Evidence Checklist: Traumatic Brain Injury (TBI)
DC 8045
Significant gaps — claim likely to be denied or underrated
Specialist Opinion (Highest Value)
Neuropsychological testing documenting cognitive deficitsCritical
A comprehensive neuropsychological battery documenting memory, attention, processing speed, and executive function deficits. VA raters use these results to assess cognitive impairment level under 38 CFR § 4.124a DC 8045.
MRI or CT brain imaging showing structural changesCritical
Neuroimaging documenting contusions, diffuse axonal injury, encephalomalacia, or other TBI-related structural changes. A normal scan does not preclude a rating — include a radiologist report.
Nexus opinion linking TBI to in-service event ("at least as likely as not")Critical
A medical opinion connecting your TBI to a documented in-service event such as blast exposure, vehicle accident, or direct head trauma.
Neurologist or physiatrist evaluation of TBI residualsCritical
A current evaluation documenting all TBI residuals including headaches, dizziness, sleep disturbance, mood changes, and cognitive symptoms — all of which contribute to the overall TBI rating.
Treatment Records
TBI treatment and rehabilitation records
Records from TBI clinic, occupational therapy, speech therapy, cognitive rehabilitation, or other TBI-focused treatment documenting functional status.
Lay Statements & Personal Documentation
Buddy statement from spouse, family, or fellow service member
A written statement from someone who can describe observable symptoms and how your condition affects daily life.
Personal statement describing symptoms and functional impact
Your own written account of how this condition affects your daily activities, work, and relationships. Describe your worst days.
Disability Benefits Questionnaire (DBQ)
Completed DBQ Traumatic Brain InjuryCritical
VA standardized form specifically for TBI that captures cognitive symptoms, neurobehavioral effects, and functional impact across all rating facets.
Service Records
In-service incident documentation (LOD, SIRS report, medical records)Critical
Line of Duty determination, Significant Incident Report, or medical records documenting the head injury event during service.
Service treatment records (STRs)Critical
Military medical records showing in-service treatment, complaints, or injuries related to this condition.