Get VA 21-2680 2018-2023
IS THE CLAIMANT LEGALLY BLIND If Yes provide explanation 24B. CORRECTED VISION LEFT EYE VA FORM MAY 2015 INCHES 21-2680 SUPERSEDES VA FORM 21-2680 JUN 2008 WHICH WILL NOT BE USED. Reginfo. gov/public/do/PRAMain. If desired you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form. VA FORM 21-2680 MAY 2015. RESPONDENT BURDEN We need this information to determine your eligibility for aid and attendance or housebound benefits. Title 38 United States Code 1521 d and e 1115 1 e 1311 c and d 1315 h 1122 1541 d e and 1502 b and c allows us to ask for this information. We estimate that you will need an average of 30 minutes to review the instructions find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet pate at http //www. OMB Control No* 2900-0721 Respondent Burden 30 minutes Expiration Date 5-31-2018 EXAMINATION FOR HOUSEBOUND STATUS OR PERMANENT NEED FOR REGULAR AID AND ATTENDANCE 1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN 4A. VETERAN S SOCIAL SECURITY NUMBER 4B. CLAIMANT S SOCIAL SECURITY NUMBER 6. DATE OF EXAMINATION 7. HOME ADDRESS 8A. IS CLAIMANT HOSPITALIZED 8B. DATE ADMITTED 3. RELATIONSHIP OF CLAIMANT TO VETERAN 5. CLAIM NUMBER 9. NAME AND ADDRESS OF HOSPITAL NO If Yes complete Items 8B and 9 YES NOTE EXAMINER PLEASE READ CAREFULLY The purpose of this examination is to record manifestations and findings pertinent to the question of whether the claimant is housebound confined to the home or immediate premises or in need of the regular aid and attendance of another person* The report should be in sufficient detail for the VA decision makers to determine the extent that disease or injury produces physical or mental impairment that loss of coordination or enfeeblement affects the ability to dress and undress to feed him/herself to attend to the wants of nature or keep him/herself ordinarily clean and presentable. Findings should be recorded to show whether the claimant is blind or bedridden* Whether the claimant seeks housebound or aid and attendance benefits the report should reflect how well he/she ambulates where he/she goes and what he/she is able to do during a typical day. 10. COMPLETE DIAGNOSIS Diagnosis needs to equate to the level of assistance described in questions 20 through 34 11A. AGE 11B. SEX 12. WEIGHT ACTUAL LBS* 13. HEIGHT FEET ESTIMATED LBS* 14. NUTRITION 15. GAIT 16. BLOOD PRESSURE 17. PULSE RATE 18. RESPIRATORY RATE 19. WHAT DISABILITIES RESTRICT THE LISTED ACTIVITIES/FUNCTIONS 20. IF THE CLAIMANT IS CONFINED TO BED INDICATE THE NUMBER OF HOURS IN BED From 9 PM to 9 AM NO 22. IS CLAIMANT ABLE TO PREPARE OWN MEALS If No provide explanation 23. DOES THE CLAIMANT NEED ASSISTANCE IN BATHING AND TENDING TO OTHER HYGIENE NEEDS If Yes provide explanation 24A.
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