A Veteran's own clinician uses this 4-page questionnaire to document sleep apnea for a VA disability claim. It records the type of sleep apnea, its history, any continuous medication or CPAP-type breathing device, findings such as persistent daytime hypersomnolence or cor pulmonale, the confirming sleep study, and the effect on work. VA weighs it with the claim to decide service connection and the rating.
The Veteran's treating or examining clinician, such as an MD, DO, NP or PA, completes all eight sections and signs Section VIII. The Veteran completes no part of the form, though history and device use come from the Veteran and the records.
Record who requested the DBQ, whether you are a VA provider, whether the Veteran is regularly seen in your clinic, and whether the exam was in person, describing the method if not. Check whether records were reviewed and identify them, such as service, VA or private treatment records, with the date range. The page also asks you to read the Privacy Act and respondent burden information before completing the form.
1A asks whether the Veteran has or has ever had sleep apnea; the note requires confirmation by a sleep study, reported in Section V. 1B checks the type: obstructive, central, mixed, or other sleep disorder, each with ICD code and date of diagnosis, and 1C takes additional related diagnoses. If another respiratory condition is diagnosed, use the Respiratory and/or Narcolepsy questionnaire instead.
2A is a brief summary of the onset and course of the Veteran's sleep disorder. 2B asks whether continuous medication is required to control it; list only the medications required for the sleep disorder. 2C asks whether the Veteran requires a breathing assistance device, such as a continuous positive airway pressure (CPAP) machine.
3A asks whether the Veteran currently has any findings, signs or symptoms attributable to sleep apnea. If yes, check all that apply: persistent daytime hypersomnolence, carbon dioxide retention, chronic respiratory failure, cor pulmonale, or a requirement for tracheostomy, and describe any other finding in the space provided.
4A captures other findings related to the diagnosed conditions. 4B asks about scars related to the conditions or their treatment. If any scar is painful or unstable, totals 39 square centimeters (6 square inches) or more, or is on the head, face or neck, also complete VA Form 21-0960f-1; otherwise give its location and measurements in centimeters here. 4C holds comments.
5A asks whether a sleep study has been performed and, if so, whether the Veteran has documented sleep disordered breathing, with the study date, the facility if known, and the results. Repeat testing is not required when results in the record reflect the current condition. 5B records other significant diagnostic findings with the type of test, date and a brief summary of results.
6A asks whether the Veteran's sleep apnea affects his or her ability to work. A Yes answer needs a description of the impact with one or more examples. 7A is open space for any remarks the examiner wants VA to read alongside the answers in the earlier sections.
The examiner certifies that the information is accurate, complete and current, beneath a penalty statement covering willful false statements and fraudulent acceptance of payment. Complete 8A to 8H: signature, printed name and title, area of practice or specialty, date signed, phone and fax, NPI, medical license number and state, and address.
Download the current version from the source each time; forms change without notice.
Sleep Apnea Disability Benefits Questionnaire
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.
Sources for this guide
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Not necessarily. The form says the diagnosis must be confirmed by a sleep study, but if diagnostic results in the medical record reflect the Veteran's current condition, repeat testing is not required. Section V asks whether a study was performed, whether it documented sleep disordered breathing, its date, the facility if known, and the results.
Section III asks whether the Veteran currently has findings attributable to sleep apnea and lists persistent daytime hypersomnolence, carbon dioxide retention, chronic respiratory failure, cor pulmonale and the need for a tracheostomy, with room for others. Section II separately records continuous medication and use of a breathing assistance device such as CPAP.
The form is intended to be completed by the Veteran's own health care provider, and the signature block accepts titles such as MD, DO, NP or PA-C. Section VIII requires the signature, printed name and title, specialty, date signed, NPI, and medical license number and state. VA reserves the right to confirm the authenticity of every completed questionnaire.
No. The form states that VA will not pay or reimburse any expenses incurred in completing or submitting it, so the Veteran and the provider agree on any fee. VA may also obtain more medical information, including its own examination, and the Veteran must attend if one is scheduled.