Va Form 21-0781 Jun 2026

This is the core of the form. You must provide specific details for each event, including:

If you can’t remember the exact day, providing a 60-day window or a season/month is often sufficient. va form 21-0781

( List any medical treatment you received for this condition ) This is the core of the form

______________________________________________________ Date: _______________________________________________________ I was the [position, e

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"On or about [Month, Day, Year], while assigned to [Unit, Company, Battalion] in [Location, e.g., Fallujah, Iraq], my convoy was struck by an IED. I was the [position, e.g., driver/turret gunner]. The explosion occurred at approximately [time of day]. I witnessed [specific: the vehicle in front of me lift off the ground, see human remains, hear screams, etc.]. Following the blast, I [describe your action: pulled casualties from wreckage, returned fire, secured the area]. I did not personally sustain a physical wound, but I observed [describe death or injury to others]. I still vividly remember [one specific sensory detail: smell of burnt explosives, the silence after the blast, a specific sound]."