VA/M-10 Manual for Gulf War Vete

VA/M-10 Manual for Gulf War Veterans (no longer published)

This publication is no longer in use and has been replaced by the 38 page VA Handbook 1303.2 for assessing Gulf War conditions and veterans. This VA/M-10 Policy Manual needs some revisions to include other (more detailed) evaluations and considerations and brought back into publication. Please keep a copy of this manual for future reference.

(Logo) Department of Veterans Affairs

ENVIRONMENTAL AGENTS SERVICE

Persian Gulf Program

M-10, Part III Veterans Health Administration

August 8, 1995 Washington, DC 20420

August 8, 1995 M-10, Part III

Department of Veterans Affairs

Veterans Health Administration

Washington, DC 20420

The Department of Veterans Affairs, Veterans Health Administration Manual M-10, “Envioronmental Agents

Service,” Part III, “Persian Gulf Program,” is published for the compliance of all concerned.

Signed by Mike Huges

for

Kenneth W. Kizer, M.D., M.P.H.

Under Secretary for Health

Distribution: RPC: 1323

Printing Date: 8/95

March 21, 1996 M-10, Part III

Change 2

iii

CONTENTS

CHAPTERS

1. PERSIAN GULF PROGRAM

2. PHASE I, PERSIAN GULF REGISTRY EXAMINATION

3. PHASE II, PERSIAN GULF UNIFORM CASE ASSESSMENT PROTOCOL

4. PERSIAN GULF REFERRAL CENTERS

5. PERSIAN GULF REGISTRY SPECIFICALLY FOR SPOUSES AND CHILDREN OF

PERSIAN GULF WAR VETERANS

M-10, Part III March 21, 1996

Change 2

RESCISSIONS

The following material is rescinded:

1. Manuals

M-10, Part III, Chapter 1 and 2, dated December 7, 1992.

2. Directives

10-95-053

August 8, 1995 M-10, Part III

Chapter 1

1-i

CONTENTS

CHAPTER 1. PERSIAN GULF REGISTRY (PGR) PROGRAM

PARAGRAPH PAGE

1.01 Purpose ........... 1-1

1.02 Background ...... 1-1

1.03 Authority and Healthcare Services Provided ................................................................................... 1-2

1.04 Health Evaluation ............................................................................................................................. 1-3

1.05 Exceptions to Services .................................................................................................................... 1-3

1.06 Responsibilities 1-4

1.07 Media and Other External Contacts.................................................................................................. 1-4

1.08 Special Health Needs of Persian Gulf Female Veterans ................................................................. 1-5

M-10, Part III August 8, 1995

Chapter 1

1-ii

RESCISSIONS

The following material is rescinded:

1. Manuals

M-10, Part III, Chapter 1, dated December 7, 1992.

August 8, 1995 M-10, Part III

Chapter 1

1-1

CHAPTER 1. PERSIAN GULF REGISTRY (PGR) PROGRAM

1.01 PURPOSE

a. This chapter provides procedures to establish a Persian Gulf Registry (PGR) Program at all Department of

Veterans Affairs (VA) health care facilities for concerned participants of “Operation Desert Shield /Storm.”

1.02 BACKGROUND

a. According to the Department of Defense (DOD) approximately 690,000 American servicemen and women

were involved in the Persian Gulf War. There may be a substantial number of troops actually exposed to unignited

petroleum and/or smoke from the sabotage of Kuwaiti oil wells by retreating Iraqi forces as well as other industrial

and environmental hazards.

b. Establishment of a PGR will assist VA in initiating a program to identify possible diseases which may result

from service of United States (U.S.) military personnel in certain areas of Southwest Asia (see par. 2.02). These

diseases may be endemic to the area or due to hazardous exposures, including heavy metals. Furthermore, air

pollutants, i.e., carbon monoxide sulfur oxides, hydrocarbons, particulate matter, and nitrogen oxides, singly or in

combination, can cause chronic as well as acute health problems.

(1) These health problems may include:

(a) Chronic bronchitis,

(b) Chronic obstructive pulmonary disease,

(d) Bronchial asthmas, and

(e) Lung cancer.

NOTE: U.S. veterans who served in the Persian Gulf theatre of war are henceforth in M-10. Part III, referred to

as Persian Gulf veterans.

(2) Persian Gulf veterans have reported a wide variety of symptoms and exposures as a consequence of

Persian Gulf service. These include, but are not limited to exposure to:

(a) Oil, smoke and other petrochemical agents;

(b) Leishmaniasis (Sand flies);

(d) Depleted Uranium (DU);

(e) Inoculations (Anthrax, botulism, etc.);

(f) Pesticides;

(g) Diesel and jet fuels and other petrochemicals and solvents;

(h) Chemical Agent Resistant Compound (CARC) paint;

(I) Chemical and/or biological warfare agents; and

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(j) Contaminated food and water obtained in the Persian Gulf.

(3) The following symptoms have been reported by a number of Persian Gulf veterans:

(a) Gastrointestinal problems;

(b) Flu-like conditions;

(d) Sinus congestion, post nasal drip;

(e) Joint pains and/or muscle soreness;

(f) Hair loss;

(g) Headaches;

(h) Memory loss;

(i) Chronic fatigue;

(j) Thickened saliva;

(k) Loose teeth, sore and/or bleeding gums;

(l) Dizziness, vertigo;

(m) Sleep disturbance; and

(n) Other symptoms and/or exposures.

(4) During the examination process, these exposures and health conditions will be identified and documented

in the Consolidated Health Record (CHR) and VA Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet.

c. The creation of a registry containing medical and other data on exposed veterans will signal VA’s

commitment to address questions concerning possible future effects of air pollutant exposure, other environmental

agents, and serve as the basis for future medical surveillance. NOTE: VA is in the process of requesting

support for future computerization of this registry.

1.03 AUTHORITY AND HEALTH CARE SERVICES PROVIDED

Title 38, United States Code (U.S.C.) Chapter 17, Section 1710, provides for health care only, and a

determination that the veteran is eligible for such care does not constitute a basis for service-connection or in any

way affect determinations regarding service-connection.

a. Health care services will be provided to veterans who while serving on active duty in the Southwest Asia

theater of operations during the Persian Gulf War may have been or were exposed to a toxic substance or

environmental hazard. Verification of service in the Persian Gulf during the Persian Gulf era (August 2, 1990 - no

ending data established by law) will be required. Inasmuch as VA presumes that a veteran was exposed to a toxic

substance or environmental hazard during any service in the Persian Gulf, a verified claim of such in-country

service constitutes the required contention of exposure and establishes eligibility for medical care within these

provisions.

b. Authorized health care services are limited to:

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(1) Hospital, nursing home care and outpatient care in VA facilities on a pre- or post-hospitalization basis or to

obviate a need for hospitalization.

(2) Such health care services will be provided without regard to the veteran’s age, service-connected status or

ability of the veteran to defray the expenses of such care.

(3) Veterans furnished outpatient care under this authority will be accorded priority ahead of most other non

service-connected veterans and equal to former Prisoners of War who are receiving care for non serviceconnected

conditions.

(4) Congress made it clear that this authority provides for health care only, and that a determination that the

veteran is eligible for such care does not constitute a basis for service-connection or in any way affect

determinations regarding service-connection.

NOTE: Health care services may not be provided under this authority for the care of conditions which

are found to have resulted from a cause other than the specified exposures.

1.04 HEALTH EVALUATION

a. Veterans claiming health conditions related to exposure to toxic substance or environmental hazard will be

evaluated clinically by means of a physical examination and appropriate diagnostic studies (see Ch. 2, App. 2B).

Where findings reveal a condition requiring treatment, the responsible staff physician shall make a determination

as to whether the conditions resulted from a cause not related to Persian Gulf Service.

b. In making this determination, the physician will consider the following types of conditions which are not

ordinarily considered to be due to toxic substances or environmental hazards:

(1) Congenital or developmental conditions, e.g., spina bifida, scoliosis.

(2) Conditions which are known to have existed before the Persian Gulf.

(3) Conditions resulting from trauma, e.g., deformity or limitation of motion of an extremity.

(4) Conditions having a specific and well-established etiology; e.g., tuberculosis or gout.

(5) Common conditions having a well-recognized clinical course, e.g., inguinal hernia or acute appendicitis.

1.05 EXCEPTIONS TO SERVICES

a. Although the types of conditions listed in paragraph 1.04 are not ordinarily considered to be due to a toxic

substance or environmental hazard, if the staff physician finds that a veteran requires care under this provision for

one or more of those conditions, the physician should seek guidance from the Chief of Staff (COS) and the

Veterans’ Registry Physician (VRP) regarding the authorization for treatment.

b. The decision and its basis will be clearly documented in the medical record or chart by the VRP.

c. Veterans who are not provided needed medical care under these provisions may be furnished care if they

are eligible under other statutory authority.

d. All non service-connected Persian Gulf veterans who respond affirmatively to the exposure question are

means tested before being seen by a physician.

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1.06 RESPONSIBILITIES

a. A PGR will be established modeled after the Agent Orange and Ionizing Radiation Registries. All VA facility

staff are to be alerted of the PGR through appropriate internal communications, e.g., medical center memoranda

providing names, locations, and office telephone numbers of the Veterans’ Registry Physician (VRP) and the

Veterans’ Registry Coordinator (VRC).

(1) The PGR is the responsibility of VA Central Office Environmental Agents Service (EAS), in coordination

with:

(a) VRPs;

(b) VRCs; and

(2) It will consist of medical examinations and other data of concerned Persian Gulf War participants. The

PGR will be the most effective means of identifying such concerned veterans.

b. The EAS has the responsibility to develop, coordinate, and monitor Veterans Health Administration (VHA)

activities relating to the Persian Gulf issue. All policy and clinical questions relating to the identity of possible

diseases which may result from service of U.S. (United States) military personnel in certain areas of Southwest

Asia should be referred to EAS.

c. The VRP and VRC at each VA facility will assume respective responsibility for coordinating the medical and

administrative aspects of the registry. The VRP, VRC, and other medical center staff, will play a key role,

beginning with the initial contact in:

(1) Providing registry participants with medical examinations and necessary treatment where medically

indicated for eligible veterans;

(2) Advising veterans of examination results; and

(3) Submitting properly completed code sheets to the AAC.

d. There will be a time lapse between the date of examination and the processing of examination results.

Accordingly, analyses used in speeches or presentations should be qualified to avoid misleading or misinforming

the audience.

1.07 MEDIA AND OTHER EXTERNAL CONTACTS

a. Media Contacts. Reports of Contact from various media sources (e.g., radio, television, newspapers, etc.)

concerning PGR Program activities will be referred by phone to the facility Public Affairs Officer. Interviews should

not be given unless approved by the medical center Public Affairs Officer who may appropriately coordinate

response with the regional VA public affairs representative.

b. Contacts to Advise Centers of “Special Cures” for Persian Gulf-Related Illnesses. Medical centers

can expect, on occasion, to be contacted by private sector physicians, researchers, and the general public with

information regarding “quick cures” for Persian Gulf-related illnesses. Such individuals should be advised that:

(1) There are medically accepted mechanisms to introduce new clinical treatments;

(2) All new treatments suggested must be reviewed by a formally designated and staff Human Subjects

Review Committee;

(3) It is important to have independent confirmation of treatment efficacy;

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(4) Provisions exist to permit the originator of new therapies to retain professional credit and be appropriately

compensated; and/or

(5) The individual might want to consider presenting the “new approach” at a VA or medical school Grand

Rounds or Staff Review Committee meeting.

1.08 SPECIAL HEALTH NEEDS OF PERSIAN GULF FEMALE VETERANS

VHA is committed to providing for the physical and psychological treatment needs of women veterans who

have been sexually or physically abused, or engaged in combat.

a. The VRP should be aware of and sensitive to the needs of Persian Gulf women veterans who were:

(1) Raped;

(2) Otherwise sexually assaulted;

(3) Sexually harassed;

(4) Combatants during military service; or

(5) Prisoners of War.

b. This can lead to long-term psychiatric and psychosomatic sequelae. When a problem is detected,

appropriate counseling and psychotherapy must be provided.

NOTE: Since this is a highly specialized area, it may be necessary to make appropriate referral to other

VA or private sector providers. This should be reported on the CHR as well as under Item 32, Part II of

VA Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet, Phase I.

August 8, 1995 M-10, Part III

Chapter 2

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CONTENTS

CHAPTER 2. PHASE I, PERSIAN GULF REGISTRY (PGR) EXAMINATION

PARAGRAPH PAGE

2.01 Purpose ................. 2-1

2.02 Eligibility Criteria .... 2-1

2.03 Program Management ........................................................................................................................... 2-2

2.04 Responsibilities ...... 2-2

2.05 Consolidated Health Report (CHR) ....................................................................................................... 2-5

2.06 Incarcerated Veterans ........................................................................................................................... 2-5

2.07 Veterans with other than Honorable Discharges ................................................................................... 2-5

2.08 Active Duty Military Personnel ............................................................................................................... 2-5

2.09 Updating VRP and VRC Appointments ................................................................................................. 2-6

2.10 Report to AAC ........ 2-6

APPENDICES

2A Definitions and Acronyms ......................................................................................................................... 2A-1

2B Protocol for Conducting the Physical Examination and Ordering Diagnostic Studies .............................. 2B-1

2C Sample and Instructions for Completing VA Form 10-9009A (July 1995), Persian Gulf Registry

Code Sheet, Phase I, Part I, II, and III .................................................................................................. 2C-1

2D Reporting Requirements .......................................................................................................................... 2D-1

2E Instructions and Sample and for Completed VA Form 7252, Transmittal Form

for Use in Shipment of Tabulated Data ................................................................................................. 2E-1

2F Instructions and Sample Format for Completion of Bi-monthly Report of Persian Gulf War

Veterans Registry Examinations (RCS 10-0875) .................................................................................. 2F-1

2G Examples of Persian Gulf Registry Follow-up Letters ............................................................................. 2G-1

M-10, Part III August 8, 1995

Chapter 2

2-ii

RESCISSIONS

The following material is rescinded:

1. Manuals

M-10, Part III, Chapter 2, dated December 7, 1992.

August 8, 1995 M-10, Part III

Chapter 2

2-1

CHAPTER 2. PHASE I, PERSIAN GULF REGISTRY (PGR) EXAMINATION

2.01 PURPOSE

This chapter sets forth clinical and administrative policies related to the maintenance of Veterans Health

Administration’s (VHAs) Persian Gulf Registry (PGR) Program for physical examinations of concerned veterans.

2.02 ELIGIBILITY CRITERIA

The Department of Veterans Affairs (VA) will provide a PGR examination to veterans who served on active

military duty in Southwest Asia during the Persian Gulf War between August 2, 1990, and the official termination

date (to be established). Active duty military personnel who served in Southwest Asia are encouraged to

participate in the PGR program, (see par. 2.07).

a. This would include service in one or more of the following areas:

(1) Iraq;

(2) Kuwait;

(3) Saudi Arabia;

(4) The neutral zone (between Iraq and Saudi Arabia);

(5) Bahrain;

(6) Qatar;

(7) The United Arab Emirates:

(8) Oman;

(9) Gulf of Aden,

(10) Gulf of Oman; and

(11) Waters of the:

(a) Persian Gulf,

(b) Arabian Sea; and

NOTE: Medical Administration Service (MAS) should be consulted to determine whether each veteran

applying for this examination meets pertinent eligibility requirements.

b. Eligible Persian Gulf veterans applying for treatment in a VA medical center and/or outpatient clinic should

be encouraged to undergo an initial (i.e., “first-time”) PGR examination. The protocol for conducting the physical

examination and ordering diagnostic studies is contained in Appendix 2B.

c. Veterans should be advised that examination or treatment does not constitute a formal claim for

compensation.

(1) Although the results of a PGR examination may be used to support a compensation claim, the examination

will not in and of itself be considered such a claim.

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NOTE: If a compensation examination is performed for a Persian Gulf War veteran and the veteran

requests inclusion in the PGR, it is not necessary to schedule an additional registry examination as long

as the information is sufficient to adequately complete the PGR code sheet for submission to the Austin

Automation Center (AAC).

(2) Veterans who wish to submit a claim for conditions possibly related to Persian Gulf service should do so via

the normal claims process through a Veterans Benefits Counselor (VBC) at the nearest VA medical center or

regional office.

2.03 PROGRAM MANAGEMENT

For current information and program activities, Veterans’ Registry Physicians (VRPs), Veterans’ Registry

Coordinators (VRCs) and MAS employees should receive and familiarize themselves with quarterly mailouts and

various materials distributed by VA Central Office. In addition, all program officials should attend the periodic

Environmental Agents Service (EAS) conference calls from VA Central Office.

2.04 RESPONSIBILITIES

The VRP, or designee, VRC and MAS staff play a significant role in determining the perceptions veterans have

concerning the quality of VA health care services and of their individual treatment by VA health care providers.

a. VRP Responsibilities. The VRP, or designee, is responsible for clinical management of the veteran on the

registry and will serve as their primary health care provider unless another has been assigned. The VRP serves in

an advisory capacity for the administrative management of the program. The VRP should be the person to

discuss with the patient the results of the examination(s) as well as providing follow-up visits and/or possible

referrals to other tertiary medical centers or Persian Gulf Referral Centers (PGRC). Major essential

responsibilities include:

(1) Counseling the veteran as to the purpose of the physical examination;

(2) Providing focused initial examination and continuum of care to those symptomatic veterans experiencing

multiple symptoms after their Persian Gulf experience;

(3) Conducting and documenting the physical examination in the medical record or Consolidated Health

Record (CHR) at the time of the visit;

(4) Providing a complete medical history including:

(a) Family;

(b) Occupation;

(d) Civilian exposure to possible toxic agents;

(e) Psychosocial condition; and

(f) Review of systems.

(5) Completing Part II (Phase I) and III (Phase II) of VA Form 10-9009A (July 1995), Persian Gulf Registry

Code Sheet, and reviewing Part I and completing that section, if necessary.

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2A-1

(a) Reviewing the code sheet to further ensure the form’s completeness, the clinical examiner will

review the code sheet and, if necessary, obtain and record any missing information from the veteran.

NOTE: Code sheets should be transmitted to AAC no later than 25 working days after initial examination.

(b) Inquiring whether any of the veteran’s natural children have any birth defects and noting in Item 22

and the CHR.

(6) Reviewing records of every Persian Gulf veteran examined to ensure that a complete physical

examination was performed and documented;

(7) Personally discussing with each veteran the findings of the physical examination and completed

diagnostic studies. The interview will be conducted in such a way as to encourage the veteran to discuss

any health concerns, as well as concerns expressed by family members;

(8) Personally discussing each veteran’s need for a follow-up examination either recommended by

VRP or requested by the veteran;

(9) Documenting these discussions and/or findings in each veteran’s CHR.

(10) Encouraging the veteran to contact VA medical center to include additional diagnoses in CHR and

PGR if the veteran is subsequently diagnosed with a significant health problem by a non-VA physician.

This new diagnosis must be submitted under non-VA physician’s signature and on official letterhead. A

code sheet identified as, follow-up examination, Type C, will be completed with this diagnosis and

subsequently forwarded to AAC for inclusion in PGR.

(11) Preparing and signing a follow-up letter to each veteran explaining the results of the examination

and associated laboratory tests. NOTE: Sample follow-up letters are provided in Appendix 2G.

(a) These letters are to be mailed to the veteran within 2 weeks of the initial examination appointment

and follow-up examination when a new diagnosis is determined. The only exception to this timeframe will

be when a consultation at a specialty clinic is requested as part of the initial examination process. This

exception suspends, but does not remove the requirement for the follow-up letter. The follow-up letter is

to be sent no later than 2 weeks after the consultation.

(b) A copy of this dated and signed letter will be filed in the veteran’s CHR.

Inappropriate wording could unduly alarm or confuse the veteran. A great deal of sensitivity and care

should be exercised in the preparation of this correspondence.

(d) The letter will explain that:

1. If the veteran who was examined has no detectable medical problems, the follow-up letter should so

indicate and suggest that the veteran contact the nearest VA health care facility if health problems appear

later.

2. If it is determined upon examination that the veteran does have medical problems, it is not

necessary to specify the problems in the letter.

3. The veteran should be advised in the letter that the recent examination indicated a health condition

or problem which may require further examination and/or treatment.

4. If the veteran is eligible for VA medical treatment, the letter should so advise and recommend that

the veteran seek follow-up medical care at the VA medical facility.

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5. If the veteran is not eligible for treatment, the letter should so advise and recommend that the

veteran seek appropriate medical care elsewhere.

6. The examination does not automatically initiate a claim for VA benefits. For information relating to

claims, refer the Persian Gulf veterans to a VBC at the nearest VA medical center or regional office.

7. The results of the examination will be maintained by VA and will be available for future use as

needed; and

8. If the veteran changes place of residence, the veteran should provide the new address to the VRC

to be recorded on a computerized record or card file and included on a corrected code sheet (Type "E"

examination code) for submission to AAC.

b. Veterans’ Registry Coordinator (VRC) Responsibilities

(1) The VRC is responsible for the administrative management of the program, including:

(a) Scheduling of appointments;

(b) Monitoring timeframe compliance;

(d) Collecting data for reporting purposes.

(2) The VRC is responsible for the following:

1. Scheduling. Facilities should make every effort to give each veteran a PGR examination within 30

days of the request date. If numerous consultations are required, all of these should be scheduled on the

same day, whenever possible, so that the veteran will not be unduly inconvenienced. When it is not

possible to provide all consultations on the same day, the VRC/scheduler should work with the veteran to

minimize disruptions in the veteran’s life. If a medical center fails to meet the time standard of 30 calendar

days from date of request, the medical center Director in coordination with the Regional Office Director

shall work together to explore all alternatives; i.e., referrals to other VA facilities, additional staff hours to

perform these examinations; and the possibility of the use of fee-basis sources or contracting out some or

all examinations with volume health care providers, to bring the medical center in line with the time

standard.

2. Disseminating Information. It is important that each Persian Gulf veteran be fully advised of the

PGR examination. Facility staff are encouraged to fully communicate all aspects of the PGR examination

by any appropriate means. The following alternatives might be considered:

a. Upon distribution by VA EAS, provide each Persian Gulf veteran reporting to the outpatient area,

with a VHA Headquarters (131) handout, “VA Persian Gulf Veterans’ Illnesses, Questions and Answers,”

Information Bulletin IB 10-41, describing the purpose of the examination and its limitations. This can be

further clarified by the examining physician prior to and during the course of the physical examination.

b, VRCs will also provide each veteran with a brief oral explanation of the purposes of the PGR and

the examination process and respond to any questions the veteran might have. This can be

accomplished during the VRCs initial contact with the veteran.

c. Computerized Record or Card File. A computer record or card file will be established to include data

on all registry participants. Each computer record or card file should include veteran’s full name, address,

telephone number, date of birth, Social Security Number (SSN), date of initial examination and date(s) of

subsequent follow-up examination(s). NOTE : This record will support the statistics included in the Bimonthly

Report of Persian Gulf War Veteran Registry Examinations (RCS 10-0860). In addition to other

information updates, every effort should be made by the VRC to maintain the veteran’s current address in

August 8, 1995 M-10, Part III

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2A-1

the computer record or card file for outreach purposes. VHA Headquarters is in the process of

establishing a VA system-wide computerization of this card file.

3. Code Sheet Completion

a. The VRC, or designee, will complete Part I of VA Form 10-9009A, and will ensure that all

information is entered on the code sheet before the veteran is referred to the clinician for the examination.

b. The VRP will complete Part II and III of VA Form 10-9009A. (Refer to instructions and sample code

sheet in App. 2C).

c. In the event that a veteran requests a PGR examination but does not wish to be included in the

registry database, a registry examination should be performed. Item 32, “Remarks,” should indicate the

current date and note that the veteran chose not to participate in the registry. This code sheet should be

filed in veteran’s CHR. Do not submit this code sheet to the AAC.

2.05 CONSOLIDATED HEATH RECORD (CHR)

The VRC will ensure that a CHR on each registry participant is created if one does not already exist.

a. All Persian Gulf veterans participating in the registry will have a VA Form 10-9009B (Persian Gulf

Identification Sticker) affixed to their CHR. VA Form 10-9009B should be affixed to the front of the record

in the lower left-hand corner of the “service connected” block.

b. These Persian Gulf registry records are subject to the same retention and disposition policies as

other medical record files, i.e., Records Control Schedule 10-1.

2.06 INCARCERATED VETERANS

VA medical facilities can provide assistance to penal authorities or institutions, which agree to provide

examinations to veterans, without reimbursement from VA, for purposes of entry in the PGR.

a. Copies of directives, code sheets, etc., will be provided to penal institutions upon request.

b. Penal authorities must be advised at the time of such requests that the results of the examinations

provided at their institutions must be returned to the VA medical facility of jurisdiction for inclusion, in the

veteran’s behalf, in PGR and in the veteran’s CHR.

2.07 VETERANS WITH OTHER THAN HONORABLE DISCHARGES

The requirements of M-1, Part I, Chapter 4, applies to veterans with less than honorable discharges

applying for PGR examinations.

2.08 ACTIVE DUTY MILITARY PERSONNEL

When active duty members of the uniformed services apply to VA facilities for a PGR examination,

Department of Defense (DOD) must authorize and provide the appropriate DOD Form 2161, Referral for

Civilian Care, requesting this examination or provide services under existing DOD/VA sharing agreement.

The requirements of M-1, Part I, Chapter 15, regarding the authorization and billing from the appropriate

branch of service will apply. Facilities should also reference the current directive providing the interagency

billing rates.

a. Procedures for processing the examination are the same as those for a veteran participating in this

program.

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2A-4

b. A military facility may perform the PGR examination according to VA instructions or the

corresponding military instructions. NOTE: DOD has established a Persian Gulf Hot Line, telephone

number 1-800-796-9699 to direct active duty personnel to military hospitals for medical examinations and

provide other related information. An additional telephone number has been established (1-800-472-

6719) for Persian Gulf War veterans to call with their recollection of "incidents" that might be related to

health problems.

c. Military facilities may obtain the pertinent VA administrative issue and appropriate forms from the

nearest VA facility. The VA Medical Center, 50 Irving Street, N.W., Washington, DC 20422, Attn:

Persian Gulf Coordinator (136), is the processing center for all active duty members of uniformed services

stationed overseas. Military facilities will complete code sheets with exception of the following which will

be filed in by VA coding clerks:

Blocks Code Identifier

Part I 2 to 7 Facility number and suffix

137 to 141 County and State

d. Military facilities will provide completed copies of the code sheet, physical examination, laboratory

tests, etc., to the nearest VA medical center or outpatient clinic. The VRC will:

(1) Prepare a colored card (or computerized facsimile) for the file with similar data as for a veteran

and label the card “Active Duty”;

(2) Complete the code sheet to include facility number/suffix, if applicable, county and state codes.

(3) Submit code sheet to the VA Office of Financial Management, AAC, 1615 Woodward Street,

Austin, TX 78722-0001, in accordance with instructions;

(4) Establish a CHR if one does not already exist and file the PGR examination in this folder; and

(5) If requested, and only with written authorization (release of information) from active duty member,

VA may supply a copy of these medical records to the military facility.

2.09 UPDATING VRP AND VRC APPOINTMENTS

Separate listings of VRPs and VRC's are maintained within EAS.

a. In an effort to keep these listings current, facilities are required to notify the EAS of any changes in

the status of appointments of VRP's and/or VRC's at their respective facilities.

b. As changes in designation occur, submit in writing the name, title, mail routing symbol, FTS and

commercial numbers including area code, to the VRC (103A), EAS, VA Central Office, 810 Vermont

Avenue, N.W., Washington, DC 20420 (Facsimile Number FTS 700-565-7572). NOTE: In order to

provide current Persian Gulf information to concerned VA Registry Staff, it is important that any changes

in designation of VRPs or VRCs at VA facilities be provided to VA Central Office (103A) as they occur.

2.10 REPORT TO AAC

The PGR report should be prepared monthly and submitted to the AAC as per instructions contained in

Appendix 2D:

a. VA Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet, and VA Form 7252, (originally 30-

7252) Transmittal Form for the Use in Shipment of Tabulating Data, should be prepared monthly and

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submitted to AAC as per instructions contained in Appendix 2D. NOTE: These code sheets should be

submitted, based on the following schedule, but no later than 25 working days following initial examination.

b. The schedule of mailing dates is:

(1) Region 1 -- 6th of month;

(2) Region 2 -- 10th of month;

(3) Region 3 -- 14th of month; and

(4) Region 4 -- l8th of month.

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DEFINITIONS AND ACRONYMS

1. AAC - The Office of Financial Management, Austin Automation Center (AAC) was formerly the Data

Processing Center in Austin, TX. It is the location of the computerized registry for code sheet collection

and database entry.

2. AMIS - Automated Management Information System.

3. ANA - Anti-Nuclear Antibody.

4. BAER - Brainstem Auditory Evoked Response.

5. CAPS-PTSD - Clinical Administered-Post Traumatic Stress Disorder.

6. CARC - Chemical Agent Resistant Compound paint.

7. CBC - Complete Blood Count.

8. CHR - Consolidated Health Record - A file containing medical records relating to patient identity,

diagnosis, prognosis or treatment at VA facility.

9. CPK - Creatine Phosphokinase.

10. CT - Computed Tomography.

11. D.O. - Doctor of Osteopathy.

12. DOD - Department of Defense.

13. DOD Form 2161, “Referral for Civilian Care.”

14. DSM-III-R - Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised.

15. DU - Depleted Uranium.

16. EAS - Environmental Agents Service - EAS (103A), VA Central Office, has the responsibility to

coordinate and monitor all VHA activities, research and otherwise, relating to the Persian Gulf issue.

17. ECG - Electrocardiogram.

18. EEG - Electroencephalogram.

19. EGD - Esophagastroduodenoscopy.

20. EMG - Electromyogram.

21. ENG - Electronystamogram.

22. Examinations

a. Initial. The first physical examination which is completed and sent to the AAC for the purpose of

entering a veteran into the Persian Gulf Registry system.

b. Follow-up. Examination performed subsequent to the initial (first) examination.

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23. Facility - Any VA entity which provides Persian Gulf Registry examinations to Persian Gulf veterans.

24. GI - Gastrointestinal.

25. GYN - Gynecology.

26. HcT - Hematocrit.

27. HgB - Hemoglobin.

28. HIV - HumanImmuno-deficiency.

29. IB-10-41 - VA Information Bulletin entitled “Persian Gulf Veterans’ Illnesses, Questions and Answers.”

30 ICD-9-CM - The International Classification of Diseases, Clinical Modification, 9th Edition provides

standardized classification of diseases.

31. IgG - Oligoconal.

32. KIA - Killed in Action.

33. KTO - Kuwait Theater of Operations.

34. LDH - Lactic Acid Dehydrogenase.

35. LP - Lumbar Puncture.

36. MAS - Medical Administration Service.

37. MIA - Missing in Action.

38. MOS- Military Occupational Specialty.

39. M.D. - Doctor of Medicine.

40. MRI - Magnetic Resonance Imaging.

41. MSLT - Multiple Sleep Latency Test.

42. NCV - Nerve Conduction Velocity.

43. O&P - Ova and Parasites.

44. P.A. - Physician’s Assistant.

45. PFT - Pulmonary Function Test.

46. PGR - Persian Gulf Registry - The PGR is a computerized index of veteran participants, is managed

centrally by the EAS in VA Central Office. The coded findings of Persian Gulf Program physical

examinations and related diagnostic results are entered into a database by the AAC.

47. PGRC - Persian Gulf Referral Centers - Selected tertiary VA Medical Centers (Birmingham, AL,

Houston, TX; , Washington, DC; and West Los Angeles, CA), with clinical and academic expertise in such

areas a

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pulmonary and infectious diseases, immunology, neuropsychology, and toxicology, where medical assistance is

provided for those Persian Gulf veterans with symptoms which defy explanation.

48. Plt - Platelet.

49. PPD - Purified Protein Derivative.

50. PTF - Patient Treatment File.

51. PTSD - Post Traumatic Stress Disorder.

52. Persian Gulf Area of Service. For eligibility purposes, active military duty in Southwest Asia during the

Persian Gulf War would include service in one or more of the following areas: Iraq, Kuwait, Saudi Arabia, the

neutral zone (between Iraq and Saudi Arabia), Bahrain, Qatar, the United Arab Emirates, Oman, waters of the

Persian Gulf, Red Sea, Arabia Sea, and Gulfs of Aden and Oman.

53. Persian Gulf War Period of Service. Public Law 102-25 established a Persian Gulf War period of service

which will affect persons serving on active duty as of August 2, 1990, with no ending date established by law.

54. Records Control Schedule (RCS) 10-1. Provides instructions for record retention and disposition.

55. Reports Control Symbol (RCS) 10-0860. Reflects the reporting requirements for VA Form 10-9009A (July

1995), Persian Gulf Registry Code Sheet, Persian Gulf Referral Center Monthly Report, and Bi-monthly Report on

Persian Gulf Uniform Case Assessment Protocol.

56. RCS 10-0875. The reporting requirements for the Bi-monthly Report on Persian Gulf War Veteran Registry

Examinations, under Directive 10-95-053 are rescinded by this manual change.

57. RHP - Reproductive Health Problems.

58. SCID - Structured Clinical Interview for DSM-III.

59. SCUDS - Soviet designed surface to surface missiles.

60. SED - Skin Erythema Dose.

61. SGPT(ALT) - Transaminase Glutamic Pyruvate.

62. SGOT(AST) - Glutamic Oxaloacetic Transaminase.

63. SMA (6/12) - SMA is a Manufacturer’s Trademark for a Chemistry Analyzer.

64. SSN - Social Security Number.

65. T4 - Thyroxine Total Serum.

66. TB - Tuberculosis.

67. TSH -Thyroid Stimulating Hormone.

68. UCAP- Uniform Case Assessment Protocol.

69. UGI- Upper Gastrointestinal.

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70. VA - Department of Veterans Affairs.

71. VBC - Veterans Benefits Counselor.

72. VDRL - Venereal Disease Research Laboratory.

73. VHA - Veterans Health Administration.

74. VRC - Veterans’ Registry Coordinator - A non-physician staff member responsible for the administrative

management of the program at each VA facility.

75. VRP - Veterans’ Registry Physician - The VRP is a physician responsible for the clinical management of the

Persian Gulf Program at each VA medical facility.

76. VA Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet.

77. VA Form 10-9009B - Identification Sticker entitled “Persian Gulf.”

78. VA Form 30-7252 changed to VA Form 7252, Transmittal Form for Use in Shipment of Tabulating Data.

79. WBC - White Blood Cells.

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PROTOCOL FOR CONDUCTING THE PHYSICAL EXAMINATION

AND ORDERING DIAGNOSTIC STUDIES

1. It is essential that a complete medical history, physical examination and interview be performed and

documented on appropriate forms . The required forms that must be fully completed are: Standard Form (SF) 88,

Report of Medical Examination, Department of Veterans Affairs (VA) Form 10-9009A, Persian Gulf Registry Code

Sheet, and SF 509, Progress Notes (for follow-up). These are to be maintained in the veteran's Consolidated

Health Record (CHR). NOTE: This should be accomplished by or under the direct supervision of the Veterans’

Registry Physician (VRP). Examination data will be recorded in the veteran’s medical record as routinely as done

for any other medical examination. The complete medical history should address the following:

(a) Family history;

(b) Occupational history;

(d) Civilian exposure(s) history to possible toxic agents;

(e) Psychosocial history; and

(f) Review of systems.

2. The person actually performing the physical examination will be identified by name, signature and title (i.e.,

Doctor of Osteopathy, Doctor of Medicine, Physician’s Assistant, etc.). A physician’s countersignature is required

if the examiner is other than a physician. Under normal circumstances, VRP will provide such countersignatures.

3. When a Persian Gulf Registry (PGR) examination is done as part of a compensation and pension examination,

the physical examination will be done by/or under the direct supervision of the VRP.

4. The physician should be aware of the variety of exposures endemic to the Persian Gulf area. These are listed

in Appendix 2C and on VA Form 10-9009A. There has been a wide distribution of major categories of diagnosis

reported by VA VRPs; however, no significant variation in occurrence of major categories of medical problems has

been identified. We are listing below (for informational purposes) some of the health problems and/or diseases

which should be considered:

NOTE: Unfortunately the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM)

coding system does not give sufficient codes to correctly identify all symptoms and diagnoses. A number of

diagnoses that have been reported by Veterans Registry Physicians do not have ICD-9-CM codes for specific

identification in the Veterans Health Administration (VHA) s database. To correct this, three new codes have been

created. They are: Apnea, Sleep (99001), Chronic Fatigue Syndrome (CFS) (99002), and Fibromyalgia (99003).

Make certain these codes are used when completing the Persian Gulf Registry code sheets for patients who have

these diagnoses. As a result of inadequate coding designations, there has been confusion between the symptoms

(complaints) and diagnoses listed on the PGR code sheets. Example one: Arthralgia (diagnostic code 7194) has

been used for the symptom “pain in the joint,” where the symptom code 7819 (other symptoms involving nervous

and musculoskeletal systems) would be more appropriate. Example two: Symptom ICD-9-CM code 78051 has

been designated for insomnia with sleep apnea; however, sleep apnea is more correctly identified as a specific

diagnosis which has the new code 99001. Symptom code 78051 may still be used for insomnia with sleep apnea.

Example three: Symptom ICD-9-CM code 7807 has been used to designate CFS and the symptoms of malaise

and fatigue. The new code 99002 has been determined for CFS, so ICD-9-CM code 7807 should be used for

medical complaints of malaise and fatigue

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International Classification of Diseases

DIAGNOSIS ICD-9-CM Code

(1) Amebiasis 006

(2) Apnea, sleep 99001

(3) Arthralgia 7194

(4) Asthma 493

(5) Brill’s Zinsser disease (recrudescent typhus) 0811

(6) Bronchiectasis 494

(7) Bronchopneumonia, organism unspecified 485

(8) Brucellosis 023

(8) Chronic obstructive pulmonary disease,

not elsewhere classified 496

(9) Chronic bronchitis 491

(10) Chronic Fatigue Syndrome 99002

(11) Chronic Laryngotracheitis 4761

(12) Chronic respiratory conditions due to fumes and vapors 5064

(13) Emphysema 492

(14) Fibromyalgia 99003

(15) Giardiasis 0071

(16) Leishmaniasis 085

(17) Malaria 084

(18) Other and unspecified diseases of upper respiratory tract 4789

(19) Pneumoconiosis due to other silica or silicates 502

(20) Pneumoconiosis, unspecified 505

(21) Unspecified chronic respiratory disease 5199

(22) Respiratory conditions due to unspecified external agent 5089

(23) Sandfly fever (phlebatomus fever) 0660

(24) Schistosomiasis (bilharziasis) 120

(25) Toxoplasmosis 130

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DIAGNOSIS ICD-9-CM Code

(26) Typhoid fever, also carrier - V02.1 0020

(27) Tuberculosis, specify variant(s) 010-018

(28) Viral hepatitis 070

(29) Memory loss 310

(30) Polyneuropathy 356-357

(31) Skin rash 680-709

(32) Adjustment disorder, including Post Traumatic Stress

Disorder (PTSD) 309

(33) Alcohol dependence syndrome 303

(34) Drug dependence 304

5. In gathering these data, it is important to determine and record, the:

a. Time of onset of the symptoms or conditions,

b. Intensity,

c. Degree of physical incapacitation, and

d. Details of any treatment received.

6. Each veteran will be given the following baseline laboratory studies (Phase I Registry Examination):

a. Complete Blood Count (CBC);

b. Electrolyte Glucose (SMA-6, SMA-12), or equivalent blood chemistries and enzyme studies; and

c. Urinalysis.

7. Appropriate additional diagnostic studies should be performed and consultations obtained as indicated by the

patient’s symptoms and the physical and laboratory findings. NOTE: If individuals have unexplained illnesses,

after a Phase I registry examination is performed, a Phase II examination is mandated. (See Ch. 3, App 3A, for

instructions.)

a. Other diagnostic studies, such as pulmonary function test, sperm counts, should be performed if medically

indicated.

b. Laboratory tests results should be filed in the CHR.

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SAMPLE AND INSTRUCTIONS FOR COMPLETING

VA FORM 10-9009A (JULY 1995), PERSIAN GULF REGISTRY CODE SHEET, PHASE I

1. General Instructions for completing Department of Veterans Affairs (VA) Form 10-9009A (July

1995).

a. An original code sheet should be prepared and a legible copy submitted to the Office of Financial

Management Austin Automation Center (AAC) in accordance with instructions for the initial and first

follow-up examinations (if required). After code sheet data has been reviewed and entered into the

computerized database at AAC, the AAC will forward these code sheets to the Senior Registry

Coordinator (103A), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC

20420, for disposition. These code sheets will not be returned to the medical center of origin unless

corrections are required.

(1) The original code sheet will be filed in the medical record with any corrections required by AAC.

Additional follow-up examinations, as required, will continue to be documented in the Consolidated Health

Record (CHR).

(2) A code sheet for additional follow-up examinations will not be prepared or submitted to the AAC

with the exception that if a diagnostic code differs from previously submitted code sheets, then a code

sheet will be prepared and submitted for entry into the Persian Gulf Registry (PGR).

b. Print clearly using a BLACK ball-point pen or a BLACK felt-tipped pen. Follow instructions carefully

to ensure that all data fields are accurately completed. Enter one letter or number per block. The

numeric zero must be slashed “Æ.” For registry coding purposes, use the International Classification of

Diseases - Clinical Modification, 9th Edition, (ICD-9-CM) codes. These must be the codes currently in use

by AAC.

(1) Part I of the code sheet should be completed in the presence of the veteran.

(2) Parts II and III of the code sheet should be completed at the time of the examination by the

Veterans’ Registry Physician (VRP). A completed Parts II and III will be returned to Medical

Administration Service (MAS) for assignment of the ICD-9-CM codes in appropriate blocks. NOTE:

Careful attention should be paid to assigning the correct code for both complaints (symptoms)

and diagnosis. ICD-9-CM code 78999, for uncodable complaints (symptoms), should be

assigned only after all coding possibilities have been thoroughly explored. The indiscriminate

use of ICD-9-CM code 78999 may result in skewed or misleading statistics of minimal value.

(3) Date all code sheets with current date in the upper right hand corner of VA Form 10-9009A (July

1995).

2. Instructions for Completing Part I (Initial Examination)

a. Item 1. Blocks 2-7. Facility Number and Suffix. Enter facility code as listed in MP-6, Part XVI,

Supplement No. 4.1, Appendix A. Use the AMIS suffix (BY, BZ, etc.) to indicate your satellite facility. DO

NOT USE Q, R, OR S. NOTE: If veteran requests the inclusion of his Department of Defense

(DOD) registry examination records in VA PGR, submit code sheet with Facility Number as 999

in Blocks 2, 3 & 4 and indicate actual VA facility number in upper left margin of codesheet.

b. Item 2. Blocks 8-33. Last Name of Veteran. Beginning in Block 8, enter veteran’s current last

name. If veteran had an earlier last name used during the veteran’s Persian Gulf service, e.g., an

unmarried woman, leave one space blank after the current name and enter “E.” If veteran has had any

other later name, leave another blank space (i.e., after “E”), and enter the later name followed by another

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blank space and then enter “L.” Do not use apostrophe and/or hyphen in the name or skip blocks

between the letters of the last name. Skip a block if the last name is followed with Jr., Sr., I, II, III, etc.

c. Item 3. Blocks 34-48. First Name of Veteran. Beginning in Block 34, enter veteran’s first name.

d. Item 4. Blocks 49-58. Middle Name of Veteran. Beginning in Block 49, enter veteran’s middle

name or initial.

e. Item 5. Block 59. Type of Examination. The following transaction type must be entered in Block

59 as appropriate:

A - Initial examination. Veteran’s first Persian Gulf examination.

B - To delete an entire initial examination with a noted error, after it has been accepted into the registry,

resubmit the original code sheet with a “B” and submit another code sheet with the correct information with

an “A.” All fields must be completed on a resubmission. The code sheets can be submitted in the same

batch. Examples of this usage are incorrect diagnosis, military statistics, Social Security Number (SSN),

etc.

C - Follow-up examination. Veteran’s second Persian Gulf examination. Additional follow-up

examinations, as required, will continue to be documented in the CHR, but a code sheet will not be

prepared or submitted to the AAC with the following exception: if a diagnostic code differs from previously

submitted code sheets, then a code sheet should be prepared and submitted for entry into the PGR.

D - To delete an entire follow-up PGR examination with a noted error, after it has been accepted into

the registry, resubmit the original code sheet with a “D” and submit another code sheet with the correct

information with a “C.”

E - To submit change in demographics, i.e., change of address or date of birth enter “E” and complete

items with name, SSN, date of birth, and address. No other items need to be completed.

I - To include those veterans whose names are not on the PGR but would like their name and address

included on a mailing list for the “Persian Gulf Review” newsletter.

X - When a registry participant has been identified and verified as being deceased, enter “X.”

Complete items with name, SSN, and date of birth. No other items need to be completed.

f. Item 6. Blocks 60-69. SSN. Shaded Block 60 is to be used ONLY if a pseudo SSN is being

submitted. In this event, the letter “P” will be entered in Block 60. Leave Block 60 blank when the actual

SSN is used. Beginning in Block 61 enter the veteran’s actual SSN, or pseudo SSN. (See M-1, Part I,

Ch. 5, Par. 5.29, for instructions on pseudo SSN assignment.) NOTE: All efforts should be made to

obtain veteran's actual SSN.

g. Item 7. Blocks 70-75. Date of Birth. Beginning in Block 70 enter numerical equivalent for the

month, day and year in that order (e.g., Æ1/19/5Æ). All blocks must be completed.

h. Item 8. Blocks 76-141. Permanent address.

(1) Blocks 76-101. Beginning in Block 76 enter veteran’s permanent street address.

(2) Blocks 102-127. Beginning in block 102 enter veteran’s city or town.

(3) Blocks 128-132. Enter zip code of permanent residence (National Zip Code Directory).

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(4) Blocks 133-136. Leave Blank (future extended Zip Code).

(5) Blocks 137-139. Enter appropriate county code as listed in M-1, Part I, Chapter 18, Appendix A.

(6) Blocks 140-141. Enter appropriate state code as listed in M-1, Pt. I, Chapter 18, Appendix A.

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i. Item 9. Block 142. Race/Ethnicity. Enter one of the following codes in Block 142:

1 = American Indian or Alaskan Native

2 = Asian or Pacific Islander

3 = Black, not of Hispanic Origin

4 = White, not of Hispanic Origin

5= Hispanic

6= Unknown

j. Item 10. Block 143. Marital Status. Enter one of the following codes in Block 143:

1 = Married

2 = Divorced

3 = Separated

4 = Widowed

5 = Single, Never Married

k. Item 11. Block 144. Sex. Enter one of the following codes in Block 144:

M = Male

F= Female

l. Item 12. Block 145. Current Status. Enter one of the following codes in Block 145:

1 = Inpatient

2 = Outpatient

3 = Incarcerated

4 = Active Duty (Outpatient)

5 = Active Duty (Inpatient)

m. Item 13. Block 146. Branch of Service. If veteran was in more than one branch of service, code

the latest Persian Gulf service. Enter one of the following codes in Block 146:

1 = Army (including Reserves & National Guard)

2 = Air Force (including Reserves & National Guard)

3 = Navy (including Reserves)

4 = Marine Corps

5 = Coast Guard

6 = Other (e.g., Public Health Service, National Oceanic and Atmospheric Administration)

n. Item 14, 14A and 14B. Blocks 147-163. Military Service in Persian Gulf.

(1) Block 147. Enter one of the following codes:

Y = Yes (If yes, list the dates of veterans last two periods of service in Persian Gulf.)

N = No (If the veteran did not serve in Persian Gulf, the veteran is not eligible for a Persian Gulf

Registry examination.)

(2) Item 14A. Enter the numerical equivalent of the month and also two digits of the year of last period

of service in Persian Gulf (e.g., from Æ2/91 to Æ5/91) in Blocks 148 through 155.

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(3) Item 14B. If veteran had two or more periods of service in Persian Gulf, the longest period of service

should be entered in Blocks 156 through 163. If only one period of service in Persian Gulf, enter in 14A and

leave 14B blank.

o. Item 15, 15A and 15B. Blocks 164-165. In What Area(s) Did Veteran Serve?

(1) Item 15A. Block 164. Enter one of the following codes:

1 = Combat Zone

2 = Other Land Area

3 = Sea Duty

(2) Item 15B. Block 165. If other service is indicated or, if the response is “Don’t Know” enter

appropriate code in Block 165.

4 = Other (Specify i.e., Air Force: Ground or Air Crew, etc.)

5 = Don’t Know

p. Item 16, 16A-16E. Military Units, MOS and Block 166. MOS-Different Duties .

(1) Item 16A. Military Units. Enter the military unit in which the veteran served. Specify complete

unabbreviated title, that is, company, battalion, corps, ship, division, etc., (e.g., Company C, 1st Battalion, 4th Army).

(2) Item 16B. Military Occupational Specialty (MOS): Enter the veteran’s MOS.

(3) Item 16C. Block 166. Were actual duties different from MOS? Enter one of the following codes in

Block 166: If no, go to Item 16E

Y = Yes

N = No

(4) Item 16D. If yes, enter actual duties which were different from MOS on code sheet and in CHR.

(5) Item 16E. Enter the name of unit with which the veteran had the longest and next to longest period

of service while in the Persian Gulf.

NOTE: Items 16A & 16E: These units could be different from the one to which the veteran was

assigned if the veteran was on detached duty.

q. Items 17, 17A and 17B. Blocks 167-182. Last two periods of service (If different from 14A and

14B). Enter the numerical equivalent of the month and the last two digits of the year for the last two

periods of service regardless of whether or not they were in the Persian Gulf (e.g., from 12/9Æ to Æ4/91

and 9/9Æ to 11/9Æ). If veteran did not have more than one period of service, leave blank. For active duty

military personnel, enter date when service began (e.g., 12/9Æ) and enter nines (e.g., 99/99) to indicate

the veteran is still actively serving in the military.

r. Items 18, 18A-18Z1. Blocks 183-216. Veteran’s Exposure to Environmental Factors. Enter the

following codes in appropriate blocks.

Y = Yes

N = No

(1) Item 18A. Block 183. Are you currently smoking cigarettes? If no, go to Item 18D.

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(2) Item 18B. Blocks 184-185. If yes, how many years have you been smoking cigarettes? Enter

number of years.

(3) Item 18C. Blocks 186-187. If yes, on the average, how many packs are you smoking per day?

(4) Item 18D. Blocks 188. Have you smoked cigarettes in the past? If no, go to Item 18G.

(5) Item 18E. Blocks 189-190. If yes, how many years did you smoke?

(6) Item 18F. Blocks 191-192. If yes, on the average how many packs did you smoke per day?

(7) Item 18G-Z1. Blocks 193-212. While in the Persian Gulf do you believe you were exposed to any

of the following? Enter the following codes:

Y = Yes

N = No

U = Unknown

(8) Item 18G. Block 193. Smoke from oil fires?

(9) Item 18H. Block 194. Smoke or fumes from tent heaters?

(10) Item 18I. Block 195. Cigarette Smoke (passive) from others?

(11) Item 18J. Block 196. Diesel and/or other petrochemical fumes?

(12) Item 18K. Block 197. Exposure to burning trash/feces?

(13) Item 18L. Block 198. Skin exposure to diesel or other petrochemical fumes?

(l4) Item 18M. Block 199. Chemical Agent Resistant Compound (CARC) paint?

(15) Item 18N. Block 200. Other paints and/or solvents and/or petrochemical substances?

(16) Item 18O. Block 201. Depleted uranium?

(17) Item 18P. Block 202. Microwaves?

(l8) Item 18Q. Block 203. Personal pesticide use, including creams, sprays, or flea collars?

(19) Item 18R. Block 204. Nerve gas or other nerve agents?

(20) Item 18S. Block 205. Drug (pyridostigmine) used to protect against nerve agents?

(21) Item 18T. Block 206. Mustard gas or other nerve agents?

(22) Item 18U. Block 207. Ate or drank food contaminated with smoke, oil or other chemical?

(23) Item 18V. Block 208. Ate food other than provided by Armed Forces?

(24) Item 18W. Block 209. Bathed in or drank water contaminated with smoke, oil or other chemical?

(25) Item 18X. Block 210. Bathed in water other than provided by Armed Forces?

(26) Item 18Y. Block 211. Immunization against anthrax?

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(27) Item 18Z. Block 212. Immunization against botulism?

(28) Item 18Z1. Other exposures? Enter on code sheet and in CHR.

s. Items 19A-F. Blocks 213-218 Persian Gulf Experience. Did you have any of the following

experiences while in the Persian Gulf?

(1) Item 19A. Block 213. Did you ever go on combat patrols or have other very dangerous duty?

Enter the following codes:

1 = No

2 = 1-3X

3 = 4-12X

4 = 13-50X

5 = 51+times

(2) Item 19B. Block 214. Were you ever under enemy fire, including, Soviet designed surface to

surface missiles (SCUDS)? Enter the following codes:

1 = Never

2 = less than 1 day

3 = less than 1 week

4 = 1-4 weeks

5 = 4 weeks or more

(3) Item 19C. Block 215. What percentage of people in your unit (your immediate group) were Killed

in Action (KIA), wounded or Missing In Action (MIA)? Enter the following codes:

1 = None

2 = 1-25%

3 = 26-50%

4 = 51-75%

5 = 76% or more

(4) Item 19D. Block 216. How often did you see someone hit by incoming or outgoing rounds? Enter

the following codes:

1 = Never

2 = 1-2X

3 = 3-12X

4 = 13-50X

5 = 51 or more

(5) Item 19E. Block 217. How often were you in danger of being injured or killed (i.e., pinned down,

overrun, ambushed, near miss, etc.)? Enter the following codes:

1 = Never

2 = 1-2X

3 = 3-12X

4 = 13-50X

5 = 51 or more

(6) Item 19F. Block 218. Witnessed chemical alarms? Enter the following codes:

Y = Yes

N = No

U = Unknown

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2C-7

t. Item 20. Block 219. Veteran’s Health (Veteran’s evaluation).

(1) Item 20A. Enter one of the following codes which best describes veteran’s health after Persian Gulf

Service:

1 = Very good

2 = Good

3 = Fair

4 = Poor

5 = Very poor

u. Item 21. Block 220. Veteran's Functional Impairment.

(1) Item 21A. Enter code which describes veteran’s assessment of the veteran’s functional

impairment, after Persian Gulf Service, using the following scale:

1 = No impairment

2 = Slight impairment

3 = Moderate impairment

4 = Severe impairment

(2) Item 21B. Blocks 221-222. How many workdays were lost by veteran due to illness in the past 90

days? Enter number of days lost in Blocks 221-222 (e.g., 8/Æ). If none fill in the blocks with Æs. If the

veteran does not work outside the home, annotate this information in item 32, Remarks.

v. Item 22. Blocks 223-262. Evidence of Birth Defects and Infant Death(s) among veteran’s

children and problems with pregnancy and infertility. NOTE: Where blanks are indicated complete

blocks with Æs.

(1) Item 22A. Blocks 223-224. How many children does the veteran have? If none, enter Æs, and go

to 22C.

(2) Item 22B. Blocks 225-226. Birth Defects. NOTE: Birth defects are any structural, functional, or

biochemical abnormality at birth whether genetically determined or induced during gestation that is not due

to injuries suffered during birth. How many of these children were born with birth defects? Enter number

of children in Blocks 225-226. If none, go to Item 22C.

(a) Item 22B1. Blocks 227-228. How many of these children were conceived before Gulf service? If

none, enter Æs, and go to Item 22B2.

(b) Item 22B1(a). Blocks 229-230. State maternal age at conception of first child conceived before

Gulf service. Enter age in Blocks 229-230.

Enter number in Blocks 231-232. If none, enter Æs, and go to Item 22C.

(d). Item 22B2(a) Blocks 233-234. State maternal age at conception of first child conceived during or

after Persian Gulf service? Enter age in Blocks 233-234.

(3) Item 22C. Blocks 235-241. Infertility (Problems of veteran or spouse becoming pregnant).

NOTE: Infertility=relative sterility defined as inability to conceive after 12 or more months of intercourse

without use of contraception when neither spouse is surgically sterilized. Has veteran or spouse had

infertility problems? Enter one of the following codes in Block 235. If none, go to Item 22D.

Y = Yes

N = No

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APPENDIX 2C

2C-8

(a) Item 22C1. Block 236. Has veteran or spouse had infertility before Gulf service? Enter one of the

following codes:

Y = Yes

N = No

If no, go to Item 22C2.

(b) Item 22C1(a). Blocks 237-238. State maternal age during first attempts to conceive. Enter age in

Blocks 237-238.

one of the following codes.

Y = Yes

N = No

If no, go to Item 22D.

(d) Item 22C2(a). Blocks 240-241. State maternal age during first attempts to conceive.

Enter age in Blocks 240-241.

(4) Item 22D. Blocks 242-248. Miscarriage(s). NOTE: Miscarriages are spontaneous expulsion of

the products of conception before 20 weeks of gestation (spontaneous abortion). Has veteran or spouse

had miscarriage(s)? Enter one of the following codes in Block 242.

Y = Yes

N = No

If no, go to Item 22E.

(a) Item 22D1. Block 243. If yes, has veteran or spouse had miscarriage(s) before Gulf service?

Enter one of the following codes:

Y = Yes

N = No

If no, go to Item 22D2.

(b) Item 22D1(a). Blocks 244-245. State maternal age at conception. Enter age in Blocks 244-245.

Enter one of the following codes:

Y = Yes

N = No

If no, go to Item 22E.

(d) Item 22D2(a). Blocks 247-248. State maternal age at conception. Enter age in Blocks 247-248.

(5) Item 22E. Blocks 249-255. Still Birth(s). NOTE: Still births are births after 20 weeks of gestation

of an infant who showed no evidence of life after birth. Has veteran or spouse had still birth(s)? Enter one

of the following codes in Block 249:

March 21, 1996 M-10, Part III

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2C-9

Y = Yes

N = No

If no, go to Item 22F.

(a) Item 22E1. Block 250. Has veteran or spouse had still birth(s) before Persian Gulf service? Enter

one of the following codes in Block 250.

Y = Yes

N = No

If no, go to Item 22E2.

(b) Item 22E1(a). Blocks 251-252. State maternal age at conception. Enter age in Blocks 251-252.

service? Enter one of the following codes in Block 253:

Y = Yes

N = No

If no, go to Item 22F.

(d) Item 22E2(a). Blocks 254-255. State maternal age at conception. Enter age in Blocks 253-254.

(6) Item 22F. Blocks 256-262. Infant Death(s). NOTE: Death that occurred within 1 year of birth

among babies born alive. Has veteran or spouse had babies with infant death(s)? Enter one of the

following codes in Block 256:

Y = Yes

N = No

If no, go to Item 22G.

(a) Item 22F1. Block 257. Has veteran or spouse had babies with infant death(s) before Gulf service?

Enter one of the following codes in Block 257:

Y = Yes

N = No

If no, go to Item 22F2.

(b) Item 22F1(a). Blocks 258-259. State maternal age at conception. Enter age in Blocks 258-259.

Gulf service? Enter one of the following code in Block 260: If no, go to Item 22G.

Y = Yes

N = No

(d) Item 22F2(a) Blocks 261-262. State maternal age at conception. Enter age in Blocks 261-262.

(7) Item 22G. If a woman veteran reports she was pregnant in the Persian Gulf, record the date of

child's birth and hospital of birth on code sheet and in the veteran’s CHR to facilitate follow-up, if needed.

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2C-10

3. Instructions for Completing PGR Code Sheet, Part II (Initial Examination). To be completed by

the examining physician)

a. Item 23. Blocks 263-270. Date of Examination. Enter the numerical equivalent for the month,

day, and year in that order (e.g., Æ9/22/1992).

b. Item 24. Blocks 271-272. Total Number of Veteran’s Complaints.

c. Item 25, 25A-M. Blocks 273-417. Veteran’s Complaints, Month and Year of Onset, Duration

in Months, Whether Symptom is Currently Present, and Most Severe Complaint.

(1) Item 25A-J. Blocks 273-417. Columns: (1) Veteran’s Complaints/Symptoms; (2) ICD-9-CM

codes; (3) Month and Year of Onset; (4) Duration in months; and (5) State whether symptom is still

present. List up to ten major and current symptoms/complaints. If veteran has more than 10, enter most

severe. Any additional symptoms should be listed in CHR. NOTE: MAS coders, use ICD-9-CM

“Symptom” codes in first five numbered blocks of each line. For uncodable symptoms use “78999.” For

no known complaints, use “78000.” (All zeros are to be slashed.) However, ICD-9 code 78999 should

ONLY be used if all possible codes have been reviewed, and if necessary, seek physician consultation to

make a correct choice.

(2) Item 25A-J(1). Give a narrative description of ten major, current symptoms as stated by veteran.

(3) Item 25A-J(2). Blocks 273-322. MAS coders are to complete the ICD-9-CM codes as they relate

to each symptom.

(4) Item 25A-J(3). Blocks 323-382. For each symptom listed in 25A-J, state month and year of onset.

(5) Item 25A-J(4). Blocks 383-402. For each symptom listed in 25A-J, state duration in months that

veteran has been experiencing this symptom.

(6) Item 25A-J(5). Blocks 403-412. For each symptom listed in 25A-J, indicate if symptom is currently

present, using one of the following codes:

Y = Yes

N = No

(7) Item 25K. Block 413-417. Most Severe Symptom/Complaint. List ICD-9-CM code for most severe

symptom (A symptom from Item A-J, which VETERAN considers the most severe; i.e., Chief Complaint).

d. Item 26, A-S. Blocks 418-435. Diagnostic workup/consultation. Enter one of the following

codes in Blocks 418-435. All blocks must be completed.

1 = No workup. No consultation done.

2 = Workup/consultation done. Unexplained illness.

3 = Workup/consultation done. Diagnosis established.

4 = Workup/consultation done. No diagnosis.

(1) Item 26A. Block 418. Allergy/Immunology.

(2) Item 26B. Block 419. Audiology.

(3) Item 26C. Block 420. Cardiology.

(4) Item 26D. Block 421. Dentistry.

(5) Item 26E. Block 422. Dermatology.

March 21, 1996 M-10, Part III

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APPENDIX 2C

2C-11

(6) Item 26F. Block 423. Ear, Nose and Throat.

(7) Item 26G. Block 424. Endocrinology.

(8) Item 26H. Block 425. Gastroenterology.

(9) Item 26I. Block 426. Hematology/Oncology.

(10) Item 26J. Block 427. Infectious Diseases/Parasitology.

(11) Item 26K. Block 428. Nephrology.

(12) Item 26L. Block 429. Neurology.

(13) Item 26M. Block 430. Occupational Medicine.

(14) Item 26N. Block 431. Pulmonary.

(15) Item 26O. Block 432. Psychiatry.

(16) Item 26P. Block 433. Psychology/Psychometric Testing.

(17) Item 26Q. Block 434. Rheumatology.

(18) Item 26R. Block 435. Other. Were any additional workups/consultations performed as part of

Persian Gulf examination which were not listed in Items 26A-Q. Enter one of the following codes:

Y = Yes

N = No

(19) Item 26S. Specify on code sheet and CHR any additional workups/consultations performed as

part of Persian Gulf examination, which were not listed in Item 26A-Q.

e. Item 27, 27A-B. Blocks 436-485. Diagnoses.

(1) Item 27A. List up to ten major definite medical diagnoses on lines 27A-J. The examining physician

will select the 10 most significant/serious in the examining physician’s opinion, listing the primary

diagnosis in Item A. The additional diagnosis(es) should be included in patient’s CHR. Blocks 436-485

are to be used for ICD-9-CM coding of each diagnosis listed. Leave blank if no diagnosis is made.

NOTE: Diagnostic coding assignment will be completed by MAS. DO NOT REPEAT OR LIST

SYMPTOM CODE ALREADY LISTED UNDER ITEM 25A-J.

f. Item 28. Block 486. No Diagnosis Made. If no diagnosis is made, enter a “1” in Block 486;

otherwise, leave this block blank. This item must be considered in conjunction with Item 27, “Diagnoses.”

A “1” should be entered for Item 28 only when no diagnosis is given in Item 27 indicating that no significant

defect, disease, injury or history of a relevant diagnosis in the past is detected.

g. Item 29, 29A-F. Blocks 487-494. Disposition. Enter one of the following codes in Block 487-494.

Y = Yes

N = No

(1) Item 29A. Block 487. Examination completed?

(2) Item 29B. Block 488. Hospitalized at the VAMC for further tests?

M-10, Part III March 21, 1996

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APPENDIX 2C

2C-12

(3) Item 29C. Block 489. Hospitalized at the VAMC for treatment?

(4) Item 29D. Block 490. Referred for outpatient care?

(5) Item 29E. Block 491. Referred to private physician, non-VA clinic or non-VA hospital?

(6) Item 29F. Block 492. Biopsy?

h. Item 30. Block 493. Phase I examination, refer to paragraph 5, has been completed and the

physician has determined that veteran has unexplained illness. Enter one of the following codes:

Y = Yes

N = No

i. Item 31. Block 494. Has Phase II examination (refer to Ch. 3) been initiated? Enter the

following codes:

Y = Yes

N = No

j. Item 32. Remarks. Utilize this section for any additional information (e.g., see par. 1.07).

k. Item 33. Name of Examiner. Print full name.

l. Item 34. Title of Examiner. Full title of Examiner.

m. Item 35. Signature of Examiner. Signature of examiner.

n. Item 35a. Signature of Physician. Signature of VRP.

4. Follow-up Examinations. Instructions for completing Parts I and II. In addition to initial registry

submissions, VA Form 10-9009A, Parts I, II and III (if applicable) will be completed in reporting the first

follow-up examination, and subsequent follow-up examinations if diagnostic code is different from

previous examinations as follows:

a. Items 1-12 must be completed - Control Data.

b. Items 13-22 require no entry, unless you have follow-up data to report in any of these items.

c. Items 23 must be completed.

d. Items 25-26 may be blank unless you have follow-up data to report in any of these items.

e. Item 27-35 must be completed.

March 21, 1996 M-10, Part III

Change 2

Chapter 2

APPENDIX 2C

2C-13

SAMPLE OF COMPLETED VA FORM 10-9009A (JULY 1995), PART I, II & III

M-10, Part III March 21, 1996

Change 2

Chapter 2

APPENDIX 2C

2C-14

March 21, 1996 M-10, Part III

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APPENDIX 2C

2C-15

M-10, Part III March 21, 1996

Change 2

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APPENDIX 2C

2C-16

March 21, 1996 M-10, Part III

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APPENDIX 2C

2C-17

M-10, Part III March 21, 1996

Change 2

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APPENDIX 2C

2C-18

March 21, 1996 M-10, Part III

Change 2

Chapter 2

APPENDIX 2C

2C-19

September 14, 1995 M-10, Part III

Chapter 2

Change 1

APPENDIX 2D

2D-1

REPORTING REQUIREMENTS

1. Submission. NOTE: The use of Persian Gulf Code Sheet, VA Form 10-9009A, December 1991, will be

discontinued on September 24, 1995. Existing stock must be destroyed. All completed Persian Gulf Code

Sheets dated December 1991, and submitted to Austin Automation Center (AAC) on and after September 24,

1995, will be rejected and returned to the submitting VA facility. The use of revised VA Form 10-9009A, dated

July 1995, must be implemented on September 25, 1995. Requirements or the submission of Department of

Veterans Affairs (VA) Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet are as follows:

a. Legible copies of completed code sheets are submitted to the Office of Financial Management Austin

Automation Center (AAC), Austin, TX, for data entry into the Persian Gulf Registry (PGR).

b. Originals are to be maintained in veteran’s Consolidated Health Record (CHR).

c. Code sheets need to be scanned to ensure all required fields are completed.

d. No medical record documentation should be attached to these code sheets.

e. Code sheets will not be returned to facility of origin unless corrections are required.

f. AAC will send copies of code sheets, once entered into the PGR, to the Senior Registry Coordinator,

Environmental Agents Service (103A), Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington,

DC 20420, for disposition.

2. Batching of Code Sheets

a. Preparation

(1) VA Form 10-9009A (July 1995) code sheets, Parts I through III, are provided in booklet form. If any of the

pages are removed, they should be stapled in the upper-left hand corner.

(2) Completed code sheets must be batched in groups of no more than 25.

(3) Facilities and/or a division of a consolidated facility must keep submissions separate, i.e., each batch will

include code sheets from one facility. These code sheets should be arranged in numerical order according to the

Social Security Number (SSN), i.e., lowest SSN first and highest SSN last).

NOTE: Corrected code sheets do not have to be batched separately. They can be mailed with the regular code

sheets as long as they are from the same facility.

b. If a veteran has had two examinations within the same mailing period, that is, an initial and a follow-up

examination, only the initial examination code sheet should be submitted in the batch. Hold the follow-up

examination code sheet until you are certain the AAC has processed and accepted the initial examination code

sheet. If submitted simultaneously, an error message may occur.

3. Transmittal Form (See App. 2E.)

a. Three copies of VA Form 7252 (formerly VA Form 30-7252), Transmittal Form for the Use in Shipment of

Tabulating Data, must accompany each batch of code sheets. One copy must be retained at the AAC and the

other copy will be returned by the AAC to the transmitting facility acknowledging receipt of code sheets and the

third will include any rejected code sheets and the edit analysis printout, entitled “Transaction Change and Error

(Reject) Listing.”

M-10, Part III September 14, 1995

Chapter 2

APPENDIX 2D

2D-2

b. If there were no examinations or code sheets processed for each month, a transmittal form must be

completed indicating “0” for the “Code Sheet Count” and sent to the AAC. This will assist the AAC in maintaining a

control on the code sheets transmitted by each facility.

(1) As batches are prepared for submission to the AAC an entry should be made on the batch control log.

(2) Using the control log, assign the appropriate number and record it on the transmittal form.

(a) Begin with batch number 001 for January of each year and continue with sequential numbers throughout

the year.

(b) Example: If there are 50 code sheets to be submitted to the AAC during the month of January, prepare

two batches of 25 per batch, with the control log number 001 and 002.

c. The Persian Gulf control log must consist of the following:

(1) Facility code number,

(2) Batch number assigned sequentially by facility beginning with 001 in January of each year (also to be

recorded on transmittal sheet);

(3) Number of code sheets in the batch (also to be recorded on the transmittal sheet),

(4) Date the batch(es) was(were) mailed to the AAC, and

(5) Date the batch(es) and associated edit output was(were) returned from the AAC.

4. Mailing

a. Code sheets must be submitted to the AAC monthly according to the following schedule:

(1) Region 1, the 6th of the month.

(2) Region 2, the 10th of the month.

(3) Region 3, the 14th of the month.

(4) Region 4, the 18th of the month.

b. The mailing address for the AAC is:

Department of Veterans Affairs

Automation Center (200/397A)

ATTN: PERSIAN GULF CLERK

1615 Woodward Street

Austin, TX 78772-0001

c. It is not appropriate to call the AAC in regard to questions on code sheet completion or correction. These

questions should be referred to the Veterans Registry Coordinator(s), the Environmental Agents Service, VA

Central Office.

September 14, 1995 M-10, Part III

Chapter 2

Change 1

APPENDIX 2D

2D-3

d. The AAC will process the data from the code sheets twice each month (10th and 25th). The AAC will return

all batches with the printout “Transaction Change and Error (Reject) Listing” to the transmitting facility.

5. Transaction Change and Error (Reject) Listing

a. A computerized printout “Transaction Change and Error (Reject) Listing” will be returned to the transmitting

facility with the processed code sheets.

(1) This printout will reflect:

(a) Rejected records, i.e., edit errors identified by an asterisk(*);

(b) Other messages not necessarily rejecting records; and

(2) Facilities must verify the number of code sheets sent to the AAC against the printout.

b. Corrections are to be made on the returned code sheet with RED pen or RED felt-tipped pen or a new code

sheet can be made with the correction in the appropriate field(s). If a new code sheet is prepared for the return of

a correction, do not complete just the corrected fields. NOTE: All of the fields must be completed as if it were an

initial input.

c. Examples of the messages on the listing and the corrective action to be taken are listed as follows:

(1) Message. “This record rejected for edit errors.”

Action: Correct error(s) (*) and resubmit code sheet.

(2) Message. “Transaction accepted, initial examination already established at (facility number); transaction

will be processed as a follow-up examination for your facility.”

Action: AAC will not return a code sheet to the facility since it has been accepted as a follow-up examination.

Original code sheet on file at facility should be corrected and card file or computerized record should reflect the

facility number where initial examination was performed.

(3) Message. “Transaction accepted but an initial examination is needed. Action Required.”

Action: The registry does not contain an initial examination record for this veteran, but the registry has

accepted the follow-up examination record that was submitted. Reconstruct, if possible, the initial examination

record and submit to the AAC. A code sheet will not be returned to the facility on this transaction since it has been

accepted in the PGR as a follow-up examination.

(4) Message. “Duplicate Follow-up Segment.”

Action: This message will appear if the examination date on the code sheet submitted on the veteran is identical

to an examination date already existing in the registry. There is the possibility of a coding or entry error.

Examination date should be verified using the veteran’s medical record. If there is a duplicate record, it should be

deleted by submitting a code sheet in accordance with instructions for deleting a record.

(5) Message. “No matching initial examination.”

M-10, Part III September 14, 1995

Chapter 2

APPENDIX 2D

2D-4

Action: When deletion of an initial record in the registry is attempted, the code sheet submitted with a type “B”

must have the identical information as on the original record previously accepted into the registry, otherwise

deletion process cannot be carried out.

6. Miscellaneous

a. Forms Acquisition. Forms can be obtained from the VA Forms and Publication Depot through local

channels. VA Form 30-7252 has been changed to VA Form 7252. The form itself has not been revised.

(1) Facilities can use either form when submitting reports. An initial supply of VA Form 10-9009A (July 1995),

has been provided to each facility.

(2) Additional forms can be obtained from the Depot.

b. Reports Control Symbol. Reports Control Symbol (RCS) 10-0860 applies to this reporting requirement.

(1) The original code sheet will be filed in the veteran’s CHR with the documentation, i.e., laboratory test

results, etc., from the PGR examination and one legible copy sent to the AAC to be entered in the PGR.

(2) If a CHR does not already exist for a veteran, one will be established. A locator card will be created with

the establishment of the CHR. NOTE: It is highly recommended that all registry records are maintained in a

separate section of CHR where they are easily identifiable for quality monitoring and research availability.

c. Record Disposition. Refer to Records Control Schedule 10-1, Section XXII, Item No. 136-5 for record

disposition (see Medical Administration Service).

d. Records Retention. Refer to Records Control Schedule 10-1 for records retention. Persian Gulf

examination information will be made part of the perpetual medical record at medical facilities following the same

retention requirements specified for VA CHR’s Agent Orange and Ionizing Radiation examinations. This includes:

(1) VA Form 10-9009A (July 1995),

(2) Progress notes,

(3) Laboratory reports,

(4) Patient locator cards, and

(5) Any other documentation that may have been part of a PGR examination.

September 14, 1995 M-10, Part III

Chapter 2

Change 1

APPENDIX 2D

2D-5

August 8, 1995 M-10, Part III

Chapter 2

APPENDIX 2E

2E-1

INSTRUCTIONS AND SAMPLE OF COMPLETED VA FORM 7252,

TRANSMITTAL FORM FOR USE IN SHIPMENT OF TABULATING DATA

1. Item 1. Addressee. Department of Veterans Affairs Automation Center (200/397), 1615 Woodward Street,

Austin, TX 78722-0001, ATTN: Persian Gulf Clerk.

2. Item 2. Facility name and address. - Enter facility name and address.

3. Item 3. Reply reference. - Enter facility number and routing symbol.

4. Item 4. Leave blank.

5. Item 5. Number of packages. - Enter number of batches.

6. Item 6. Dispatch Date. - Enter date submitting to the Office of Financial Management Austin Automation

Center (AAC).

7. Item 6a. Final Batch. - Leave blank.

8. Item 7. Official Responsible for Shipment. - Enter name, title and FTS telephone number of individual

responsible for transmitting code sheets to the AAC.

9. Item 8. Tabulating Data.

a. Column A. Enter Records Control Symbol number 10-0860.

b. Column B. Job Number. Enter “1Æ” in first segment and “2ÆA1” in second segment.

c. Column C. Description.

(1) First line enter “PERSIAN GULF;”

(2) Second line enter “Facility Number;"

(3) Third line enter “Batch Number;”

(4) Fourth line enter “Code Sheet Count;” and

(5) Fifth line enter “Cumulative Count.” NOTE: This figure should be the total number of veterans who

have had registry examinations since the onset of the Persian Gulf Registry Program in 1992.

(d) Columns D and E. Leave blank.

10. Item 9. Remarks. Enter number of VA Form 10-9009A’s uly 1995).

M-10, Part III August 8, 1995

Chapter 2

APPENDIX 2D

2E-2

SAMPLE OF COMPLETED VA FORM 7252

August 8, 1995 M-10, Part III

Chapter 2

APPENDIX 2E

2E-3

March 21, 1996 M-10, Part III

Change 2

Chapter 2

APPENDIX 2F

2F-1

INSTRUCTIONS AND SAMPLE FORMAT FOR COMPLETION OF BI-MONTHLY REPORT ON PERSIAN GULF

WAR VETERANS REGISTRY

EXAMINATIONS (RCS 10-0860)

A bi-monthly report is required from all Department of Veterans Affairs (VA) facilities providing up-to-date

statistical information on Persian Gulf Registry (PGR) examinations. Instructions are provided below for the

completion and submission of this report.

1. Date of Report. Each report should include the date the report was prepared and submitted to the following

address:

2. Mailing Address. This report should be transmitted to the following address:

Department of Veterans Affairs

Environmental Agents Service (131)

ATTN: Persian Gulf Coordinator

810 Vermont Avenue, N.W.

Washington, DC 20420

3. Mailing Date. This report should be sent to the above address NO LATER THAN 5 WORKING DAYS

FOLLOWING THE END OF EACH BI-MONTHLY REPORTING PERIOD.

4. The following statistical information is required (see sample 2F-3 and 2F-4).

a. Initial Examination. (The first physical examination of the Persian Gulf veteran.) List the total number of

completed initial examinations performed during the current 2-month reporting period. NOTE: A completed code

sheet has already been sent to Austin Automation Center (AAC) which was completed for the purpose of entering

a Persian Gulf veteran into the PGR. This count should be verified with the computerized or card file records

maintained at each facility (see par. 2.04) describing the computerized or card file requirement.

b. Cumulative Initial Examinations. The total number of cumulative initial examinations listed in the previous

bi-monthly report.

c. Cumulative Initial Examination. The total number of “first-time” examinations performed by the medical

facility since the beginning of the PGR in 1992. This number should include the current month’s initial

examinations (par. 4a) plus the sum of the previous month’s cumulative initial examinations (par. 4b). NOTE:

Examinations performed by satellite outpatient clinics should be included in the total cumulative figure for VA

medical center of jurisdiction. Justification for exceptions to this requirement should be directed to EAS (131), VHA

Headquarters. Independent outpatient clinics should report in a manner similar to VA medical centers.

d. Initial Incomplete Examinations (In process). The total number of incomplete (code sheet(s) that

has/have not been sent to AAC) initial examinations in process during the period of the current report.

e. Follow-up Examinations. (A first-time examination subsequent to the initial examination-a completed

initial examination code sheet has been sent to AAC.) The total number of follow-up examinations during the

period of the current report.

f. Cumulative Follow-up Examinations. The total number of follow-up examinations performed by the

medical facility since the beginning of the registry in 1992. This total should be the sum of the previous months’

cumulative follow-up examination total and the current bi-monthly follow-up examinations.

M-10, Part III March 21, 1996

Change 2

Chapter 2

APPENDIX 2F

2F-2

g. Follow-up Examinations in Process. The total number of follow-up examinations being processed

(completed code sheet(s) has/have not been sent to AAC).

h. Pending Examination Appointments. The total number of initial Persian Gulf examinations for which

appointments have been scheduled beyond the end of the bi-monthly report period. NOTE: This is not cumulative

and applies to the current bi-monthly report.

I. Next Appointment Date. Indicate the next available appointment date.

j. Number of Veterans Failing to Keep an Initial Examination Appointment. The total number of veterans

who failed to keep a scheduled appointment during the bi-monthly reporting report. NOTE: This is not cumulative

and applies to reporting period only.

k. Comments or Problems Regarding Pending Examination Appointments. Problems or challenges

should be documented with comments regarding examination workload. An explanation and action plan to

alleviate delays should be provided in situations where a facility has 50 or more examinations pending, and/or the

next available appointment is more than 30 days beyond the date of request. If statistics have been adjusted due

to AAC acceptance of code sheets, the message “Cumulative statistics adjusted per transaction acceptance at

AAC” need to be included in this paragraph.

l. Name and Telephone Number: The name and telephone number of the person preparing the report must

be indicated.

March 21, 1996 M-10, Part III

Change 2

Chapter 2

APPENDIX 2F

2F-3

SAMPLE FORMAT FOR BI-MONTHLY REPORT ON PERSIAN GULF VETERANS

(RCS-10-0860)

DEPARTMENT OF VETERANS AFFAIRS

Medical Center

Anywhere, USA 85012

In Reply Refer To:

August 7, 1995

Department of Veterans Affairs

Environmental Agents Service (131)

ATTN: Persian Gulf Coordinator

810 Vermont Avenue, N.W.

Washington, DC 20420

SUBJECT: Bi-monthly Report of Persian Gulf War Veteran Registry Examinations,

(RCS-10-0860) - Period Ending July 31, 1995 (Station #600)

The subject report is submitted for the 2-month period ending July 31, 1995:

a. Initial Examination (Current Bi-Monthly Reporting Period):

List total number of completed initial examinations performed for 2-month

period ending July 31, 1995 (i.e. total number of Persian Gulf Registry

code sheets submitted to Austin Automation Center (AAC):

100

b. Cumulative Initial Examinations from Previous Bi-Monthly Report: +450

c. Cumulative Number of Completed Initial Examinations Performed

Since Onset of Program (August, 1992):

Total of numbers listed in Paragraphs 1-a and 1-b. 550

Note: This should be the total number of all initial examination code sheets

submitted to AAC since onset of program. If code sheets have not been sent

to AAC, do not include in this total.

d. Initial Incomplete Examinations (In process):

Total number of initial (incomplete) examinations in process:

(code sheets have not been sent to AAC): 75

e. Follow-Up Examinations (Code Sheets Sent To AAC):

Total number of follow-up examinations performed for current reporting period

(follow-up examinations are those performed subsequent to the initial

examination where a completed code sheet for an initial examination has

been sent to AAC): 15

f. Cumulative Follow-up Examinations:

Includes the total of follow-up examinations performed (this total

includes the number listed in above (par. 1-e) and all follow-up

examinations previously reported since August, 1992): 75

g. Follow-up Examinations in Process:

M-10, Part III March 21, 1996

Change 2

Chapter 2

APPENDIX 2F

2F-4

Total number of follow-up examinations in process (code sheets

have not been sent to AAC during this reporting period): 12

h. Pending Examination Appointments:

Total number of initial examinations for which appointments have been

scheduled beyond the end of the bi-monthly report period: 20

i. The next Available Appointment Date: 8/10/95

j. Number of Veterans Failing to Keep an Initial Examination Appointment:

Total number of veterans who failed to keep a scheduled appointment

during the current bi-monthly reporting period. This is not

cumulative. 10

. k. Comments/problems regarding pending examinations: None

l. The name, address and telephone number of the person preparing this report:

(Signature)____________________

John Doe

Medical Center Director

August 8, 1995 M-10, Part III

Chapter 2

APPENDIX 2G

2G-1

EXAMPLES OF PERSIAN GULF REGISTRY FOLLOW-UP LETTERS

SAMPLE PERSIAN GULF REGISTRY FOLLOW-UP LETTER

(MEDICAL PROBLEMS INDICATED)

DEPARTMENT OF VETERANS AFFAIRS

Medical Center

Anywhere, U.S.A. Zip

In Response Reply To:

(Date)

(Name/Address)

Dear __________________:

We sincerely appreciate your recent participation in the Department of Veterans Affairs (VA) Persian Gulf Registry. This effort should prove

to be helpful in assisting us to serve you and other veterans who are concerned about the possible health problems which may have

resulted from service in Southwest Asia during the Persian Gulf War.

As discussed at the conclusion of your visit, results of your examination and laboratory tests showed certain problems (optional--these

findings may be described in lay terms). In view of these findings, we have scheduled you for treatment of these health problems on (date).

If for any reason you cannot keep this appointment, please call (telephone number) at the earliest possible time to cancel and reschedule.

The results of your examination will be maintained by VA and will be available for future use as needed. If you have any questions or

concerns about your Persian Gulf Registry examination, please contact the Veterans’ Registry Coordinator at (telephone number) for

assistance.

Whether you are entitled to cost-free treatment or will be responsible for partial co-payment will be determined by your income and other

factors unless the VA determines that your health problems are service connected. You may wish to file a claim for compensation to

establish possible service connection. The injury or illness need not have been incurred in combat; the law requires only that a disease or

disability was incurred or aggravated during military service.

Please remember that this examination does not automatically initiate a claim for VA benefits. If you wish to file a claim, please contact

your nearest VA Regional Office. In your area, the Regional Office is located at (address). Their telephone number is (telephone number).

If you need any further assistance, you may contact a Veterans’ Benefits Counselor by calling the VA toll-free telephone number 1-800-827-

1000.

An outreach program has been implemented by which VA notifies all individuals listed in the Registry of significant VA activities, including

the health consequences of military service in the Persian Gulf theater of operations during the Persian Gulf War. You will be receiving a

“Persian Gulf Review” which is published periodically by VA’s Environmental Agents Service. A copy of this “Review” is enclosed for your

reference.

We trust this information is helpful to you. Once again, your participation in the registry is appreciated.

Sincerely,

(Signature)

Name of Veterans’ Registry Physician

Enclosure

M-10, Part III August 8, 1995

Chapter 2

APPENDIX 2G

2G-2

SAMPLE PERSIAN GULF REGISTRY FOLLOW-UP LETTER

(NO MEDICAL PROBLEMS INDICATED)

DEPARTMENT OF VETERANS AFFAIRS

Medical Center

Anywhere, U.S.A. Zip

In Response Reply To:

(Date)

Name/Address

Dear ___________________:

We sincerely appreciate your recent participation in the Department of Veterans Affairs (VA) Persian Gulf

Registry. This effort should prove to be helpful in assisting us to serve you and other veterans who are

concerned about the possible health problems which may have resulted from service in Southwest Asia during

the Persian Gulf War.

As discussed at the conclusion of your visit, results of your examination and laboratory tests indicate that there

are no detectable medical problems. At this time you have no reason to be concerned about any adverse health

effects resulting from your service in the Persian Gulf. However, in the future if you have a medical problem, I

would encourage you to seek the help and advice of your nearest VA medical center or outpatient clinic. You

may reach us at (telephone number).

The results of your examination will be maintained by VA and will be available for future use as needed.

Please remember that this examination does not automatically initiate a claim for VA benefits. If you wish to file

a claim, please contact your nearest VA Regional Office. In your area, the Regional Office is located at

(address). Their telephone number is (telephone number). If you need any further assistance, you may contact

a Veterans’ Benefits Counselor by calling the VA toll-free telephone number 1-800-827-1000.

An outreach program has been implemented by which VA notifies all individuals listed in the Registry of

significant VA activities, including the health consequences of military service in the Persian Gulf theater of

operations during the Persian Gulf War. You will be receiving a “Persian Gulf Review” which is published

periodically by VA’s Environmental Agents Service. A copy of this “Review” is enclosed for your reference.

We trust this information is helpful to you. Once again, your participation in the registry is appreciated.

Sincerely,

__________(Signature)_____________________

Name of Veterans’ Registry Physician

Enclosure

August 8, 1995 M-10, Part III

Chapter 3

3-i

CONTENTS

CHAPTER 3. PHASE II, PERSIAN GULF UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)

PARAGRAPH PAGE

3.01 Purpose .............. 3-1

3.02 Background ........ 3-1

3.03 Authority .............. 3-1

3.04 Policy ................... 3-1

3.05 Responsibilities ... 3-2

APPENDICES

3A Uniform Case Assessment Protocol (UCAP) ........................................................................................ 3A-1

3B Instructions and Sample Format for Completion of VA Form 10-9009A (July 1995),

Persian Gulf Registry Code Sheet, Part III, Uniform Case Assessment, Phase II ................................. 3B-1

3C Instructions and Sample Format for Completion of Bi-monthly Report on

Persian Gulf Uniform Case Assessment, Phase II (RCS 10-0860) ........................................................ 3C-1

August 8, 1995 M-10, Part III

Chapter 3

3-1

CHAPTER 3. PHASE II, PERSIAN GULF UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)

3.01 PURPOSE

This chapter provides a Uniform Case Assessment Protocol (UCAP) for the evaluation of Persian Gulf veterans

with unexplained illnesses.

3.02 BACKGROUND

a. Many of the almost 690,000 personnel who served in the Persian Gulf have reported health problems since

their return to the United States. While most of the health problems of these veterans have been diagnosed as

conditions that are readily definable, some veterans have unexplained illnesses which developed after their

Persian Gulf service. Many of the Gulf War veterans seen by Department of Veterans Affairs (VA) Veteran's

Registry Physicians (VRPs) have complex, multifaceted health problems that provide difficult diagnostic

challenges. Veterans are understandably frustrated that definitive answers regarding the cause(s) of their

problems are not immediately forthcoming.

b. VA and the Department of Defense (DOD) working cooperatively developed a UCAP for the evaluation of

these Persian Gulf veterans who after a thorough routine medical evaluation are determined to have unexplained

illnesses. NOTE: This UCAP, grew out of the medical experience in diagnostic evaluation of Gulf War veterans

seen at VA Referral Centers. The protocol was then further refined and adapted for use by both VA and DOD

facilities.

c. The UCAP includes a group of supplemental baseline laboratory tests and consultations which should be

provided to every veteran with debilitating unexplained illness. It gives guidelines for the minimum diagnostic

work-up of the most frequent complaints experienced by Gulf War veterans with unexplained illnesses. This

protocol utilizes validated and readily available diagnostic tests to thoroughly evaluate each of the common

symptoms reported by Gulf War veterans.

d. The concept behind the protocol was to identify previously unrecognized major diagnostic entities which

could provide an explanation for the symptoms commonly reported in Persian Gulf veterans with unexplained

illnesses. It should be emphasized that the protocol is not designed to be all-encompassing; therefore, it needs to

be carried out with a high degree of clinical judgment. All significant symptoms and abnormalities not specifically

outlined in the protocol, must be fully evaluated according to the medical judgment of the VRP who is directing the

work-up. The information gathered by this process is to be entered into a computerized database through the use

of VA Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet, Part III (see App. 3B), and will be analyzed

for patterns of disease.

3.03 AUTHORITY

The UCAP for Persian Gulf veterans with unexplained illnesses was administratively established by the Under

Secretary for Health to assist in addressing the unique health concerns of the Persian Gulf veterans. On

November 2, 1994, Public Law (Pub. L.) 103-446 amended Title 38 United States Code (U.S.C.) 1117

implementing the uniform and comprehensive medical evaluation protocol for the veterans of the Persian Gulf

War.

3.04 POLICY

It is VA policy that all VA health care facilities must examine the available services for Persian Gulf veterans to

ensure that quality outreach, diagnostic, and treatment services are furnished as intended; and if these services

cannot be provided by the local VA facility, a mechanism must be developed to provide these services by contract,

sharing agreements or referral to other VA facilities.

M-10, Part III August 8, 1995

Chapter 3

3-2

3.05 RESPONSIBILITIES

a. VRPs. The responsibility of the VRP is to:

(1) Conduct the Registry examination (Phase I), which is the first step toward diagnosis of the health problems

of a Persian Gulf veteran; and

(2) If a diagnosis is not readily apparent after conducting routine medical evaluations, to initiate the UCAP,

(Phase II) using the protocol provided in Appendix 3A.

b. Veterans' Registry Coordinators (VRCs) The VRC is responsible for:

(1) Reporting instructions as included in Appendix 2D and Appendix 3B.

(2) Providing accurate coding of both symptoms and diagnoses and ,when questions arise about these items,

consult with VRP, or designee.

(3) Completing and submitting the UCAP and VA Form 10-9009A (July 1995) through appropriate channels to

VA Central Office of Environmental Agents Service (EAS). NOTE: Related questions may be referred to EAS,

telephone (202) 565-4183.

August 8, 1995 M-10, Part III

Chapter 3

APPENDIX 3A

3A-1

UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)

1. Phase I Level Laboratory Evaluations

a. Complete Blood Count (CBC),

b. Urinalysis, and

c. Blood Chemistry - SMA-6.

2. Phase II-Level Evaluation Protocol. Phase II Level Evaluations are recommended for those

veterans after complete clinically indicated evaluations are conducted and the physician determines that

the patient has an unexplained illness. Individuals who after completing Phase I or Registry evaluations,

have a disability and do not have a clearly defined diagnosis which explains their symptoms, must receive

the following supplemental baseline laboratory tests and consultations.

a. Supplemental Baseline Laboratory Tests

(1) CBC,

(2) Sedimentation Rate Erythrocyte Sedimentation Rate (ESR),

(3) C-Reactive Protein,

(4) Rheumatoid Factor,

(5) Anti-Nuclear Antibody (ANA),

(6) Liver Function,

(7) Creatine Phosphokinase (CPK),

(8) Hepatitis Serology,

(9) Human Immuno-deficiency (HIV),

(10) Venereal Disease Research Laboratory (VDRL),

(11) B-12 and Folate,

(12) Thyroid function Test,

(13) Urinalysis, and

(14) Tuberculosis (TB) skin test Purified Protein Derivative (PPD).

b. Consultations, to include:

(1) Dental, but only if participant’s annual screening is not done.

(2) Infectious Disease.

(3) Psychiatry, but only with physician-administered instruments.

M-10, Part III August 8, 1995

Chapter 3

APPENDIX 3A

3A-2

(a) Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Third

Edition, Revised (DSM III-R). NOTE: Delete nodules for mania and psychosis.

(b) Clinician Administered Post Traumatic Stress Disorder (PTSD) Scale (CAPS).

(4) Neuropsychological Testing, but only as indicated by a psychiatry consult.

c. Symptom-specific Examination. Individuals who have the following symptoms should have the

listed minimum work-up.

(1) Diarrhea, to include:

(a) Gastrointestinal (GI) consult,

(b) Stool for Ova and Parasites (O&P),

(d) Stool Culture,

(e) Stool Volume,

(f) Colonoscopy with biopsies, and

(g) Esophagastroduodenoscopy (EGD) with biopsies and aspiration.

(2) Abdominal pain to include:

(a) GI consult,

(b) EGD with biopsy and aspiration,

(d) Abdominal Ultrasound,

(e) Upper Gastrointestinal (UGI) series with small bowel follow-through, and

(f) Abdominal Computed Tomography (CT) Scan.

(3) Headache

(a) Magnetic Resonance Imaging (MRI) of the head, and

(b) Lumbar Puncture (LP) to include:

1. Glucose,

2. Protein,

3. Cell Count,

4. VDRL,

5. Oligoclonal (lgG),

September 14, 1995 M-10, Part III

Chapter 3

Change 1

APPENDIX 3A

3A-3

6. Myelin basic protein,

7. Opening pressure, and

8. Neurology.

(4) Muscle Aches and/or Numbness

(a) Electromyogram (EMG), and

(b) Nerve Conduction Velocity (NCV).

(5) Memory Loss, only if verified by neuropsychological testing, to include:

(a) Magnetic Resonance Imaging (MRI),

(b) LP, NOTE: See tests on headache evaluation.

(d) Neuro-psychological testing,

(6) Vertigo and/or Tinnitus, to include:

(a) Audiogram,

(b) Electronystamogram (ENG), and

(7) Chronic Fatigue, to include:

(a) Polysomnography, and

(b) Multiple Sleep Latency Test (MSLT).

(8) Chronic Cough and/or Shortness of Breath, to include:

(a) Pulmonary Consult,

(b) Pulmonary Function Test (PFT) with exercise and Arterial Blood Gases (ABG),

(d) Bronchoscopy with biopsy and/or lavage which is to be considered if PFTs are normal.

(9) Chest Pain and/or Palpitations, to include:

(a) Electrocardiogram (ECG),

(b) Exercise Stress Test, and

M-10, Part III September 14, 1995

Chapter 3

Change 1

APPENDIX 3A

3A-4

(10) Skin Rash, to include:

(a) Dermatology consult, and

(b) Consider a biopsy.

(11) Reproductive Concerns, to include for:

(a) Males, an urology consult; and

(b) Females, a gynecology (GYN) consult.

Reproductive Health Problems (RHP):

1. Detailed genitourinary history and/or problems, e.g.:

a. Sexual,

b. Genitourinary symptoms,

c. Menstrual,

d. Contraceptive practices,

e. Pregnancy-related,

f. Conception,

g. Birth defects,

h. Congenital disorders,

i. Menopause,

j. Prior infections,

k. Prior surgery, and

l. Exposures to toxic agents, etc.

2. Detailed genital/pelvic examination.

3. Laboratory and ancillary testing, e.g.;

a. Pap tests; and

b. Tests for genitourinary infections.

4. Urologist consultation for male veterans who have RHP that cannot be diagnosed or managed successfully

by primary care practitioners.

5. Gynecology consultation for female veterans who have RHP that cannot be diagnosed or managed

successfully by primary care practitioners.

September 14, 1995 M-10, Part III

Chapter 3

Change 1

APPENDIX 3A

3A-5

(d) Additional elements for evaluation of Persian Gulf veterans with complaints of infertility.

1. Detailed menstrual and reproductive history (such as the Infertility Questionnaire utilized by Walter Reed

Army Medical Center*).

2. Semen analysis, e.g.:

a. Volume,

b. pH,

c. Liquefaction,

d. Sperm concentration,

e. Motility,

f. Progressive motility,

g. Sperm viability,

h. Leukocytes, and

I. Morphology.

3. Referral to an infertility specialist or program.

(e). Additional elements for evaluation of Persian Gulf veterans with complaints related to birth defects or

genetic disorders in offspring conceived during or after Persian Gulf service.

1. Detailed history of congenital or genetic disorders (such as the Patient Genetic Screen Questionnaire utilized

by Walter Reed Army Medical Center*).

2. Detailed occupational exposures questionnaire (such as Worker and Supervisor Questionnaires utilized by

National Naval Medical Center*).

3. Referral to a genetic disease specialist or program.

* For copies of these questionnaires (Items d-1 and e-1 and 2) contact VA Environmental Agents Service (103A)

at 202-565-4183.

March 21, 1996 M-10, Part III

Change 2

Chapter 3

APPENDIX 3B

3B-1

INSTRUCTIONS AND SAMPLE FORMAT FOR COMPLETION OF

VA FORM 10-9009A (JULY 1995), PERSIAN GULF REGISTRY CODE SHEET, PART III,

UNIFORM CASE ASSESSMENT PROTOCOL (UCAP), PHASE II

1. General Instructions for Completing Department of Veterans Affairs (VA) Form 10-9009A, Part III, Phase

II Persian Gulf Registry Examination.

a. The Phase II examination (VA Form 10-9009A, Part III) should be offered to all eligible Persian Gulf War

veterans with unexplained illnesses. The Phase II examination should be performed after the completion of the

Phase I registry examination and a thorough clinically-based evaluation of the veteran’s symptoms as deemed

necessary by the examining physician.

b. Phase II should be performed at the local VA medical facility or if the medical expertise is unavailable, local

referral must be made to the nearest regional tertiary care center or Persian Gulf Referral Center.

c. Reporting requirements described in Appendix 2D will apply to, VA Form 10-9009A, Part III.

(1) Part III of the code sheet must be completed at the time of the examination by the veteran's registry

physician (VRP). A completed Part III will be returned to Medical Administration Service (MAS) for completion of

ICD-9-CM codes where appropriate.

(2) A bi-monthly report of Phase II examinations is to be sent to Department of Veterans Affairs, Environmental

Agents Service (131), 810 Vermont Avenue, N.W., Washington, DC 20420, 5 work days following the end of each

reporting period (refer to instructions and sample report in App. 3B).

2. Instructions for Completing VA Form 10-9009A, Part III, Phase II

a. Tests and Consultations NOTE: Only those items which are related to the veteran’s symptoms and

deemed necessary by the examining physicians should be completed; leave test and consult questions that are

not applicable blank.

(1) Item 1. Blocks 1-24. Were the following tests performed? Enter one of the following codes in designated

blocks:

Y = Yes

N = No

(2) Item 2. Blocks 1-18. Blood Tests

(a) Block 1. Complete Blood Count (CBC)?

(b) Block 2. Skin Erethyma Dose (SED) Rate?

(d) Block 4. Rheumatoid Factor?

(e) Block 5. Fluorescent Anti-Nuclear Antibody (ANA)?

(f) Block 6. SGOT (AST) (Glutamic Oxaloacetic Transaminase)?

(g) Block 7. SGPT (ALT) (Transaminase Glutamic Pyruvate)?

(h) Block 8. Lactic Acid Hydrogenase (LDH)?

M-10, Part III March 21, 1996

Change 2

Chapter 3

APPENDIX 3B

3B-2

(i) Block 9. Alkaline Phosphatase

(j) Block 10. Creatine Phosphokinase (CPK)?

(k) Block 11. Hepatitis B Surface Antibody?

(l) Block 12. Hepatitis B Core Antigen?

(m) Block 13. Venereal Disease Research Laboratory (VDRL)?

(n) Block 14. Vitamin B-12?

(o) Block 15. Folate?

(p) Block 16. Human Immuno-deficiency (HIV)?

(q) Block 17. Thyroxine Total Serum (T4)?

(r) Block 18. Thyroid Stimulating Hormone (TSH)?

(3) Item 3. Block 19. Urinalysis?

(4) Item 4. Block 20. Tuberculosis (TB) Skin Test Purified Protein Derivative (PPD)?

(5) Item 5. Block 21. Chest X-ray?

(6) Item 6. Block 22. Psychiatric Consultation?

(a) Item 6A. Block 23. Structured Clinical Interview for Diagnoses (SCID) for Diagnostic and Statistical

Manual of Mental Disorders, Third Edition, Revised (DSM-III-R). Was the SCID interview given?

(b) Item 6B. Block 24. Clinical Administered Post-Traumatic Stress Disorder (PTSD) Scale (CAPS). Was the

CAPS performed?

(7) Item 7. Blocks 25-39. List of Diagnoses. Designated physician staff or physician assistants are to

provide narrative description of diagnoses. If none, leave blank. NOTE: MAS coders: Enter ICD-9-CM codes in

Blocks 25-39.

(8) Item 8. Block 40. Psychology-Neuropsychological Test. Was this test performed? Enter one of the

following codes in Block 40.

Y = Yes

N = No

(9) Item 8A. Blocks 41-55. List of Diagnoses. Designated physician staff or physician assistants are to

provide narrative description of diagnoses. If none, leave blank. NOTE: MAS coders: Enter ICD-9-CM codes in

Blocks 41-55.

(10) Item 9. Block 56. Infectious Disease-Screening Examination. Was this examination performed? Enter

one of the following codes in Block 56.

Y = Yes

N = No.

March 21, 1996 M-10, Part III

Change 2

Chapter 3

APPENDIX 3B

3B-3

(11) Item 9A. Blocks 57-66. List of Diagnoses. Designated physician staff or physician assistants are to

provide narrative description of diagnoses. If none, leave blank. NOTE: MAS coders: Enter ICD-9-CM codes in

Blocks 57-66.

(12) Item 10. Block 67. Dental Examination. If there was a medical indication, was this examination

performed? Enter one of the following codes in Block 67.

Y = Yes

N = No

(13) Item 10A. Blocks 68-77. List of Diagnoses. Designated dental staff are to provide narrative

description of diagnoses. If none, leave blank. NOTE: MAS coders: Enter ICD-9-CM codes in Blocks 68-77.

SYMPTOM-SPECIFIC EXAMINATIONS , PHASE II NOTE: Complete only those questions which are

appropriate to the veteran’s symptoms; otherwise leave these blocks blank.

(14) Item 11. Blocks 78-98. Diarrhea and/or Abdominal Pain

(a) Item 11A. Block 78. Did patient receive a GI (Gastroenterology) consult? Enter one of the following

codes in Block 78.

Y = Yes

N = No

(b) Item 11B. Blocks 79-98. List Diagnoses. Designated physician staff are to provide narrative

description of diagnoses. If none, leave blank. NOTE: MAS coders: Enter ICD-9-CM codes in Blocks 79-98.

(15) Item 12. Blocks 99-109. Headache and/or Memory Loss

(a) Block 12A. Block 99. Did patient receive neurology consult? Enter one of the following codes in Block 99:

Y = Yes

N = No

(b). Item 12B. Blocks 100-109. List Diagnoses. Designated physician staff are to provide narrative

description of diagnoses. If none, leave blank. NOTE: MAS coders: Enter ICD-9-CM codes in Blocks 100-109.

(16) Item 13. Blocks 110-120. Muscle Aches or Numbness

(a) Item 13A. Block 110. Did patient receive a neurology consult? Enter one of the following codes:

in Block 110.

Y = Yes

N = No

(b) Item 13B. Blocks 111-120. List Diagnoses. Designated physician staff are to provide narrative description of

diagnoses. If none, leave blank. NOTE: MAS coders: Enter ICD-9-CM codes in Blocks 111-120.

(17) Item 14. Blocks 121-131. Chronic Fatigue

(a) Item 14A. Block 121. Did patient receive consult(s) relating to chronic fatigue? Enter one of the following

codes in Block 121.

(b) Item 14B. Blocks 122-131. List Diagnoses. Designated physician staff are to provide narrative

description of diagnoses. If none, leave blank. NOTE: MAS coders: Enter ICD-9-CM codes in Blocks 122-131.

M-10, Part III March 21, 1996

Change 2

Chapter 3

APPENDIX 3B

3B-4

(18) Item 15. Blocks 132-142. Joint Pain

(a) Item 15A. Block 132. Rheumatology Consult. Did patient receive rheumatology consult? Enter one of the

following codes in Block 132:

Y = Yes

N = No

(b). Item 15B. Blocks 133-142. List Diagnoses. Designated physician staff are to provide narrative

description of diagnoses. If none, leave blank. NOTE: MAS coders: Enter ICD-9-CM codes in Blocks 133-142.

(19) Item 16. Blocks 143-153. Chronic Cough and/or Shortness of Breath

(a) Item 16A. Block 143. Pulmonary Consult. Did patient receive pulmonary consult? Enter one of the

following codes in Block 143:

Y = Yes

N = No

(b). Item 16B. Blocks 144-153. List Diagnoses. Designated physician staff are to provide narrative description of

diagnoses. If none, leave blank. NOTE: MAS coders: Enter ICD-9-CM codes in Blocks 144-153.

(20) Item 17. Blocks 154-164. Skin Rash

(a) Item 17A. Block 154. Dermatology Consult. Did patient receive a dermatology consult? Enter one of the

following codes in Block 154.

Y = Yes

N = No

(b) Item 17B. Blocks 155-164. List Diagnoses. Designated physician staff are to provide narrative description

of diagnoses. If none, leave blank. NOTE: MAS coders: Enter ICD-9-CM codes in Blocks 155-164.

(21) Item 18. Blocks 165-175. Vertigo and/or Tinnitus

(a) Item 18A. Block 165. Audiology consult? Did patient receive an audiology consult? Enter one of the

following codes in Block 165:

Y = Yes

N = No

August 8, 1995 M-10, Part III

Chapter 3

APPENDIX 3B

3B-5

SAMPLE OF COMPLETED VA FORM 10-9009A (JULY 1995), PART III

UCAP (UNIFORM CASE ASSESSMENT PROTOCOL) PHASE III

M-10, Part III August 8, 1995

Chapter 3

APPENDIX 3B

3B-6

August 8, 1995 M-10, Part III

Chapter 3

APPENDIX 3B

3B-7

M-10, Part III August 8, 1995

Chapter 3

APPENDIX 3B

3B-8

August 8, 1995 M-10, Part III

Chapter 3

APPENDIX 3C

3C-1

INSTRUCTIONS AND SAMPLE FORMAT FOR COMPLETION OF BI-MONTHLY REPORT

ON PERSIAN GULF UNIFORM CASE ASSESSMENT PROTOCOL (UCAP), PHASE II

(RCS-10-0860)

A bi-monthly report is required from all Department of Veterans Affairs (VA) facilities for all Persian Gulf

veterans receiving a Uniform Case Assessment Protocol (UCAP). Instructions are provided below for the

completion and submission of this report: NOTE: A sample report is provided in Appendix 3C.

1. Title of Report: Bi-monthly Persian Gulf Registry Phase II Examination Report

2. Reporting Months: The 2-month reporting period including month and year.

3. Reporting Facility, Address, and Station Code: Identify name, address and station code of each reporting

facility. If Uniform Case Assessments (UCAs) are performed by satellite outpatient clinics, these clinics should be

identified and UCEs reported by VA medical center of jurisdiction.

4. Column A: Include the Persian Gulf veteran’s name, Social Security Number, (SSN), race, sex and branch of

service.

5. Column B: If Persian Gulf veteran was an outpatient, indicate this by providing the date of the initial Persian

Gulf Registry examination, in Column B.

6. Column C: If Persian Gulf veteran was an inpatient, indicate this by providing the date of admission, date of

discharge, and the date of the initial Persian Gulf Registry examination in Column C.

7. Column D: List up to ten exposures as indicated by veteran.

8. Column E: List up to ten symptoms/complaints (with ICD-9 codes) as indicated by veteran.

9. Column F: List up to ten diagnoses (with ICD-9 codes). If there are no diagnoses, indicate “None.”

10. Column G: List all pending tests, consultations, and procedures, if incomplete prior to discharge.

11. Evaluation: Summarize the total number of Persian Gulf veterans (inpatients, outpatients receiving UCA’s

during the current reporting months, and cumulative statistics since the onset of this program (June, 1994). The

total number of pending UCA’s (those Persian Gulf veterans for whom a UCAE has been scheduled but not

performed) should be listed for the current month and not cumulative.

12. Reporting Information: Provide the date of this report and the name of the staff member preparing this

report and the staff member’s telephone contact.

13. Mailing Address: This report should be transmitted to the following address:

Department of Veterans Affairs

Environmental Agents Service (103A)

ATTN: Persian Gulf Coordinator

810 Vermont Avenue, N.W.

Washington, DC 20420

M-10, Part III August 8, 1995

Chapter 3

APPENDIX 3C

3C-2

SAMPLE FORMAT OF BI-MONTHLY PERSIAN GULF REGISTRY PHASE II

UCAP (UNIFORM CASE ASSESSMENT PROTOCOL) REPORT (RCS-10-0860)

SAMPLE FORMAT OF

BI-MONTHLY PERSIAN GULF REGISTRY PHASE II UCAP (UNIFORM CASE ASSESSMENT PROTOCOL)

REPORT (RCS-10-0860)

REPORTING PERIOD-JUNE-JULY, 1994

VAMC: PHOENIX, AZ (644)

(A) (B) (C) (D) (E) (F) (G)

NAME/SSN/

AGE/RACE/SEX

BRANCH OF

SERVICE

OUTPATIENT

DATE OF

EXAMINATIO

INPATIENT

ADMISSION/

DISCHARGE/

PRGR EXAM

DATES

LIST OF

EXPOSURES

(UP TO TEN)

LIST OF

SYMPTOMS

(UP TO TEN)

ICD-9

CODES

LIST OF

DIAGNOSIS

(UP TO TEN) &

ICD-9 CODES

PENDING

TESTS/CON-

SULTATIONS/

PROCE-DURES

PRIOR, RICHARD

222-222-2222

30 Y.O.W.M.

ARMY

6/17/94 DIESEL FUEL

MICROWAVES

NERVE GAS

ANTHRAX

FATIGUE/

MALAISE

(7807)

NEURASTHENIA

(3005)

MRI;

THYROID

FUNCTION

TEST

MAITLAND, JANE

777-77-7777

25 Y.O.B.F.

ARMY

7/17/94

7/20/94

6/18/94

SANDFLY

OIL WELL

SMOKE.

JOINT

PAIN(78999);

RASH (7821);

WEIGHT

LOSS (7832);

HEADACHES

(7840);

INSOMNIA

(78050);

DEPRESSIO

(7809)

MULTIPLE

SYMPTOMS

UNKNOWN

ETIOLOGY

(7999)

NEURO-

PSYCHOLOGICAL

SUMMARIES

INPATIENT INPATIENT PENDING

ADMISSIONS DISCHARGES OUTPATIENTS: UCE’S

CURRENT MONTH: 1 1 1 2

CUMULATIVE: 0 0 0 0

TOTALS: 1 1 1 2

DATE: 8/7/94; PREPARED BY: JANE DOE; PHONE #602-222-2222

* Y.O.W.M. = Year old white male; ** Y.O.B.F.= Year old black female

August 8, 1995 M-10, Part III

Chapter 4

4-i

CONTENTS

CHAPTER 4. PERSIAN GULF REFERRAL CENTERS (PGRCs)

PARAGRAPH PAGE

4.01 Purpose ........... 4-1

4.02 Background ...... 4-1

4.03 Authority .......... 4- 1

4.04 Policy .............. 4- 1

4.05 Program Guidance ............................................................................................................................4-1

4.06 Responsibilities 4-2

4.07 Reporting Requirements .................................................................................................................. 4-4

4.08 Media and Other External Contacts ................................................................................................. 4-5

APPENDIX

4A Instructions and Sample Format for Completion of the Persian Gulf

Referral Center (PGRC) Monthly Report (RCS 10-0860) ............................................................ 4A-1

August 8, 1995 M-10, Part III

Chapter 4

4-1

CHAPTER 4. PERSIAN GULF REFERRAL CENTERS (PGRCs)

4.01 PURPOSE

This chapter sets forth clinical and administrative policies concerned with program management of Veterans

Health Administration (VHA) Persian Gulf Referral Center (PGRC) examination programs established at

Department of Veterans Affairs (VA) Medical Centers in Birmingham, AL, Houston,TX, Washington, DC, and West

Los Angeles, CA.

4.02 BACKGROUND

a. In August 1992, VA established three PGRCs to medically assist Persian Gulf veterans whose symptoms

defy explanation through the usual diagnostic and therapeutic endeavors of local VA medical centers. An

additional center was established in June, 1995. The centers were established when it became clear that

increasing number of Desert Storm veterans appeared to be incapacitated and had symptoms which eluded

routine medical diagnosis despite thorough medical work-ups at VA medical centers. VA determined that for

these veterans it was desirable to provide for inpatient stays to allow for observation, multidisciplinary consultation,

documentation of lengthy occupational and exposure histories, and an opportunity for frequent re-examination.

For such veterans, local VA medical centers make special arrangements for the transfer, following consultation

with the referral center clinicians, to the appropriate center.

b. The referral centers, located at VA Medical Center in Birmingham, AL, Houston, TX, Washington, DC, and

West Los Angeles, CA, were selected based on availability of clinical and academic expertise in such areas as

pulmonary and infectious diseases, neurology, immunology, neuropsychology and access to toxicologic expertise.

The centers place an emphasis on specific symptom complexes, such as fevers of unknown origin, chronic

fatigue, memory loss, unexplained weight loss and other adverse health conditions possibly associated with

chemical/toxic environmental exposures in the Persian Gulf.

4.03 AUTHORITY

Authority for the VHA PGRCs is provided by Persian Gulf-related legislation including:

a. Public Law (Pub. L.) 102-25 which established a Persian Gulf War period of service affecting persons

serving on active duty as of August 2, 1990. At this time, there is no ending date established by law.

b. Pub. L. 102-585, Title VII, “Persian Gulf War Veterans’ Health Status Act,” enacted November 4, 1992,

mandates the Secretary of Veterans Affairs to establish and maintain a Persian Gulf Registry and provide health

examinations and counseling for eligible veterans;.

c. Pub. L. 103-210, enacted December 20, 1993, provides the Secretary of Veterans Affairs, with authority to

provide priority health care for eligible Persian Gulf veterans presenting adverse health conditions possibly

associated with service in the Persian Gulf.

4.04 POLICY

Persian Gulf veterans already determined to be eligible for a Persian Gulf Registry examination and/or health

care under the authorities cited in paragraphs 2.02 and 3.02, and who have been admitted for outpatient and/or

inpatient care at a VA medical center, may be considered for referral to a PGRC NOTE: Final eligibility

determinations for admission to a PGRC is be left to the discretion of the PGRC Director.

4.05 PROGRAM GUIDANCE

a. Special directives and other program guidance prepared by VA Central Office’s Environmental Agents

Service (EAS) (103A), provides the basis for PGRC program activities.

M-10, Part III August 8, 1995

Chapter 4

4-2

b. Appropriate means, i.e., medical center memoranda, need to be taken to circulate this information

throughout each Referral Center.

c. PGRC staff must be aware of educational information and other materials and publications prepared by EAS

(e.g., Persian Gulf posters, Persian Gulf Reviews, Persian Gulf Staff Updates, Persian Gulf Fact Sheets, etc.).

d. It is expected that PGRC staff will participate in national education meetings and attend periodic nationwide

conference calls conducted by the EAS. NOTE: They should be joined by VA medical center staff

concerned with the delivery of health care to Persian Gulf veterans and the maintenance of the Persian

Gulf Registry Examination Program.

4.06 RESPONSIBILITIES

a. PGRC program management requires close coordination and interaction between PGRC staff and VA

medical center staff making medical referrals of Persian Gulf veterans with difficult to diagnose health conditions.

b. VA Central Office’s EAS (103A) provides program guidance and administratively oversee activities of the

PGRCs and referring medical centers.

c. PGRC Responsibilities. A specially dedicated clinical and administrative support staff headed by a “Referral

Center Clinical Director” is established at each PGRC. The Director is responsible for the clinical management of

all medical and administrative activities associated with the special diagnostic program. Major responsibilities

include:

(1) Consulting with VA medical center staff to determine appropriateness of referral of Persian Gulf veteran to

the PGRC.

(2) Providing medical consultation to VA medical centers of origin for those cases in which it is determined that

a PGRC admission is not required. Such consultative support is to assist the local medical center in arriving at a

diagnosis and treatment regimen for Persian gulf veteran(s) in question.

(3) Providing for all administrative aspects of admission, with the close support and assistance of the medical

center’s Medical Administration Service (MAS), of patient referrals to the PGRC.

(4) Developing a medical plan of action on each referral, i.e.:

(a) Reviewing and confirming the complete medical history in veteran’s Consolidated Health Record (CHR),

(b) Providing a comprehensive physical examination,

(d) Providing other diagnostic testing as required, and

(e) Arranging specialty consultations as determined medically appropriate.

(5) Advising the veteran(s) if they have not already done so, of the opportunity to participate in, and be included

in VA’s computerized Persian Gulf Veterans Health Registry Examination Program. If veteran wishes to

participate in the registry, the PGRC is to ensure compliance with all registry procedures as outlined in M-10, Part

III, Chapter 2. NOTE: Before referral to one of VA’s PGRCs, it is requested that all VA medical centers

perform a Persian Gulf Registry Examination (Phase I) and if at all possible a Uniform Case

Assessment Protocol (UCAP) (Phase II).

(6) Providing for the documentation in the veteran’s CHR of all medical information pertinent to each referral

(PGR code sheets, laboratory reports, etc.).

August 8, 1995 M-10, Part III

Chapter 4

4-3

(7) Upon conclusion of the PGRC’s diagnostic work-up of each veteran, providing for administrative referral of

that individual back to the referring medical center. The PGRC contacts the medical center of referral prior to the

veteran’s departure from the facility.

(8) Providing each veteran with a final “consultation” by the PGRC Director, and/or other PGRC staff as

designated, of results of diagnostic procedures/treatment.

(9) Providing each referral with a follow-up letter discussing the results of the diagnostic work-up at the PGRC

including results of examination and laboratory tests with recommendations, as appropriate, personalized to each

referral.

(10) Providing copies of pending test or consultation results for each referred veteran to EAS (103A) and VA

facility of origin.

(11) Completing a VA Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet, and sending to Austin

Automation Center (AAC) as a follow-up examination when there is a new diagnosis or a change in diagnosis

since the initial registry examination code sheet should have been completed by the referral facility and sent to

AAC as an initial examination.

(12) Maintaining a special file on each referral at PGRC, for easy accessibility.

(13) Providing cumulative monthly reports to EAS (103A) no later than 5 working days following the end of

each month, see paragraph 3.05 and Appendix 3B.

(14) Providing copies of discharge summaries, laboratory test results and code sheets (both initial examination

and follow-up, if there is a new diagnosis or a change in diagnosis, for each referred Persian Gulf veteran, to EAS

(103A) within 5 working days following the end of each monthly reporting period (see par. 3.05 and App. 3B).

d. Originating Medical Center Responsibilities. VA medical centers are responsible for the medical referral to

the PGRCs of those Persian Gulf veterans for whom a medical diagnosis cannot reasonably be determined in

spite of extensive diagnostic, including comprehensive clinical examination work-ups. Routine responsibilities of

the medical centers making the referral are:

(1) Contacting the Director, PGRC, or other appropriate PGRC clinical staff member to discuss patients who

meet the necessary criteria for referral. Referral criteria include:

(a) Performing a Persian Gulf Registry examination, Phase I and Phase II (if facility has these medical

capabilities), prior to referral consideration; and

(b) Reviewing medical records of those Persian Gulf veterans with multiple symptoms for which a diagnosis

has not been determined or those veterans requiring a “second opinion.”

(2) Providing, when necessary, the appropriate PGRC with any documentation which will assist the PGRC in

making its determination whether a referral is appropriate, i.e., any examination data described in the patient’s

CHR including, among others, medical history, progress notes, test results, Persian Gulf Registry diagnostic code

sheets, and any other relevant medical/demographic information.

(3) Coordinating with the PGRC clinical and medical administrative service staff, all necessary travel and per

diem arrangements for the veteran(s), including dates of planned transfer to the referral center and projected

return date.

(4) Obtaining the veteran’s permission for transfer and providing counseling concerning the reason(s) for

referral, projected period of inpatient admission at the PGRC, travel arrangements and responding to any

questions the veteran might have concerning the referral. NOTE: In some instances veterans may not wish to

be referred. Ensure that documentation of the veteran’s decision in this regard is fully documented in

the CHR progress notes.

M-10, Part III August 8, 1995

Chapter 4

4-4

(5) Upon notification of a referral’s return from the PGRC, initiating follow-up contact by telephone and/or letter

with the veteran within 2 weeks of discharge from the referral center to determine the veteran’s health status and

to provide any assistance for which the veteran may be eligible.

(6) Discussing with Referral Center Directors outstanding consultation results, either performed at referral

centers or to be completed at the local medical centers, and maintained in patient’s files at both facilities (local and

referral).

(7) Documenting within the veteran’s CHR all results, findings and recommendations of the special diagnostic

work-up provided by the PGRC.

4.07 REPORTING REQUIREMENTS

a. Originating VA medical centers

(1) Prepare an original VA Form 10-9009A (July 1995) for each referred Persian Gulf Registry veteran.

(2) Submit a legible copy to the ACC in accordance with the general instructions found in Appendix 2C.

(3) Submit a legible copy of the VA Form 10-9009A (July 1995) to the PGRC with the patients CHR.

(4) Submit all follow-up results of specialty consultations obtained after the veteran’s discharge from a PGRC,

including further consultation with the veteran, if appropriate, to:

Department of Veterans Affairs

EAS (103)

ATTN: Senior Registry Coordinator

810 Vermont Avenue, N.W.

Washington, DC 20420

b. PGRC

(1) Submit follow-up Persian Gulf Code Sheets (VA Form 10-9009A (July 1995)) to AAC when new diagnostic

code differs from previously submitted code sheets, (see App.2B).

(2). Submit a PGRC report of admissions and/or discharges to EAS (103A) , Attn.: Senior Registry

Coordinator, within 5 working days following the end of each reporting month (refer to App. 2B for instructions and

sample format).

(3) Submit a negative PGRC report if there were no admissions or discharges during the reporting month.

(4) Submit copies of discharge summaries, laboratory reports, i.e., chest x-ray, blood count, blood chemistries

or enzyme studies, urinalysis and code sheets to EAS (103A), Attn.: Senior Registry Coordinator, no later than 10

working days following the end of each month.

(5) Submit all original medical records to local VA medical center to be maintained in veteran’s CHR.

(6) Maintain copies at PGRC in a special file for each referred patient.

(7) Submit copies of results of follow-up specialty consultation after discharge of veteran from PGRC to EAS

and local VA medical center for patient’s CHR and/or further consultation with veteran, if appropriate.

4.08 MEDIA AND OTHER EXTERNAL CONTACTS

a. Media Contacts. Reports of Contact from various media sources (e.g., radio, television, newspapers, etc.)

concerning PGRC activities will be referred by phone to the facility public affairs officer. Interviews should not be

August 8, 1995 M-10, Part III

Chapter 4

4-5

given unless approved by the medical center Public Affairs Officer who may appropriately coordinate response

with the regional VA public affairs representative.

b. Contacts to Advise Centers of “Special Cures” for Persian Gulf-related Illnesses. Referral centers

can expect, on occasion, to be contacted by private sector physicians, researchers, and the general public with

information regarding “quick cures” for Persian Gulf-related illnesses. Such individuals need to be politely advised

that:

(1) There are medically accepted mechanisms to introduce new clinical treatments.

(2) All new treatments suggested must be reviewed by a formally designated and staffed human subjects

review committee.

(3) It is important to have independent confirmation of treatment efficacy.

(4) Provisions exist to permit the originator of new therapies to retain professional credit and be appropriately

compensated.

(5) The individual might want to consider presenting the “new approach” at a VA or medical school grand

rounds or staff review committee meetings.

(6) VA and the National Institutes of Health fund quality research proposals.

M-10, Part III August 8, 1995

Chapter 4

4-6

March 21, 1996 M-10, Part III

Change 2

Chapter 3

APPENDIX 3B

3B-1

INSTRUCTIONS AND SAMPLE FORMAT FOR COMPLETION OF

PERSIAN GULF REFERRAL CENTER MONTHLY REPORT

(RCS 10-0860)

A monthly report is required from all Department of Veterans Affairs (VA) Persian Gulf Referral Centers

(PGRC) receiving an extensive, additional diagnostic and therapeutic work-up to evaluate those Persian

Gulf War veterans who are incapacitated and experiencing symptoms that have eluded medical diagnosis

despite thorough examinations at local VA facilities. The following instructions are provided for the

completion and submission of this reported NOTE: A sample report is provide on page 4A-2.

1. Title of Report. Monthly Persian Gulf Referral Center Report

2. Reporting Period. Month and Year of the reporting period.

3. Reporting Facility, Address and Station Code. Identify name, address and station code of each

reporting PGRC.

4. Column A. Include the Persian Gulf veteran’s name, Social Security Number, Race, Sex and Branch

of Service.

5. Column B. Provide the name, city and state of the VA facility from which the Persian Gulf veteran was

referred.

6. Column C. Indicate date of admission, date of discharge, and the date of initial Persian Gulf Registry

examination.

7. Column D. List up to ten exposures as indicated by the veteran.

8. Column E. List up to ten symptoms/complaints (with ICD-9 codes) as indicated by the veteran.

9. Column F. List up to ten diagnoses (with ICD-9 codes). If there are no diagnoses, -indicate “None.”

10. Column G. List all pending tests/consultations/procedures, either those that have been performed at

the PGRC or those to be performed at the local VA medical center.

11. Number of Veterans. List the total number of Persian Gulf veterans admitted, discharged and any

pending referrals for current reporting month and cumulative numbers from the onset of this program:

a. Total Admissions;

b. Total Discharges; and

c. Total Referrals Pending: (current month).

12. Date of Report. Submit the date of this report.

13. Contact. Name of staff member preparing this report and the telephone contact.

14. Mailing Address. This report must be transmitted to the following address:

Department of Veterans Affairs

Environmental Agents Service (103A)

ATTN: Persian Gulf Coordinator

810 Vermont Avenue, N.W.

Washington, DC 20420

M-10, Part III March 21, 1996

Change 2

Chapter 3

APPENDIX 3B

3B-2

PERSIAN GULF REFERRAL CENTER MONTHLY REPORT (RCS 10-0860)

REPORTING MONTH JULY, 1994

PGRC: HOUSTON, TX (580)

(A) (B) (C) (D) (E) (F) (G)

NAME/SSN/

AGE/RACE/SEX

BRANCH OF

SERVICE

REFERRED

BY:

VAMC/OPC

ADMISSION/

DISCHARG

PGR EXAM

DATES

LIST OF

EXPOSURES

(UP TO TEN)

LIST OF

SYMPTOMS

(UP TO TEN)&

ICD-9 CODES

LIST OF

DIAGNOSIS

(UP TO TEN) &

ICD-9 CODES

PENDING

TESTS/CON-

SULTATIONS/

PROCEDURES

JONES,HARRY

555-55-5555

40 Y.O.W.M.

ARMY

ALBANY, NY

VAMC

5/1/94

5/10/94

4/11/93

DU;

CARC;

PESTICIDES

FATIGUE/

MALAISE (7807)

NEURASTHENIA

(3005)

MRI;

THYROID

FUNCTION

TEST

SMITH,JOHN

333-33-3333

25 Y.O.B.M.*

NAVY

MONTROSE,

NY VAMC

5/2/94

5/19/94;

3/10/94.

OIL FIRE

SMOKE;

ANTHRAX

VACCINE.

JOINT PAIN

(78999);

MEMORY LOSS

(7809);

LOOSE BOWEL

STOOLS (7879);

FATIGUE (7807);

HEARING LOSS

(78999);

HEADACHES

(7840);

MULTIPLE

SYMPTOMS

OF UNKNOWN

ETIOLOGY

(7999)

NEURO-

PSYCHO-

LOGICAL

WRIGHT, ANN

666-66-6666

30 Y.O.W.F.**

ARMY

DURHAM

VAMC

5/20/94;

5/30/94;

3/4/94.

TENT HEATER

SMOKE;

ATE LOCAL

FOOD;

MICROWAVES.

FATIGUE (7807);

JOINT PAINS

(78999);

HEADACHES

(7840);

SLEEPLESSNESS

(78050);

LOOSE BOWEL

STOOLS (7879)

ARTHRALGIA

(7194);

DIARRHEA

(3064)

NONE

SUMMARIES

ADMISSIONS DISCHARGES: PENDING EXAMS:

CURRENT MO. 3 3 10

CUMULATIVE: 10 10 N/A

DATE: 8/7/94;

PREPARED BY: JOHN DOE; PHONE #713-222-222

*-Y.O.B.M. (Year Old Black Male)

**-Y.O.W.F. (Year Old White Female)

March 21, 1996 M-10, Part III

Change 2

Chapter 3

APPENDIX 3B

3B-3

March 21, 1996 M-10, Part III

Change 2

Chapter 5

5-i

CONTENTS

CHAPTER 5. PERSIAN GULF REGISTRY III SPECIFICALLY FOR SPOUSES AND CHILDREN OF

PERSIAN GULF WAR VETERANS

PARAGRAPH PAGE

5.01 Purpose ........... 5-1

5.02 Authority .......... 5-1

5.03 Eligibility ........... 5-1

5.04 Responsibilities 5-1

5.05 Reporting Requirements .................................................................................................................. 5-2

APPENDICES

5A Protocol for Conducting the Physical Examination, Phase I, and Ordering

Diagnostic Studies ..................................................................................................................... 5A-1

5B Sample and Instructions for Completing VA Form 10-9009c, Persian Gulf Code

Sheet, Part I and Part II, Registry Examination, Phase I, for Spouses or Children

of Persian Gulf Registry Veterans ............................................................................................ 5B-1

5C VA Uniform Case Assessment Protocol (UCAP), Phase II ............................................................ 5C-1

5D Sample and Instructions for Completing VA Form 10-9009c, Persian Gulf Code Sheet

Part III, UCAP, Phase II, for Spouses and Children of Persian Gulf Veterans ......................... 5D-1

5E Sample Cover Letter to Non-VA Physician ..................................................................................... 5E-1

March 21, 1996 M-10, Part III

Change 2

Chapter 5

5-1

CHAPTER 5. PERSIAN GULF REGISTRY III FOR SPOUSES AND CHILDREN

OF PERSIAN GULF WAR VETERANS

5.01 PURPOSE

This chapter sets forth administrative policies for collection of medical and demographic data on the

spouses and children of Persian Gulf War veterans (hereafter referred to as Persian Gulf (PGW)

veterans) in an additional and separate registry identified as Persian Gulf Registry III (PGR III) to

supplement the Persian Gulf Registry initiated in 1992 and revised in 1995 for PGW veterans.

5.02 AUTHORITY

To respond to concerns about health problems of spouses and children of PGW veterans, the

Department of Veterans Affairs (VA) will include in PGR III medical data provided by non-VA, licensed

physicians (Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.)). Although the VA has no

general/blanket authority to provide registry examinations or treatment to spouses or children of PGW

veterans, the Secretary of the Department of Veterans Affairs, hereafter referred to as the Secretary, has

been mandated by Public Law (Pub. L.) 103-446, dated November 2, 1994, to include any relevant

medical data of spouses and children of PGW veterans in the VA PGR III. These examinations can be

provided by non-VA licensed physicians who certify that examinations were conducted using standard

protocols and guidelines, provided by VA. These registry data will facilitate program and policy

development for PGW veterans.

5.03 ELIGIBILITY

VA includes in PGR III relevant medical data as provided by non-VA physicians of any individual who:

a. Is a spouse or child of a veteran who is: (1) Listed in the PGW Veteran Registry, established under

Pub. L. 102-585, Section 702; and (2) Suffering from an illness or disorder.

b. Is apparently suffering from, or may have suffered from, an illness or disorder (including a birth

defect, miscarriage, or stillbirth) which cannot be disassociated from the veterans service in the Southwest

Asia theater of operations.

c. In the case of a spouse, has granted the Secretary permission to include in the Registry relevant

medical data (including a medical history and the results of diagnostic testing and medical examinations)

and such other information as the Secretary considers relevant and appropriate with respect to such

individual.

5.04 RESPONSIBILITIES

The VA Veterans' Registry Physician (VRP), or designee, Veterans' Registry Coordinator (VRC) and

Medical Administration Service (MAS) staff play a significant role in carrying out the mandates of Pub. L.

103-446, in conducting outreach activities to PGW veterans, the veteran’s spouses and children, and non-

VA physicians (M.D. or D.O.) conducting tests and examinations. In order to ensure uniform collection of

medical data, standard protocols, guidelines and code sheets have been developed (refer to App. 5C),

with a sample letter of enclosure (refer to App. 5E) and should be provided to any PGW veteran, spouse,

child (parent), and non-VA physician requesting copies of these protocols and guidelines.

a. VRP Responsibilities. The VRP, or designee, is responsible for the clinical management of the

program and serves as their primary health care consultant to non-VA physicians, veterans and their

families. The VRP will:

(1) Ensure that the non-VA physician receives guidelines and protocols to be used when performing

examinations for spouses and children of PGW veterans.

M-10, Part III March 21, 1996

Change 2

Chapter 5

5-2

(2) Ensure that the non-VA physician receives a cover letter (refer to sample in App. E), with protocols

and code sheets to provide a brief background describing the purpose of collecting and recording these

medical data.

(3) Review the medical records of every PGW veteran spouse and/or children examined to ensure that

a complete physical examination was performed and documented.

(4) Review Part II (Phase I) and III (Phase II) of VA Form 10-9009c, Persian Gulf Registry Code Sheet

for Spouses and/or Children, before submission to the Austin Automation Center (AAC) for entry into PGR

III.

b. VRC Responsibilities. The VRC is responsible for the administrative management of the program.

The VRC will:

(1) Coordinate outreach activities to ensure that all PGW veterans with spouses and/or children with

health problems that may be related to veteran's service are aware of VA's commitment to include the

veteran’s family members in the PGR III.

(2) Enter the results of diagnostic tests, medical histories and medical examinations conducted by

licensed non-VA physicians into VA PGR III if requested by the PGW veteran (who must be a registry

participant prior to entry of data on spouse or child), spouse, or child.

(3) Provide the appropriate examination guidelines, protocols, code sheets, with cover letters, and

other related documentation (refer to App. 5B) for completion by non-VA physician.

(4) Collect data for reporting purposes.

(5) Review the code sheet to further ensure the form’s completeness, and, if necessary, obtain and

record any missing information from the non-VA physician. NOTE: Code sheets should be transmitted to

AAC no later than 25 working days after receipt from veteran, spouse or non-VA physician.

(6) Submit completed code sheets to AAC for database entry.

(7) File results of the spouse's or child's diagnostic tests, medical histories, medical examinations,

copies of code sheets and other relevant records in PGW veteran's Consolidated Health Record (CHR).

NOTE: These Persian Gulf registry records are subject to the same retention and disposition policies as

other medical record files; use Records Control Schedule 10-1.

c. Code Sheet Completion

(1) The non-VA physician (M.D. or D.O.), will complete Part I of VA Form 10-9009c, and will ensure

that all information entered on the code sheet is complete.

(2) The non-VA licensed physician will complete Part II and III of VA Form 10-9009c; refer to

instructions and sample code sheet in Appendix 5A.

5.05 REPORTING REQUIREMENTS

The VA's VRCs must submit the following report when received from veteran, spouse, or non-VA

physician performing evaluation of veteran's spouse and/or children:

a. VA Form 10-9009c (original) must be prepared monthly and submitted to AAC as per instructions

contained in Chapter 2, Appendix 2B. Reports Control Symbol 10-0860 reflects the reporting requirement

for VA Form 10-9009c.

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b. VA Form 7252 (formerly VA Form 30-7252), Transmittal Form for the Use in Shipment of Tabulating

Data, must be prepared monthly and submitted to AAC, ensuring that code sheets are identified as VA

Form 10-9009c for Persian Gulf Spouses or Children, as per instructions contained in Chapter 2,

Appendices 2D and 2E.

NOTE: These code sheets should be submitted, based on the following schedule, but no later than 25

working days following receipt from veteran, spouse, child (parent) or non-VA physician.

c. The schedule of mailing dates is as follows for:

(1) Former Region 1, the 6th of month;

(2) Former Region 2, the 10th of month;

(3) Former Region 3, the 14th of month; and

(4) Former Region 4, the l8th of month.

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5A-1

PROTOCOL FOR CONDUCTING THE PHYSICAL EXAMINATION, PHASE I,

AND ORDERING DIAGNOSTIC STUDIES

1. It is essential that a complete medical history, physical examination and interview be performed by the

private physician (Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.)) and documented on

appropriate forms. The Department of Veterans Affairs (VA) forms that must be fully completed are:

Standard Form 88, Report of Medical Examination, VA Form 10-9009c, Persian Gulf Registry Code

Sheet, and Standard Form 509, Progress Notes (for follow-up). These are to be submitted to local VA

facility for maintenance in veteran's Consolidated Health Record (CHR). These forms must be provided to

the non-VA licensed physician for use when performing examinations of spouses and/or children of

Persian Gulf veterans. The complete medical history should address the following: NOTE: Non-VA

physicians may use their own medical examination reports and progress notes as long as they contain the

following information:

(a) Family history;

(b) Occupational history;

(d) Civilian exposure(s) history to possible toxic agents;

(e) Psychosocial history; and

(f) Review of systems.

2. The person actually performing the physical examination must be identified by name, address, medical

license, signature and title (i.e., M.D., D.O., Physician’s Assistant, etc.). A licensed physician’s

countersignature is required if the examiner is a physician's assistant or nurse practitioner.

3. The physician must be aware of the variety of exposures endemic to the Persian Gulf area. These are

listed in Appendix 2C and on VA Form 10-9009c. There has been a wide distribution of major categories

of diagnoses reported by VA Veterans' Registry Physicians (VRP) and no significant variation in

occurrence of major categories of medical problems has been identified. For informational purposes,

some of the health problems and/or diseases which should be considered, are as follows:

Unfortunately the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM)

coding system does not give sufficient codes to correctly identify all symptoms and diagnoses. A number

of diagnoses that have been reported by the VRP do not have ICD-9-CM codes for specific identification

in the Veterans Health Administration (VHA) s database. To correct this three new codes have been

created. They are : Apnea, Sleep (99001), Chronic Fatigue Syndrome (CFS) (99002), and Fibromyalgia

(99003). Make certain these codes are used when completing the Persian Gulf Registry (PGR) code

sheets for patients who have these diagnoses. As a result of inadequate coding designations, there has

been confusion between the symptoms (complaints) and diagnoses listed on the PGR code sheets.

Example one: Arthralgia (diagnostic code 7194) has been used for the symptom “pain in the joint,” where

the symptom code 7819 (other symptoms involving nervous and musculoskeletal systems) would be more

appropriate. Example two: Symptom ICD-9-CM code 78051 has been designated for insomnia with sleep

apnea; however, sleep apnea is more correctly identified as a specific diagnosis which has the new code

99001. Symptom code 78051 may still be used for insomnia with sleep apnea. Example three: Symptom

ICD-9-CM code 7807 has been used to designate CFS and the symptoms of malaise and fatigue. The

new code 99002 has been determined for CFS, so ICD-9-CM code 7807 should be used for medical

complaints of malaise and fatigue

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DIAGNOSIS ICD-9-CM Code

(1) Amebiasis 006

(2) Apnea, sleep 99001

(3) Arthalgia 7194

(4) Asthma 493

(5) Brill’s Zinsser disease (recrudescent typhus) 0811

(6) Bronchiectasis 494

(7) Bronchopneumonia, organism unspecified 485

(8) Brucellosis 023

(9) Chronic obstructive pulmonary disease,

not elsewhere classified 496

(10) Chronic bronchitis 491

(11) Chronic Fatigue Syndrome 99002

(12) Chronic laryngotracheitis 4761

(13) Chronic respiratory conditions due to

fumes and vapors 5064

(14) Emphysema 492

(15) Fibromyalgia 99003

(16) Giardiasis 0071

(17) Leishmaniasis 085

(18) Malaria 084

(19) Other and unspecified diseases of upper

respiratory tract 4789

(20) Pneumoconiosis due to other silica or silicates 502

(21) Pneumoconiosis, unspecified 505

(22) Unspecified chronic respiratory disease 5199

(23) Respiratory conditions due to

unspecified external agent 5089

(24) Sandfly fever (phlebatomus fever) 0660

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DIAGNOSIS ICD-9-CM CODE

(25) Schistosomiasis (bilharziasis) 120

(26) Toxoplasmosis 130

(27) Typhoid fever, also carrier - V02.1 0020

(28) Tuberculosis, specify variant(s) 010-018

(29) Viral hepatitis 070

(30) Memory loss 310

(31) Polyneuropathy 356-357

(32) Skin rash 680-709

(33) Adjustment disorder, including Post

Traumatic Stress Disorder (PTSD) 309

(34) Alcohol dependence syndrome 303

(35) Drug dependence 304

4. In gathering these data, it is important to determine and record the:

a. Time of onset of the symptoms or conditions,

b. Intensity,

c. Degree of physical incapacitation, and

d. Details of any treatment received.

5. Each veteran's spouse or child will be given the following baseline laboratory studies (Phase I Registry

Examination): NOTE: As a routine children should not be subjected to laboratory studies such as

complete blood count (CBC),electrolyte glucose or equivalent blood chemistries and enzyme studies.

Diagnostic testing should only be performed as judged medically necessary by the examining physician.

a. CBC;

b. Electrolyte Glucose (SMA-6, SMA-12), or equivalent blood chemistries and enzyme studies; and

c. Urinalysis.

6. Appropriate additional diagnostic studies should be performed and consultations obtained as indicated

by the patient’s symptoms and the physical and laboratory findings. NOTE: If individuals have

unexplained illnesses, a Phase II examination is recommended after Phase I registry examination is

completed.

a. Other diagnostic studies, such as pulmonary function test, pap smear, sperm counts, should be

performed as medically indicated.

b. Laboratory tests results will be provided to VA for filing in the CHR.

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March 21, 1996 M-10, Part III

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APPENDIX 5B

5B-1

SAMPLE AND INSTRUCTIONS FOR COMPLETING VA FORM 10-9009c, PERSIAN GULF REGISTRY

CODE SHEET, PART I AND PART II REGISTRY EXAMINATION PHASE I, FOR SPOUSE OR

CHILDREN OF PERSIAN GULF VETERAN

1. General Instructions for completing VA Form 10-9009c for spouses and children.

a. An original code sheet should be prepared by the non-VA physician (Doctor of Medicine (M.D.) or

Doctor of Osteopathy (D.O.)), or designee, and submitted to the Veterans' Registry Coordinator (VRC), at

a local Department of Veterans Affairs (VA) facility. The VRC and Veterans' Registry Physician (VRP) will

review the document, and submit the ORIGINAL CODE SHEET to the Office of Financial Management

Austin Automation Center (AAC) in accordance with instructions for the initial and first follow-up

examinations (if clinically indicated). After code sheet data has been reviewed and entered into the

computerized database at AAC, AAC staff will forward the code sheets to:

Senior Registry Coordinator (131)

Department of Veterans Affairs

810 Vermont Avenue, N.W.

Washington, DC 20420.

NOTE: These code sheets will not be returned to the medical center of origin unless corrections are

required.

(1) A legible copy of the code sheet will be filed in the PGW veteran's medical record with any

corrections required by AAC. Additional follow-up examinations, as provided by the private physician, as

clinically indicated, can be submitted for inclusion in veteran's Consolidated Health Record (CHR).

(2) A code sheet for additional follow-up examinations need not be prepared or submitted to the AAC

except when a diagnosis and diagnostic code differs from previously submitted code sheets. For any

diagnostic change, a code sheet will be prepared and submitted for entry into the Persian Gulf Registry III

(PGR III).

b. The non-VA licensed physician, or designee, should complete this form using the following marking

instructions:

(1) PRINT CLEARLY USING A NO. 2 PENCIL OR BLUE OR BLACK INK PEN ONLY.

(2) DO NOT USE PENS WITH INK THAT SOAK THROUGH THE PAPER.

(3) MAKE SOLID MARKS THAT FILL OVALS COMPLETELY.

(4) COMPLETE ALL HORIZONTAL GRIDS IN ACCORDANCE WITH EXAMPLE SHOWN ON

UPPER RIGHT HAND SIDE OF PAGE 1, OF CODE SHEET.

(5) WHERE BLOCKS ARE INDICATED AND/OR NUMBERED; E.G., 2-117, ENTER ONE LETTER

OR NUMBER PER BLOCK. VETERAN AND PRIVATE PHYSICIAN SHOULD BE AWARE THAT THE

NUMERIC ZERO MUST BE SLASHED “Æ.”

(6) MAKE NO STRAY MARKS ON THIS FORM.

(7) DO NOT FOLD, TEAR, OR MULTILATE THIS FORM.

(8) FOLLOW INSTRUCTIONS CAREFULLY TO ENSURE THAT ALL DATA FIELDS ARE

COMPLETED ACCURATELY.

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5B-2

c. For registry coding purposes, VA coding clerks should use the International Classification of

Diseases - Clinical Modification, 9th Edition, (ICD-9-CM) codes. These must be the codes currently in use

by AAC.

(1) Part I of the code sheet should be completed by the non-VA physician (M.D. or D.O.) during the

medical history taken from veteran’s spouse or in the case of a child, by one of the parents.

(2) Parts II and III of the code sheet should be completed at the time of the examination by the

licensed non VA-physician (M.D. or D.O.) Completed Parts I, II and III will be returned to VRC at the local

VA facility for review and assignment of the ICD-9-CM codes in appropriate blocks. NOTE: VA coders

should pay careful attention to assigning the correct code for both complaints (symptoms) and diagnosis.

ICD-9 CM code 78999, for uncodable complaints (symptoms), should be assigned only after all coding

possibilities have been thoroughly explored. The indiscriminate use of 78999 may result in skewed or

misleading statistics of minimal value.

(3) Date all code sheets with current date in the upper right hand corner of VA Form 10-9009c.

2. Instructions for Completing Part I (Initial Examination)

a. Item 1. Blocks 2-7. Facility Number and Suffix. VA coders are to enter facility code as listed in

MP-6, Part XVI, Supplement No. 4.1, Appendix A. Use the AMIS suffix (BY, BZ, etc.) to indicate your

satellite facility. DO NOT USE Q, R, OR S. NOTE: If spouse or child requests the inclusion of

Department of Defense (DOD) registry examination records in VA PGR, submit code sheet with Facility

Number as 999 in Blocks 2, 3 and 4 and indicate actual VA facility number in upper left margin of code

sheet.

b. Item 2. Blocks 8-33. Last Name of Spouse or Child. Beginning in Block 8, enter spouse's or

child's current last name. Do not use apostrophe and/or hyphen in the name or skip blocks between the

letters of the last name. Skip a block if the last name is followed with Jr., Sr., I, II, III, etc.

c. Item 3. Blocks 34-48. First Name of Spouse or Child. Beginning in Block 34, enter spouse's or

child's first name.

d. Item 4. Blocks 49-58. Middle Name of Spouse or Child. Beginning Block 49, enter spouse's or

child's middle name or initial.

e. Item 5. Block 59. Type of Examination. The following transaction type should be entered in

Block 59 as appropriate:

A - Initial examination. Spouse's or Child's first Persian Gulf examination.

B - To delete an entire initial examination with a noted error, after it has been accepted into the registry,

resubmit the original code sheet with a “B” and submit another code sheet with the correct information with

an “A.” All fields