• VA Disability Intake Form

    VA Disability Intake Form

    We are here to walk you through the process of obtaining VA disability benefits. Please complete this intake form and we will contact you via email within 1-2 business days to discuss the next steps to appoint OSDRI as your representative.
  • Date
     - -

  • Your Contact Information

  • Format: (000) 000-0000.

  • Your Information (continued)

  • Date of Birth*
     / /
  • Gender*

  •  

    Count biological, step, or adopted children who live with you full time and are:
    • Under age 18, or
    • 18–23 and in school full-time, or
    • Any age if they became disabled (permanently incapable of self-support) before 18.

  • How Did You Hear About Us?

  • Special Circumstances

    Sometimes the VA will move a case faster in emergencies. Tell us if any of these apply to you here.
  • Right now, do any of the following describe your current situation? (Check all that apply.)*
  • Can you provide copies of the following? (check all that apply)*

  • *In order to request priority processing of your case, we need evidence to support this request. We will put together this request to submit with the evidence you provide.

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  • Your Time in Service

    Tell us about your military service
  • Are you still in the National Guard or Reserves?*
  • Date of Entry*
     / /
  • Date of Discharge*
     / /
  • Are you still on Active Duty?*
  • Do you have another period of service?*

  • Second Period of Service

  • (Second NG) Are you still in the National Guard or Reserves?*
  • (Second) Date of Entry*
     / /
  • (Second) Date of Discharge*
     / /
  • (Second) Are you still on Active Duty?*
  • Do you have more than two periods of service?*

  • Third Period of Service

  • (Third NG) Are you still in the National Guard or Reserves?*
  • (Third) Date of Entry*
     / /
  • (Third) Date of Discharge*
     / /
  • (Third) Are you still on Active Duty?*
  • Do you have more than three periods of service?*

  • While there are limited exceptions, you must have at least one period of honorable service or service under honorable conditions in order to be eligible to receive VA disability compensation. 

    If you do not have a period of service under honorable conditions and you need assistance upgrading your discharge status, please email Dan Evangelista or call him directly at (401) 474-4764.

  • Combat Service

  • Did you serve in combat?*
  • After any blast, did you experience any of the following symptoms? (Check all that apply.)
  • While you were in service, did a doctor ever tell you that you had a concussion or traumatic brain injury (TBI)?*
  • Did you experience any sleep disruption, hypervigilance, or headaches during service?*

  • Your MOS Duties

  • 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 us for clarification.

  • Which of the following best describe the type of work you did in service? (Select ALL that apply)*

  • MOS: Physical

    These questions help us understand wear and tear on your body from service.
  • (Physical) What types of physical activities did you perform regularly while you were in service?*

  • MOS: Administrative

  • (Administrative) Do you have any of the following symptoms?*

  • MOS: Fuels

  • During your time in the military, did your job require you to drive, ride in, or work on any vehicles? (Select ALL)*

  • Noise Exposure

  • Which of these weapons were you around regularly in the military? (Check all that apply)*
  • On average, how many hours per week were you around gunfire, artillery, aircraft, engines, or generators?*

  • Presumptive Exposures

    Agent Orange, Burn Pits, Camp Lejeune
  • Which environmental or deployment toxins were you exposed to during service? Select ALL that apply.*

  • Agent Orange

  • Agent Orange - Did you serve in any of the following locations?*

  • Burn Pits

  • Image field 230
  • Burn Pits - Did you serve in any of the following locations?*

  • Camp Lejeune

  • Image field 100
  • (CL) Did you serve in any of the following locations for at least 30 days?*

  • Chemical Exposures

  • Do you believe you may have been exposed to any of the following hazardous materials during service?*

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

  • Asbestos

  • For more information on how you may have been exposed to asbestos in service, visit mesothelioma.net

  • Depleted Uranium

  • Jet Fuel

  • Mustard Gas

  • Firefighting Foam (PFOS/PFAS)

  • Radiation

  • MOS: Other Exposure

  • Your Current Benefits

  • Are you currently receiving or have you received any of the following? Select all that apply.*

  • How Are Your Current Symptoms Related to Service?

  • To get VA disability benefits, at least one of your medical conditions must be connected to your military service.This means:• It started while you were in the military, OR• It was caused by something that happened in service, OR• Service made a pre-existing condition worse.*

  • Why Do We Ask This? Sleep apnea is a common condition we can often link to military service, even if you didn't have symptoms in service. If you have other service-connected conditions, we can often link sleep apnea to one or more of those conditions to increase your overall combined rating. 
     

  • Your Current Symptoms

  • Medications

  • Employment

  • Last Date Worked Full Time*
     / /
  • Do your medical conditions keep you from working full-time (about 40 hours per week) in any job?*
  • Do you have access to reliable transportation?*

  • Any Additional Information

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  • PLEASE READ!!

    Here are the few things we need you to agree to before we can enter into representation in your case
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