Claimant Report Trauma to the Neck or Base of the Skull Cerebrovascular Accident



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Claimant Report - Trauma to the Neck or Base of the Skull

Cerebrovascular Accident

This form is in connection with your claim for pension and medical treatment and the information you supply will assist in deciding eligibility for benefits under the Veterans' Entitlements Act 1986 and/or Military Rehabilitation and Compensation Act 2004. In the event of an appeal against a decision, this information may be provided to the Veterans' Review Board, Administrative Appeals Tribunal or Federal Court.



Veteran's Details

Surname




Given Names




DVA File Number
















Report Detail

1. Is there a history of trauma to the neck or the base of the skull? Note: The Repatriation Medical Authority defines this trauma as either:



  1. a non-penetrating injury, involving extension, rotation, hyperflexion or compression of the neck;

  2. a penetrating injury to the neck or the base of the skull; or

  3. an injury resulting in fracture or dislocation of the cervical spine.

No - Please sign the form and return it to the Department

Yes - Please give date and describe the cause of the trauma to the neck or the base of the skull (Indicate if the trauma was due to another medical condition - eg. a fall caused by a medical condition such as epilepsy):



Date of trauma:
/ /

Description of events:










Description of injury suffered:









2. Was medical treatment required for the trauma to the neck or the base of the skull?

No - Please sign the form and return it to the Department

Yes - Please give details of the medical treatment required for the trauma to the neck or the base of the skull and indicate where this treatment was given:















Claimant's Signature

You are reminded that:

 The Declaration you signed on the claim form also covers the information you supply on this form.



 There are penalties for knowingly making false or misleading statements.




/ /




CSCG0101CR9076 19/06/1996


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