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Get VA 28-8861 1990-2024

CHECK BOX IF APPLICABLE SEPARATE MEDICAL REPORT WILL FOLLOW VA FORM AUG 1990 18. DATE 28-8861 Date Rec d. Department of Veterans Affairs REQUEST FOR MEDICAL SERVICES - CHAPTER 31 PART I - To be completed by Vocational Rehabilitation Specialist or Counseling Psychologist Director 136 Vocational Rehabilitation and Counseling Division RETURN TO INSTRUCTIONS The veteran named below is a participant under Chapter 31 Title 38 U*S*C. Determine whether he or she needs medical or dental treatment and if needed provide under appropriate VA Regulations. If the veteran s medical condition either requires a leave of absence or makes training or employment questionable include this information in item 16. 1. FIRST - MIDDLE - LAST NAME OF VETERAN 2. TELEPHONE NUMBER Include Area Code 3. SOCIAL SECURITY NUMBER TRA2. ADDRESS OF VETERAN 5. SERVICE DATES Mo. day yr. 6. VA FILE NUMBER FROM 7. DOB Mo. day yr. 8. REHABILITATION OBJECTIVE OF VETERAN 9. ANTICIPATED DATE OF REHABILITATION 10A. SERVICE-CONNECTED DISABILITIES 10B. COMBINED SERVICE-CONNECTED DISABILITY RATING 10C. NONSERVICE-CONNECTED DISABILITIES 11. DESCRIBE REASONS FOR REFERRAL 12. PREFERRED DAY AND TIME FOR APPOINTMENT 13. SIGNATURE OF VOCATIONAL REHABILITATION SPECIALIST OR COUNSELING PSYCHOLOGIST 14. TELEPHONE 16A. REPORT OF SERVICES PROVIDED AND DISPOSITION OF CASE 16B. Department of Veterans Affairs REQUEST FOR MEDICAL SERVICES - CHAPTER 31 PART I - To be completed by Vocational Rehabilitation Specialist or Counseling Psychologist Director 136 Vocational Rehabilitation and Counseling Division RETURN TO INSTRUCTIONS The veteran named below is a participant under Chapter 31 Title 38 U*S*C. Determine whether he or she needs medical or dental treatment and if needed provide under appropriate VA Regulations. Determine whether he or she needs medical or dental treatment and if needed provide under appropriate VA Regulations. If the veteran s medical condition either requires a leave of absence or makes training or employment questionable include this information in item 16. If the veteran s medical condition either requires a leave of absence or makes training or employment questionable include this information in item 16. 1. FIRST - MIDDLE - LAST NAME OF VETERAN 2. TELEPHONE NUMBER Include Area Code 3. SOCIAL SECURITY NUMBER TRA2. 1. FIRST - MIDDLE - LAST NAME OF VETERAN 2. TELEPHONE NUMBER Include Area Code 3. SOCIAL SECURITY NUMBER TRA2. ADDRESS OF VETERAN 5. SERVICE DATES Mo. day yr. 6. VA FILE NUMBER FROM 7. DOB Mo. day yr. 8. REHABILITATION OBJECTIVE OF VETERAN 9. ADDRESS OF VETERAN 5. SERVICE DATES Mo. day yr. 6. VA FILE NUMBER FROM 7. DOB Mo. day yr. 8. REHABILITATION OBJECTIVE OF VETERAN 9. ANTICIPATED DATE OF REHABILITATION 10A. SERVICE-CONNECTED DISABILITIES 10B. COMBINED SERVICE-CONNECTED DISABILITY RATING 10C. ANTICIPATED DATE OF REHABILITATION 10A. SERVICE-CONNECTED DISABILITIES 10B. COMBINED SERVICE-CONNECTED DISABILITY RATING 10C. NONSERVICE-CONNECTED DISABILITIES 11. DESCRIBE REASONS FOR REFERRAL 12. PREFERRED DAY AND TIME FOR APPOINTMENT 13. .

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