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VA Hematologic & Lymphatic DBQ (Leukemia, Lymphoma)

Blood and lymphatic conditions claimed for VA disability, from iron deficiency and pernicious anemia to CLL, CML, Hodgkin's and non-Hodgkin's lymphoma, multiple myeloma, MGUS and polycythemia vera, are documented on this 12-page questionnaire. For each diagnosis the clinician picks the current status from condition-specific options, such as infusion frequency, platelet range, transplant dates or remission, and adds the most recent CBC.

Who completes it

The Veteran's treating or examining clinician completes the form and signs the Section 10 examiner's certification. The Veteran does not complete any section.

Submitting and payment

How to submit it
The clinician gives the signed DBQ to the Veteran, who uploads it with the claim on VA.gov or mails it to the VA Evidence Intake Center; a representative may also submit it.
Who pays
VA does not pay or reimburse the cost of completing this DBQ; any fee is between the Veteran and the provider.

Good to know

  • Each diagnosis has its own status choices, for example iron deficiency anemia needing IV iron 4 or more times per 12 months, or immune thrombocytopenia by platelet range and bleeding history.
  • Transplants and transfusions need hospitalization and discharge dates; if treatment went beyond the listed options or there was more than one course, describe it in Remarks.
  • The form accepts current validated biomarkers for diagnosing multiple myeloma, smoldering myeloma and MGUS as defined by ASH and the International Myeloma Working Group.
  • Residuals after remission, such as neuropathy after pernicious anemia or hypertension and stroke from polycythemia vera, need their own questionnaires.

Get the official form

Download the current version from the source each time; forms change without notice.

Hematologic and Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Does the VA hematologic DBQ cover non-Hodgkin's lymphoma?

Yes. Section 5 covers Hodgkin's and non-Hodgkin's lymphoma, polycythemia vera and solitary plasmacytoma. For lymphoma the examiner marks active disease without treatment, the indolent non-contiguous phase of low-grade NHL, undergoing treatment with start and expected end dates, or remission, and lists any residual effects.

Which lab values does this DBQ request?

Section 7 asks for the most recent complete blood count where appropriate: hemoglobin, hematocrit, red cell count, white cell count and platelet count, each with its date. Existing results that reflect the current condition do not need to be repeated.

How is CLL staged on the form?

Item 4B covers CLL, hairy cell and other B-cell leukemias and monoclonal B-cell lymphocytosis. The examiner chooses asymptomatic Rai Stage 0, active without treatment including Rai Stages I to IV, undergoing treatment, or in remission, with dates for treatment and any residuals.