Military and civilian jobs
Military jobs by service branch, rating or specialty, tasks and exposures and years worked, then civilian jobs by industry, description and years worked.
10-0445
Occupational and Environment Exposure History
- Agency
- VA
- Revision
- December 2006
- Fillable fields
- 137
- Pages
- 3
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-0445: Occupational and Environment Exposure History
VA Form 10-0445 is the U.S. Department of Veterans Affairs Occupational and Environment Exposure History. The PDF is headed Occupational and Environmental Exposure History. It is a questionnaire a patient completes about jobs, substances, hobbies and home conditions. The form says many chronic lung diseases can result from or be modified by a broad range of factors, including exposures in the work place or the home, and that the clinician examining you will review the form and discuss possible factors that may be related to your disease. VA's form page lists it under VHA.
The form is three pages. Page 1 lists military jobs, civilian jobs and a substance checklist. Page 2 covers mold, dusts, metals and hobbies. Page 3 covers home and housing since leaving military service. Each page has a line for the patient's name and SSN. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-0445
Substance checklist
Paints or varnishes, glues or adhesives, organic solvents, pesticides, gasoline or oil products, grain dusts or hay, vegetable matter, metals and metal grinding, and animal husbandry, with average hours per week and years.
Mold and water problems at work
Yes or no questions on working in a moldy or musty environment and in a building, other than your home, with sustained water problems or moldy odors, with space to explain.
Dusts, metals and fluids
Asbestos, wood, coal and sand or stone dust, abrasive blasting, beryllium, non-skid coating, other dust, metals, dusts or fumes and metalworking fluids, each with whether particles were visible, hours per week and years.
Hobbies and pastimes
Yes or no questions on keeping birds as pets, gardening or working with compost, using pesticides and wood-working projects.
Home and housing
Questions on any house lived in since leaving military service: a musty, wet or flooded basement, whether the kitchen stove and bathroom air are exhausted to the outside, and mold on the bathroom wall or shower curtain, with dates and duration.
How to complete VA Form 10-0445
- 1
Enter your name and SSN
Each of the three pages has a line for the patient's name and SSN at the bottom.
- 2
List your jobs
List military jobs with job codes if known and a brief description, then civilian jobs since high school, beginning with the most recent and working backwards.
- 3
Check the substances
Check each substance that applies and enter the average hours per week and number of years you worked with it.
- 4
Answer the yes or no questions
Answer the questions on pages 2 and 3 and use the spaces provided to explain how you were exposed or to describe home problems with dates and duration.
- 5
Review it with your clinician
The form says the clinician examining you will review it and discuss possible factors that may be related to your disease.
Why fill Form 10-0445 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes
No mailing address
The form prints no mailing address, fax number or email. It says the clinician examining you will review it.
Paper form only
VA's form page offers VA Form 10-0445 as a downloadable PDF and lists no online version.
Edition
The current edition is dated DEC 2006 and has three pages.
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Who uses VA Form 10-0445?
The form describes who fills it in and who reads it.
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Questions about Form 10-0445
What is VA Form 10-0445 used for?
It records a patient's work, military, hobby and home exposures. The form says the clinician examining you will review it and discuss possible factors that may be related to your disease.
Which jobs does the form ask about?
All jobs held while in military service, and all jobs held since completing high school, including periods of unemployment greater than one year, starting with the most recent job.
What if I don't know my military job code?
The form asks for the Navy Enlisted Code, Navy Officer Billet Code, Military Occupational Specialty or Air Force Specialty Code if known, plus a brief job description.
Does the form ask about my home?
Yes. Page 3 asks about any house you have lived in since leaving military service: basement odor, water or flooding problems, kitchen and bathroom exhaust to the outside, and mold in the bathroom.
Where do I send VA Form 10-0445?
The form prints no mailing address. It says the clinician examining you will review the form.