Request for Employment Information in Connection with Claim for Disability Benefits
This form is sent to your current or former employers to gather information about your work history, accommodations, and any limitations related to your disabilities. It's often used in TDIU claims.
Used in these claim stages:
Last updated by VA: January 1, 2024
How to Complete This Form
This form is typically completed by your employer, not you:
**Section I - Employee Information**
VA pre-fills your information.
**Section II - Employment Details**
Employer provides:
- Dates of employment
- Job title and duties
- Hours worked per week
- Rate of pay
- Reason for leaving (if applicable)
**Section III - Accommodations and Limitations**
Employer documents:
- Any accommodations made for disabilities
- Time missed due to disability
- Whether performance was affected by disability
- Any job modifications made
**Section IV - Employer Certification**
Employer signs certifying the information.
**Note:** VA sends this directly to employers. You may want to give your employer a heads up that they'll receive this form.
Helpful Tips
- Let your employer know to expect this form
- If you had accommodations at work, make sure your employer documents them
- Former employers may be harder to reach - provide current contact info if possible
- If employer doesn't respond, submit your own statement about your work
- This form is important for TDIU claims - employer responses carry weight
- Keep your own records of work limitations and accommodations
Common Mistakes to Avoid
- Not alerting employer that VA will contact them
- Providing outdated employer contact information
- Not following up when employer doesn't respond
- Relying solely on this form without providing your own work history statement
Deadline Information
Employers are asked to respond within 30 days. If your employer doesn't respond, VA may make a decision based on other evidence.