensation for this primary condition?*

  • "service-connected" means the VA has acknowledged that the primary condition (the condition you entered in the box above) is related to service and you are receiving disabilty compensation for it.

  • How did your primary condition ({whatOther}) cause or contribute to your {whichMedical} condition? Check ALL that apply — most veterans check more than one.*

  • CURRENT SYMPTOMS

  • Please answer the following questions to build a timeline of your symptoms related to your claim for {whichMedical}.

  • Why didn't you see a doctor about your symptoms related to your {whichMedical} right after you were discharged from service?*

  • EMPLOYMENT

  • Consider the following examples of how your symptoms may have impacted your ability to work:

    • Have you missed days of work due to your symptoms?
      • how many work days?
      • did you need a doctor's note?
      • has this affected your pay?
    • Have your symptoms led to lower productivity at work? Describe all tasks you struggle with or can no longer complete.
      • Do you require help to complete these tasks?
      • Does this affect your pay?
      • Does this affect your mental health?
    • Do your symptoms affect your physical appearance such as bathing and grooming?
    • Have your symptoms strained your family relationships and friendships/relationships with coworkers?
    • Have you had trouble traveling because of your symptoms?

  • REVIEW & SUBMIT

  • Please answer the following questions about your claim for {whichMedical}.

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