TDIU

Unemployability

Total Disability based on Individual Unemployability (TDIU) is a special VA benefit for veterans who can't maintain substantially gainful employment due to their service-connected disabilities. Even if your VA combined rating is less than 100%, you may still qualify to be paid at the 100% rate if your conditions prevent you from working. To qualify, you generally need: one service-connected condition rated at least 60%, or two or more service-connected conditions with a combined rating of at least 70%, with one rated at least 40%, and evidence showing your disabilities prevent you from working full-time.
Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Who are you working with at OSDRI?

Medical Treatment
Have you been under a doctor's care within the past 12 months?

YesNo
WHEN did you start seeing this doctor?
Name and Address of Doctor
Have you been hospitalized within the past 12 months?

YesNo
When were you hospitalized in the last 12 months?
Name and Address of Hospital

Employment Background
Are you currently working full-time?
What is your current monthly income?
If you are not physically working, this amount should be $0. However, if you are working, provide the amount that you earn per month.
What is your TOTAL EARNED INCOME for the past 12 months?
Generally, this amount should be $0 if you haven't worked at all. However, if you stopped working within the past 12 months or are working part time, you will need to indicate how much you earned/are earning.
💵 What is EARNED income?
This is money earned from physically working and receiving payment. This does NOT include: pensions, retirement, IRA’s, 401ks, VA Disability, SSD or SSI.
When did you last work full time?

MonthDayYear
This is the date you transitioned from full-time to part-time employment OR when you last worked full-time hours.
When did you start to notice your symptoms affecting your work performance at your full-time job?

MonthDayYear
When did you start to notice your symptoms interfering with your work? (ie. when did you have to cut down your hours, did you start getting written up at work more, missing work for doctors' visits, calling out sick more, asking to have your shift covered more often)
When did you become too disabled to work?

MonthDayYear
This is the date you stopped working all together. After this date you did not work full time or part time.
Did you leave your last job/self-employment because of your disability?
Answer YES if you were fired, laid off, or resigned from your last job because of your health.
Do you receive/expect to receive Social Security Retirement or Disability Insurance Benefits?
In addition to Disability Retirement benefits, this also includes any Social Security benefits, such as SSD and SSI.
Do you receive/expect to receive Workers Compensation Benefits?
What is the MOST you have ever earned in one year?
What YEAR was that in?
What year did you make the most money you've ever made in your lifetime?
What was your OCCUPATION during that year?

Employment History

Please provide all employment, including self-employment, FOR THE LAST 5 YEARS YOU WORKED. This means five years of work history, not necessarily the last five consecutive years. For example, if you stopped working in 2010, the VA wants to know where you worked from 2005-2010.
Employer #1*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of work?*
Hours per week?*
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
How much time have you lost from work because of your symptoms (of your service-connected disabilities)?*
Think in terms of frequency. Did you call out monthly or weekly? Did you have to use all your vacation time? Were you out two weeks a year? Ten hours a week?
What were your Highest Gross Earnings Per MONTH at this job?*
The VA wants to know the most amount of money that you made per month at that particular company. If you cannot remember the exact amount, but do remember what you were being paid hourly, multiply that number by the hours you worked in a week, and calculate your monthly pay that way.

Employer #2

Please provide all employment, including self-employment, FOR THE LAST 5 YEARS YOU WORKED. This means five years of work history, not necessarily the last five consecutive years. For example, if you stopped working in 2010, the VA wants to know where you worked from 2005-2010.
Employer #2
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of work?
Hours per week?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
How much time have you lost from work because of your symptoms (of your service-connected disabilities)?
Think in terms of frequency. Did you call out monthly or weekly? Did you have to use all your vacation time? Were you out two weeks a year? Ten hours a week?
What were your Highest Gross Earnings Per MONTH at this job?
The VA wants to know the most amount of money that you made per month at that particular company. If you cannot remember the exact amount, but do remember what you were being paid hourly, multiply that number by the hours you worked in a week, and calculate your monthly pay that way.

Employer #3

Please provide all employment, including self-employment, FOR THE LAST 5 YEARS YOU WORKED. This means five years of work history, not necessarily the last five consecutive years. For example, if you stopped working in 2010, the VA wants to know where you worked from 2005-2010.
Employer #3
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of work?
Hours per week?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
How much time have you lost from work because of your symptoms (of your service-connected disabilities)?
Think in terms of frequency. Did you call out monthly or weekly? Did you have to use all your vacation time? Were you out two weeks a year? Ten hours a week?
What were your Highest Gross Earnings Per MONTH at this job?
The VA wants to know the most amount of money that you made per month at that particular company. If you cannot remember the exact amount, but do remember what you were being paid hourly, multiply that number by the hours you worked in a week, and calculate your monthly pay that way.

Employer #4

Please provide all employment, including self-employment, FOR THE LAST 5 YEARS YOU WORKED. This means five years of work history, not necessarily the last five consecutive years. For example, if you stopped working in 2010, the VA wants to know where you worked from 2005-2010.
Employer #4
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of work?
Hours per week?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
How much time have you lost from work because of your symptoms (of your service-connected disabilities)?
Think in terms of frequency. Did you call out monthly or weekly? Did you have to use all your vacation time? Were you out two weeks a year? Ten hours a week?
What were your Highest Gross Earnings Per MONTH at this job?
The VA wants to know the most amount of money that you made per month at that particular company. If you cannot remember the exact amount, but do remember what you were being paid hourly, multiply that number by the hours you worked in a week, and calculate your monthly pay that way.

Employer #5

Please provide all employment, including self-employment, FOR THE LAST 5 YEARS YOU WORKED. This means five years of work history, not necessarily the last five consecutive years. For example, if you stopped working in 2010, the VA wants to know where you worked from 2005-2010.
Employer #5
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of work?
Hours per week?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
How much time have you lost from work because of your symptoms (of your service-connected disabilities)?
Think in terms of frequency. Did you call out monthly or weekly? Did you have to use all your vacation time? Were you out two weeks a year? Ten hours a week?
What were your Highest Gross Earnings Per MONTH at this job?
The VA wants to know the most amount of money that you made per month at that particular company. If you cannot remember the exact amount, but do remember what you were being paid hourly, multiply that number by the hours you worked in a week, and calculate your monthly pay that way.

Self Employment
Do you have any other skills that could be used for a job or career? *
Does your employment history include self-employment? *
Describe your job duties during your self-employment:
What did you do on a day-to-day basis while self employed? Did you lift/move/pull/push heavy objects? How Heavy? 50lbs? 100lbs? Every day? Every week? Did you climb ladders? How high? With material? How heavy? Did you work in an office? Were you required to sit all day? Did you work with people? Did you struggle with work relationships? Explain.

Education History
What is the highest level of education you have completed?*
Did you have any other education or training BEFORE you were too disabled to work?*
This applies to any education or training before you stopped working. This could include trade schools or specialized training, such as truck driving school, welding school, mechanics, etc.
Please list the names of each facility and the dates of enrollment for additional education or training you have received BEFORE you became too disabled to work:
Have you had any additional education or training SINCE AFTER you became too disabled to work?*
This applies to any education or training that you had in an attempt to get a job after you became too disabled to work. This could include vocational rehab.
Please list the names of each facility and the dates of enrollment for additional education or training you have received SINCE AFTER you became too disabled to work:

Symptoms & Employment
How have your symptoms interfered with your ability to work?*
THIS SECTION SHOULD BE AT LEAST 5 SENTENCES.
Please use multiple specific examples to describe the different ways your symptoms have affected your work life.

When you were working full-time, did you have to call out of work or leave work early because of your symptoms?

Were your relationships with superiors, co-workers, clients, or customers strained because of your symptoms?

Did you have a difficult time completing job duties or responsibilities because of your symptoms?

Were you written up or terminated because your symptoms prevented you from doing your job?

Please describe what tasks or responsibilities are/were difficult for you to complete.

Please describe any physical and/or impairments that prevent you from working.

THIS SECTION SHOULD BE AT LEAST 5 SENTENCES LONG

Is there anything else you would like to add to your statement?
Are there any documents you would like to upload with your statement?

Cancelof
Should be Empty:

Unemployability

Medical Treatment

Employment Background

Employment History

Employer #2

Employer #3

Employer #4

Employer #5

Self Employment

Education History

Symptoms & Employment