Residuals of Traumatic Brain Injury (TBI)

Your doctor will complete VA Form 21-0960C-1 (Residuals of Traumatic Brain Injury (TBI) DBQ) after examining you. This walkthrough helps you prepare them. The DBQ is a standardized questionnaire; your doctor's answers directly determine your VA rating. Brief them on these specific points before the exam so nothing important is missed or underdocumented.

Common mistakes

• ×Asking your doctor to just "fill out the VA form" without briefing them - an uninformed completion is often generic and leads to lower ratings.
• ×Bringing the DBQ to a provider who has never seen you before - your treating physician who knows your history will write the most credible documentation.
• ×Going to the exam and waiting for the doctor to ask questions - come prepared with specific examples of your worst days and functional limitations.

These are the key clinical questions from the Residuals of Traumatic Brain Injury (TBI) DBQ. Help your doctor understand what each question is asking and give them concrete examples for your situation. Print this section and bring it to the appointment. 1. Does the Veteran have a diagnosis of TBI? WHY IT MATTERS: Confirms the in-service TBI event and current diagnosis required for service connection. TIPS: Document the in-service event (blast, fall, MVA, sports, combat).; List all medical providers who diagnosed or treated the TBI. 2. What is the level of impairment in the 10 facets of TBI residuals? WHY IT MATTERS: TBI is rated on 10 facets per 38 CFR 4.124a - the highest single facet level drives the overall rating (0, 10, 40, 70, or 100). TIPS: The 10 facets: memory/attention/concentration/executive function; judgment; social interaction; orientation; motor activity; visual spatial orientation; subjective symptoms; neurobehavioral effects; communication; consciousness.; Describe your WORST functioning across each facet, not your best days.; A single facet at "Total" (level 3) can warrant 100% rating regardless of the others. 3. Are there any residual physical or neurological deficits? WHY IT MATTERS: Physical residuals (seizures, vision loss, hearing loss, balance, headaches, paralysis) may be rated SEPARATELY from the TBI cognitive rating. TIPS: Migraine headaches secondary to TBI rate separately under DC 8100.; Seizures secondary to TBI rate separately under DC 8910/8911.; Balance/vestibular dysfunction may rate separately under DC 6204.; Each separate rating compounds via combined-rating math. 4. Is there an emotional / behavioral disorder secondary to TBI? WHY IT MATTERS: Mental health conditions secondary to TBI (depression, anxiety) typically rate under their OWN diagnostic code, not as a TBI facet - but the rater must determine which symptoms attribute to TBI vs the secondary mental condition. TIPS: If you have both TBI and PTSD, request that overlapping symptoms be attributed to whichever produces the higher rating (pyramiding rule, 38 CFR 4.14).; A separately diagnosed depression secondary to TBI gets its own rating under DC 9434.

Common mistakes

• ×Letting the rater fold PTSD symptoms into the TBI facets (or vice versa) instead of getting both rated where they produce more compensation
• ×Not bringing documentation of the in-service event (line-of-duty, sick call, buddy statements)
• ×Underreporting cognitive symptoms because they "feel normal" after years of accommodation

VA raters use the Residuals of Traumatic Brain Injury (TBI) DBQ to determine your disability rating. The most important rating factors for this condition are: 1. Highest single facet level among the 10 cognitive/behavioral facets (a level "Total" alone = 100%) 2. Severity of subjective symptoms (mild vs moderate vs severe headaches, fatigue, dizziness) 3. Presence and frequency of neurobehavioral effects (irritability, impulsivity) 4. Communication impairment (mild vs total inability to communicate) 5. Consciousness changes (persistent altered state would warrant 100%) 6. Whether mental, physical, or sensory residuals warrant SEPARATE compensable ratings For each factor, give your doctor specific examples from your daily life so they can document accurately (not generically).

Common mistakes

• ×Forgetting to claim secondary headaches, sleep disturbance, depression, vision/hearing changes separately
• ×Not requesting neuropsychological testing when memory or executive-function complaints exist

Authority

• 38 CFR 4.1 - Functional impairment as the basis for rating.

Preparation checklist for the Residuals of Traumatic Brain Injury (TBI) DBQ exam: 1. Bring all neurology + neuropsych testing reports, especially baseline vs current. 2. Bring buddy / family statements describing changes in personality, memory, judgment since the injury. 3. List every secondary condition you want claimed (headaches, vertigo, sleep, depression, vision). 4. Track WORST symptoms in a log for 30 days before the C&P (frequency, severity, impact). 5. Request neuropsychological testing in advance if not already done - many TBI raters defer without it. 6. If PTSD is also claimed, prepare to advocate for non-overlapping symptom attribution per 38 CFR 4.14. Remember: Describe your WORST days, not your average days. VA raters evaluate the full range of your disability including its worst manifestations.

Common mistakes

• ×Describing your best days or average functioning instead of your worst - VA rates the full range of disability.
• ×Minimizing symptoms out of stoicism or pride - accurate documentation is not exaggeration; it is honesty.
• ×Not mentioning secondary symptoms, side effects, or additional conditions the doctor may not ask about.