Unlike most DBQs, this 5-page questionnaire documents the claimant child rather than the Veteran: it supports a spina bifida claim for the natural child of a Veteran exposed to herbicides. The examiner records the spina bifida type and surgeries, then picks the level that fits for locomotion, upper extremity function, IQ, urinary continence and bowel continence. VA uses those levels to set the child's monthly allowance.
The claimant's health care provider completes all sections and signs the Section XII examiner's certification with NPI, license and specialty. The claimant and the Veteran parent complete no part of the form.
Download the current version from the source each time; forms change without notice.
Spina Bifida Disability Benefits Questionnaire
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The natural child of a Veteran exposed to herbicides. The form identifies both the Veteran and the claimant with their Social Security numbers, and every question describes the claimant, including whether the claimant can manage benefit payments, with an option for a child under 18.
Urinary continence ranges from continent without medication to unable to stay dry for three hours during waking hours at least three times a week despite treatment. Bowel continence ranges from continent to needing manual evacuation or digital stimulation, absorbent materials at least four days a week, or a colostomy bag.
Item 3A asks for the claimant's primary means of mobility in the community: walking without braces or other external support, walking with braces or external support, or using a wheelchair. Items 4A to 4C ask whether upper extremity impairment prevents grasping a pen, self-feeding or self-care.