TBI VA Claim Field Manual

Key takeaways

• TBI ratings under DC 8045 use a 10-facet evaluation. Level 0 = 0%, Level 1 = 10%, Level 2 = 40%, Level 3 = 70%, Total = 100%. The highest facet determines your rating.
• Presumptive secondary conditions under 38 CFR § 3.310(d) include depression (within 3 years for moderate/severe TBI, 12 months for mild), hormone deficiency, Parkinson's disease, unprovoked seizures, and certain dementias.
• Neuropsychological evaluation is the gold standard for documenting cognitive impairment. Request one through VA or obtain privately with a nexus opinion.

Situation Brief

TBI claims require a different approach than most VA disabilities. Instead of rating based on a single diagnostic code, the VA evaluates 10 separate facets of impairment and assigns your rating based on the highest-scored facet. This means documenting all areas of dysfunction—not just the most obvious symptoms.¹

Prep Checklist

Before filing, gather evidence that documents the in-service TBI event, current residuals across all 10 facets, and any secondary conditions.

• File an Intent to File (VA Form 21-0966) to lock in your effective date while you gather TBI evidence and schedule evaluations.
• Request service treatment records documenting the TBI event: incident reports, medical records, line of duty determinations, and Purple Heart citations if applicable.
• Obtain a neuropsychological evaluation from a VA or private neuropsychologist—this is the gold standard for documenting cognitive impairment.
• Request brain imaging (CT or MRI) if not already in your records. While normal imaging doesn't rule out TBI, abnormal findings strengthen your claim.
• Ask your treating provider to complete a TBI Disability Benefits Questionnaire (DBQ) addressing all 10 facets of impairment.
• Gather prescription records: cognitive medications, antidepressants, anti-seizure medications, and any treatments for TBI symptoms.
• Collect lay statements from family members and coworkers describing personality changes, memory problems, and behavioral issues they've observed.
• If claiming secondary conditions, obtain nexus letters linking migraines, PTSD, depression, or other conditions to your TBI.

For mild TBI (concussion), focus heavily on lay statements and functional impact documentation. Imaging is often normal, making witness testimony critical.

Step-by-step playbook

1. Lock in your effective date: Submit VA Form 21-0966 (Intent to File) online or by phone. This gives you one year to gather TBI evidence while preserving your earliest possible effective date.
2. Document the in-service TBI event: Gather service records showing the traumatic event: combat action reports, incident documentation, medical records, or buddy statements confirming blast exposure, vehicle accidents, or falls.
3. Get a neuropsychological evaluation: Request a comprehensive neuropsych evaluation through VA or obtain one privately. This 4-8 hour battery of tests documents cognitive impairment across memory, attention, executive function, and processing speed.
4. Document all 10 facets: Review the DC 8045 facets and ensure you have evidence addressing each: memory/attention/executive function, judgment, social interaction, orientation, motor activity, visual-spatial, subjective symptoms, neurobehavioral, communication, and consciousness.
5. Stage secondary claims: Identify conditions caused or aggravated by TBI. Migraines, PTSD, depression, sleep disorders, tinnitus, and vertigo are common secondaries. Obtain nexus letters for each.
6. Prepare for the C&P exam: Bring your neuropsych results, symptom logs, and lay statements. Be prepared to describe your worst days across all 10 facets. Don't minimize—the examiner needs to understand your actual level of impairment.

Keep symptom logs and lay statements consistent with your neuropsych evaluation and treatment records. The VA looks for patterns across multiple evidence sources when rating TBI.

Evidence Arsenal

Organize your proof to demonstrate the in-service TBI, current impairment across all 10 facets, and secondary conditions.

Key evidence tip: Lay statements are critical for TBI claims because cognitive impairment often isn't visible to the veteran themselves. Family members and coworkers often notice changes the veteran has adapted to or doesn't recognize.

Intel & Tools

Master the 10-facet system and leverage presumptive connections to build the strongest possible TBI claim.

• Understand facet levels: Level 0 = normal, Level 1 = mild (10%), Level 2 = moderate (40%), Level 3 = moderately severe (70%), Total = complete impairment (100%). Your overall rating equals your highest single facet.
• Memory/attention/executive function (Facet 1): This facet covers concentration, planning, organization, and short-term memory. Document specific examples: forgetting appointments, losing track of conversations, inability to multitask.
• Judgment (Facet 2): Covers decision-making ability. Examples: poor financial decisions, inability to recognize dangerous situations, inappropriate responses to problems.
• Social interaction (Facet 3): Document relationship difficulties, social withdrawal, inappropriate behavior in social settings, or inability to maintain friendships.
• Presumptive secondaries (38 CFR § 3.310(d)): Depression is presumptive within 3 years of moderate/severe TBI or 12 months of mild TBI. Parkinson's disease, unprovoked seizures, hormone deficiency (within 12 months), and certain dementias (within 15 years) are presumptive for moderate/severe TBI.
• File migraines separately: Post-traumatic headache is one of the most common TBI residuals—studies show roughly one-third of veterans with mild TBI are referred to neurology for persistent headaches. Migraines are rated under DC 8100, separate from TBI. See the Migraine Playbook for evidence strategies.

Update your symptom log weekly and share it with your treatment providers so your medical records reflect consistent, documented impairment across all facets.

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