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Is the Claimant currently on appeal, and/or has the Claimant received an unfavorable VA decision within the last year?*
—Please choose an option—YesNoDoes Not Apply

How Did You Hear About Us?*
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Do you have a current or previous diagnosis of cancer?*

Are you Employed?*
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Did you or the claimant spend time at Camp Lejeune from 1953-1987 for 30 or more total days and later develop a cancer or serious systemic disease?
—Please choose an option—YesNo

Were you or a loved one seriously injured after 9/11/2001 in Iraq or Afghanistan by an attack involving an IED, rocket, mortar, small arms fire or similar incident resulting in serious bodily injury such as an amputation, serious nerve or muscular injury, shrapnel injuries, lost vision, significant scarring, organ damage, or other similar types of bodily harm?
—Please choose an option—YesNo