+-----------------------------------+-----------------------------------+
| Department of Veterans Affairs    | ###### VHA HANDBOOK 1303.2        |
+-----------------------------------+-----------------------------------+
| **Veterans Health                 | **Transmittal Sheet**             |
| Administration**                  |                                   |
+-----------------------------------+-----------------------------------+
| **Washington, DC 20420**          | **March 7, 2005**                 |
+-----------------------------------+-----------------------------------+

## GULF WAR (INCLUDING OPERATION IRAQI FREEDOM) REGISTRY (GWR) PROGRAM- (FORMERLY PERSIAN GULF REGISTRY (GWR) PROGRAM)

**1. REASON FOR ISSUE.** This Veterans Health Administration (VHA)
Handbook is revised to provide updated procedures for the established
Gulf War Registry (GWR) Program at all Department of Veterans Affairs
(VA) health care facilities for concerned participants of "Operation
Desert Shield and Desert Storm," and "Operation Iraqi Freedom (OIF)."
***NOTE:** This Handbook addresses only the Registry and its
implementation; it does not address treatment or enrollment issues for
Gulf War or other combat veterans.*

**2. SUMMARY OF CONTENTS.** This Handbook clarifies eligibility for
veterans who served in the Gulf War (GW), initiates new electronic
reporting of GWR examination data via website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/),
discontinues reporting GWR examinations (Report Control Number
(RCN)-10-0860), implements name change of GWR Physicians and
Coordinators to Environmental Health (EH) Clinicians and (EH)
Coordinators, and confirms the discontinuation of the GW Referral
Centers with provision of alternative methods of referrals of combat
veterans with undiagnosed, disabling illnesses to War Related Illness
and Injury Study Centers (WRIISC).

**3. RELATED ISSUES AND WEBSITES.** VHA Handbooks 1301.1, and
[www.va.gov/environagents/](http://www.va.gov/environagents/) ; and
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
.

**4. RESPONSIBLE OFFICE.** The Office of Environmental Agents (131) is
responsible for the contents of this Handbook. Questions may be referred
to 202-273-8463.

**5. RECISSIONS.** M-10, Part III, Chapters 1, 2, and 3 are rescinded.

**6. RE-CERTIFICATION.** This VHA Handbook is scheduled for
re-certification on or before the last working day of March 2010.

  ------------------------------- ---------------------------------------
                                  

                                  S/Jonathan B. Perlin, MD, PhD, MSHA,
                                  FACP

                                  Acting Under Secretary for Health
  ------------------------------- ---------------------------------------

  ---------------- ------ ------------------------------------------------
  DISTRIBUTION:    CO:    E-mailed 3/8/2005

                   FLD:   VISN, MA, DO, OC, OCRO, and 200 -- E-mailed
                          3/8/2005
  ---------------- ------ ------------------------------------------------

### CONTENTS

**GULF WAR (INCLUDING OPERATION IRAQI FREEDOM) REGISTRY (GWR) PROGRAM**

# PARAGRAPH PAGE

1\. Purpose 1

2\. Background 1

3\. Registry Evaluation 4

4\. Responsibilities 4

5\. Gulf War Registry (GWR) Examination 6

a\. Purpose 6

b\. Eligibility Criteria 6

c\. Program Management 8

d\. Responsibilities 8

e\. Establishing, Updating, Retaining and Disposition of Health Records
12

f\. Incarcerated Veterans 12

g\. Veterans with other than Honorable Discharges 13

h\. Active Duty Military Personnel 13

i\. Updating EH Clinician and/or EH Coordinator Appointments 14

6\. Gulf War Uniform Case Assessment Protocol (UCAP) 14

a\. Background 14

b\. Authority 14

c\. Scope 15

d\. Responsibilities 15

7\. Media and Other External Contacts 5

**CONTENTS** Continued...

# PARAGRAPH PAGE

# 

# APPENDIXES

A Definitions and Acronyms A-1

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

C Instructions for Completing VA Form 10-9009a, Gulf War Registry

Code Sheet, Phase I C-1

D Example of Gulf War Registry Follow-up Letter (Medical Problem
Indicated) D-1

E Example of Gulf War Registry Follow-up Letter (No Medical Problem
Indicated) E-1

F Uniform Case Assessment Protocol (UCAP) F-1

G Instructions for Completing Gulf War Uniform Case Assessment

Protocol (UCAP) Phase II, Part III G-1

## GULF WAR (INCLUDING OPERATION IRAQI FREEDOM) 

## REGISTRY (GWR) PROGRAM

***NOTE:** This Handbook addresses only the Registry and its
implementation; it does not address treatment or enrollment issues for
Gulf War or other combat veterans.*

**1. PURPOSE**

This Veterans Health Administration (VHA) Handbook provides procedures
to maintain a Gulf War (including Operation Iraqi Freedom (OIF))
Registry (GWR) Program at all Department of Veterans Affairs (VA) health
care facilities for concerned participants of "Operation Desert Shield
and Desert Storm, and OIF." ***NOTE:** For purposes of this Handbook,
veterans who served in the Persian Gulf theatre of war are referred to
as Gulf War (GW) veterans.*

**2. BACKGROUND**

a\. In response to Iraq's invasion of Kuwait on August 2, 1990, the
United States (U.S.) began deploying troops to the Arabian Gulf 5 days
later in Operation Desert Shield. A total of forty coalition countries
eventually deployed military forces to the Gulf region, including troops
from the U.S., the United Kingdom, France, and Canada. On January 17,
1991, the air war against Iraq began (Operation Desert Storm), which was
followed by a 4-day ground war starting on February 24, 1991.

b\. By the end of active hostilities on February 28, 1991, the U.S. had
deployed 697,000 troops to the theater of operations. The British
deployed approximately 53,000 military personnel, the French 25,000, and
the Canadians 4,500. In contrast to previous conflicts, a larger
proportion of U.S. troops was from the Reserves and/or National Guard
(17 percent) and were women (7 percent). Along with a rapid buildup of
Coalition combat forces, an extensive medical care infrastructure and
preventive medicine effort was established in the theater of operations.
For further details and updates refer to website
[www.va.gov/gulfwar/](http://www.va.gov/gulfwar/) .

c\. By the end of the GW, VA medical care personnel became concerned
about potential

health problems of U.S. service members exposed to oil well fire smoke.
Consequently, VA developed a proposal to create a clinical registry of
GW veterans to evaluate the health problems they were experiencing and
to provide better health care for returning troops. This proposal led to
the establishment of the VA Persian Gulf War Health Examination
Registry, authorized in November 1992 by the "Persian Gulf War Veterans
Health Status Act" (Public Law 102-585).

d\. The GW examination registry was established after the first Gulf War
to identify possible diseases resulting from U.S. military personnel
service in certain areas of Southwest Asia (see par. 7.b). These
diseases were endemic to the area or may have been 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, could have caused chronic
health problems.

\(1\) Due to the un-ignited petroleum and/or smoke from the sabotage of
Kuwaiti oil wells, the following health problems are to be considered in
veterans of the first Gulf War:

\(a\) Chronic bronchitis,

\(b\) Chronic obstructive pulmonary disease,

\(c\) Pulmonary emphysema,

\(d\) Bronchial asthmas, and

\(e\) Lung cancer.

\(2\) GW veterans reported a wide variety of symptoms and exposures as a
consequence of GW service. These include, but are not limited to
exposure to:

\(a\) For veterans of the first Gulf War, oil, smoke, and other
petrochemical agents; and

\(b\) For veterans of all Gulf Wars including OIF, Leishmaniasis (spread
by sand flies).

e\. **[OIF.]{.underline}** The U.S. began deploying troops to the Gulf
region in late 2002. As of May 19, 2004, among 139,778 veterans of OIF
who have separated from active military duty, 15 percent (21,021) have
sought health care from VA. OIF veterans are presenting to VA with a
wide range of both medical and psychological conditions similar to those
found in other young military populations. To date, no unusual illnesses
have been found among OIF veterans.

f\. With the exception of health problems relating to exposure to oil
fires, the type of

symptoms and exposures listed above may be reported by veterans of OIF.
Refer to website [www.va.gov/gulfwar/](http://www.va.gov/gulfwar/) for
health risks details.

g\. During the examination process, these exposures and health
conditions are identified and documented in the veterans' health or
administrative record as appropriate.

h\. The registry containing medical and other data on exposed veterans
signals 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.

**3. REGISTRY EVALUATION**

Veterans claiming health conditions related to exposure to toxic
substance or environmental hazard must be evaluated clinically by means
of a physical examination and appropriate diagnostic studies (see App.
B). Where findings reveal a condition that may require treatment, refer
the veteran to the Enrollment Coordinator in the Business Office to
determine if the veteran is eligible for treatment.

**4. RESPONSIBILITIES**

a\. The GWR is modeled after the Agent Orange and Ionizing Radiation
Registries. All VA facility staff must be alerted of the GWR through
appropriate internal communications, e.g., medical center memoranda and
posters providing names, locations, and office telephone numbers of the
Environmental Health (EH) Clinician and EH Coordinator.

\(1\) The GWR is the responsibility of VA Central Office Environmental
Agents Service (EAS), in coordination with:

\(a\) EH Clinicians;

\(b\) EH Coordinators; and

\(c\) The VA Austin Automation Center (AAC), Austin, TX.

\(2\) The GWR consists of medical examinations and other data of
concerned GW participants. The GWR is the most effective means of
identifying such concerned veterans.

b\. The EAS has the responsibility to develop, coordinate, and monitor
VHA activities relating to the GW issue. ***NOTE:** All policy and
clinical questions relating to the identity of possible diseases that
may result from service of U.S. military personnel in certain areas of
Southwest Asia should be referred to EAS.*

c\. The EH Clinician and EH Coordinator at each VA facility has the
responsibility for coordinating the medical and administrative aspects
of the registry. They and other medical center staff, play a key role,
beginning with the initial contact in:

\(1\) Providing registry participants with comprehensive health
screening examinations at no cost.

\(2\) Advising veterans of examination results; and

\(3\) Reporting examination findings to the AAC via website:
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
.

d\. There is a time lapse between the date of examination and the
processing of examination results. Accordingly, analyses used in
speeches or presentations needs to be qualified to avoid misleading or
misinforming the audience.

5\. GULF WAR REGISTRY (GWR) EXAMINATION

a\. **[Purpose.]{.underline}** This paragraph sets forth clinical and
administrative policies related to the maintenance of VHA's GWR Program
for physical examination of concerned veterans. ***NOTE:** Active duty
military personnel who served in Southwest Asia are eligible to
participate in the GWR Program.*

b\. **[Eligibility Criteria.]{.underline}** VA must provide a GWR
examination to veterans who request the examination and who served on
active military duty in Southwest Asia during the GW which began in
1990, and continues to the present {per 38 U.S.C. § 101(33)} including
OIF. ***NOTE 1:** The Business Office (163) should be consulted to
determine whether each veteran applying for this examination meets
pertinent eligibility requirements.*

\(1\) This includes service in one or more of the following areas:

\(a\) Iraq,

\(b\) Kuwait,

\(c\) Saudi Arabia,

\(d\) The neutral zone (between Iraq and Saudi Arabia),

\(e\) Bahrain,

\(f\) Qatar,

\(g\) The United Arab Emirates,

\(h\) Oman,

\(i\) Gulf of Aden,

\(j\) Gulf of Oman, and

\(k\) Waters of the:

[1]{.underline}. Persian Gulf,

[2]{.underline}. Arabian Sea; and

[3]{.underline}. Red Sea.

**NOTE**: Veterans who served in Afghanistan (Operation Enduring
Freedom) are not eligible for GWR examinations. Information on
Afghanistan or other combat areas can be accessed on website
<http://vaww.vhaco.va.gov/vhahq/publicat.htm>.

\(2\) Eligible GW and/or OIF veterans applying for treatment in a VA
medical center and/or outpatient clinic need to be encouraged to undergo
an initial (i.e., "first-time") GWR examination. ***NOTE:** The protocol
for conducting the physical examination and ordering diagnostic studies
is contained in Appendix B.*

\(3\) Veterans need to be advised that the registry examination or
treatment does not constitute a formal claim for compensation.

\(a\) Although the results of a GWR examination may be used to support a
compensation claim, the examination will not in and of itself be
considered such a claim.

***NOTE:** If a compensation examination is performed for a GW veteran
and the veteran requests inclusion in the GWR, it is not necessary to
schedule an additional registry examination as long as the information
is sufficient to adequately complete the registry examination questions
included in website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)*
.

\(b\) Veterans who wish to submit a claim for conditions possibly
related to GW service need to do so via the normal claims process
through a Veterans Service Representative (VSR) at the nearest VA
medical center or regional office. For further assistance, the veteran
may call one of the following toll-free numbers:

[1]{.underline}. Veterans Health Benefits Service Center 1-877-222-VETS
(8387), or

[2]{.underline}. VA Helpline 1-800-749-8387.

c\. **[Program Management.]{.underline}** For current information and
program activities, EH Clinicians, EH Coordinators, and Business Office
employees need to receive and familiarize themselves with quarterly
mail-outs, the EAS website
[www.va.gov/environagents/](http://www.va.gov/environagents/) and
[www.va.gov/gulfwar/](http://www.va.gov/gulfwar/), and various materials
distributed by VA Central Office. In addition, all program officials
need to attend the periodic EAS conference calls from VA Central Office.

d\. **[Responsibilities.]{.underline}** The EH Clinician, or designee,
EH Coordinator, and Business Office 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.

\(1\) **EH Clinician Responsibilities**

\(a\) The EH Clinician, 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 EH
Clinician serves in an advisory capacity for the administrative
management of the program, discusses with the patient the results of the
examination(s) and as appropriate providing follow-up visits and/or
possible referrals to other tertiary medical centers or War Related
Illness and Injury Study Centers (WRIISCs).

***NOTE**: Some veterans who return from combat missions may experience
persistent, unexplained, disabling symptoms. VA's WRIISCs are VA's
response to this important health issue. VA primary care providers
examining eligible combat veterans with undiagnosed illnesses can
request a veteran's evaluation at one of the Centers. Refer to VHA
Handbook 1303.5 and website <http://www.va.gov/environagents> for WRIISC
referral protocol and brochures and view the VHA video entitled "War and
Health: Treating War-Related Illnesses at VA's WRIISCs,"which describes
the clinical, risk communication, education and research programs of the
WRIISCs. This video also illustrates the type of patient for whom
referral may be indicated.*

\(b\) Major essential responsibilities of the EH Clinician include:

[1]{.underline}. Counseling the veteran as to the purpose of the
physical registry examination;

[2]{.underline}. Providing focused initial registry examination and
continuum of care if assigned responsibility as the primary care
clinician to those symptomatic veterans experiencing multiple symptoms
after their GW experience;

[3]{.underline}. Conducting and documenting the physical registry
examination in the veterans' health or administrative record, as
appropriate.

[4]{.underline}. Providing a complete medical history including:

[a]{.underline}. Family;

[b]{.underline}. Occupation;

[c]{.underline}. Social, including tobacco, alcohol, and drug use;

[d]{.underline}. Civilian exposure to possible toxic agents;

[e]{.underline}. Psychosocial condition; and

[f]{.underline}. Review of systems.

[5]{.underline}. Completing all elements of the registry examination,
then reviewing and reporting the code sheets to the AAC via website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
no later than 10 working days after initial examination.

[6]{.underline}. Personally discussing with each veteran the findings of
the physical registry examination and completed diagnostic studies. The
interview must be conducted in such a way as to encourage the veteran to
discuss any health concerns, as well as concerns expressed by family
members. ***NOTE:** When a follow-up examination is recommended by the
EH Clinician, the EH Clinician serves as the primary care provider to
the veteran, unless another primary care clinician has been assigned.*

[7]{.underline}. Personally discussing each veteran's need for a
follow-up examination either recommended by EH Clinician or requested by
the veteran.

[8]{.underline}. Documenting these discussions and/or findings in each
veteran's health record.

[9]{.underline}. Encouraging the veteran to contact a VA medical center
to document additional diagnoses in an appropriately titled progress
note in the veterans' health record if the veteran is subsequently
diagnosed with a significant health problem by a non-VA physician. This
new diagnosis must be submitted over the non-VA physician's signature
and on official letterhead and subsequently transmitted to AAC via
website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
for inclusion in the registry database.

[10]{.underline}. 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
Appendixes D and E.*

[a]{.underline}. These letters are to be mailed to the veteran within 2
weeks of the initial examination appointment. For any examination where
there is a new diagnosis, another letter is to be mailed within 2 weeks.
The only exception to this timeframe is 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]{.underline}. A copy of this dated and signed letter must be filed
and/or scanned into the veteran's health record.

[c]{.underline}. It is essential that this letter be written in language
that can be easily understood by the veteran. Inappropriate wording
could unduly alarm or confuse the veteran. ***NOTE:** A great deal of
sensitivity and care must be exercised in the preparation of this
correspondence.*

[d]{.underline}. The letter must explain that:

([1]{.underline}) If the veteran who was examined has no detectable
medical problems, the follow-up letter needs to so indicate and suggest
that the veteran contact the nearest VA health care facility if health
problems appear later.

([2]{.underline}) If it is determined upon examination that the veteran
does have medical problems, it is not necessary to specify the problems
in the letter.

([a]{.underline}) The veteran needs to be advised in the letter that the
recent examination indicated a health condition or problem which may
require further examination and/or treatment.

([b]{.underline}) If the veteran is eligible for VA medical treatment,
the letter needs to so advise and recommend that the veteran seek
follow-up medical care at the VA medical facility.

([c]{.underline}) If the veteran is not eligible for treatment, the
letter needs to so advise and recommend that the veteran seek
appropriate medical care elsewhere.

([3]{.underline}) The examination does not automatically initiate a
claim for VA benefits. For information relating to claims, refer the GW
veterans to a VSR at the nearest VA medical center or regional office.

([4]{.underline}) The results of the examination must be maintained by
VA and will be available for

future use as needed.

([5]{.underline}) If the veteran changes place of residence, the veteran
needs to provide the new address to the EH Coordinator and report the
new address to the AAC as a Type E entry via website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
.

\(2\) **EH Coordinator Responsibilities**

\(a\) The EH Coordinator is responsible for the administrative
management of the program, including:

[1]{.underline}. Completing Registry Code Sheets (see App. C),

[2]{.underline}. Scheduling of appointments,

[3]{.underline}. Monitoring timeframe compliance, and

[4]{.underline}. Reviewing records for accuracy and completeness.

\(b\) The EH Coordinator is specifically responsible for:

[1]{.underline}. [Scheduling]{.underline}. Facilities need to make every
effort to give each veteran a GWR examination within 30 days of the
request date. If numerous consultations are required, whenever possible,
all of these should be scheduled on the same day, so that the veteran
will not be unduly inconvenienced. When it is not possible to provide
all consultations on the same day, the EH Coordinator, or the scheduler,
needs to work with the veteran to minimize the number of 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
must 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. If, after these alternative
measures have been explored and the time standard still cannot be met,
an exemption needs to be requested by contacting EAS, VA Central Office
(202) 273-8463 or (202) 273-8465.

[2]{.underline}. [Disseminating Information]{.underline}. It is
important that each GW veteran be fully advised of the GWR examination.
Facility staff are encouraged to fully communicate all aspects of the
GWR examination by any appropriate means. The following alternatives
might be considered:

[a]{.underline}. Upon distribution by VA EAS, provide each GW veteran,
reporting to the outpatient area, with the following: ***NOTE:**
Information Bulletin (IB) 10-41 and IB 10-42 are also available in
Spanish.*

([1]{.underline}) "Gulf War Review," newsletter;

([2]{.underline}) IB10-41, "VA Gulf War Veterans' Illnesses, Questions
and Answers," which describes the purpose of the examination and its
limitations;

([3]{.underline}) IB 10-42, "Gulf War Research -- A Report to Veterans,"
which is for veterans specifically interested in research; and

([4]{.underline}) If appropriate, IB 10-166, "Operation Iraqi
Freedom/Enduring Freedom Review."

***NOTE:** These publications are accessible on website:
[www.va.gov/gulfwar/](http://www.va.gov/gulfwar/). Any questions and/or
answers can be further clarified by the examining physician prior to and
during the course of the physical examination.*

[b]{.underline}. EH Coordinators provide each veteran with a brief oral
explanation of the purposes of the GWR and the examination process and
respond to any questions the veteran might have. This can be
accomplished during the EH Coordinator's initial contact with the
veteran.

[3]{.underline}. [Data Entry Completion]{.underline}

[a]{.underline}. The EH Coordinator, or designee, must complete the
demographic sections of the Gulf War registry code sheet and ensure that
all information is entered into the AAC database via website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
before the veteran is referred to the clinician for the examination.

[b]{.underline}. The EH Clinician completes the Symptoms and Exams
Section of the Gulf War registry code sheet. These data may be entered
by the clinician or EH Coordinator. ***NOTE:** It is preferable that the
clinician enter the data to ensure accuracy and timeliness.*

[c]{.underline}. In the event that a veteran requests a GWR examination,
but does not wish to be included in the registry database, a registry
examination needs to be performed. In the "Remarks" indicate the current
date and note that the veteran chose not to participate in the registry.
This Gulf War code sheet needs to be filed in the veteran's
administrative or health record, as appropriate. Do not transmit this
code sheet to the AAC.

e\. **[Establishing, Updating, Retaining and Disposition of Health
Records]{.underline}**

\(1\) The EH Coordinator must establish a health record on each registry
participant if one does not already exist. VA Form 10-9009B, Gulf War
Identification Sticker, must be affixed to the front of the paper health
record, if appropriate, or posting "Gulf War Registry Examination," in
CPRS.

\(2\) These GWR records are subject to the same retention and
disposition policies as other medical record files, i.e., Records
Control Schedule (RCS) 10-1. The GWR examination information (registry
code sheet, progress notes, laboratory reports and other pertinent
examination documentation) must be made part of the perpetual medical
record following the same retention requirements specified for VA Agent
Orange and Ionizing Radiation examinations.

> f\. **[Incarcerated Veterans]{.underline}**

\(1\) GWR examinations may be provided to incarcerated veterans. The
examination may be provided either in the prison or jail, or in the VA
facility.

\(2\) If an incarcerated veteran is accepted for an GWR examination, VA
may conduct such an examination in a VA facility, but only after the
veteran has been released by an official under circumstances where there
is no obligation placed on VA to exercise custodial restraint, or to
ensure the return of the veteran to custody upon completion of the
examinations. VA is encouraged to work with said penal institution to
avoid potential disruptions at the VA medical center upon reporting for
the examination (example, the wearing of prison uniforms and restraints
are to be discouraged).

***NOTE:*** *The clinic Director, or designee, must notify the civil
authorities when the GWR examination is completed.*

\(3\) A bill is not issued to the penal institution for the GWR
examination of an incarcerated veteran conducted at a VA facility.

\(4\) For purposes of entry into the GWR, VA medical facilities can
provide assistance to penal authorities or institutions agreeable to
conducting examinations to veterans. ***NOTE.** VA will not reimburse
the penal authorities when they conduct these GWR examinations.*

\(a\) Copies of this Handbook 1303.2, GW registry examination code
sheets, etc., must 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 are
to be returned to the VA facility of jurisdiction for inclusion, on the
veteran's behalf, in VA\'s GWR.

\(c\) A recommendation can be made to the penal institution to retain a
copy of the examination documents submitted to VA. ***NOTE:** Such
documents need to be maintained by penal authorities and provided to the
individual upon release from the penal institution.*

g\. **[Veterans With Other Than Honorable Discharges]{.underline}.** The
requirements of M-1, Part I, Chapter 4, apply to veterans with less than
honorable discharges applying for GWR examinations.

h\. **[Active Duty Military Personnel.]{.underline}** When active duty
members of the uniformed services apply to VA facilities for a GWR
examination, the Department of Defense (DOD) must authorize and provide
the appropriate DOD Form 2161, Referral for Civilian Care, or equivalent
form, requesting this examination, or DOD must provide services under an
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 apply. ***NOTE:** VA facilities need to reference the
current directive providing the interagency billing rates.*

\(1\) Procedures for processing the examination are the same as those
for a veteran participating in this program.

\(2\) A military facility may perform the GWR examination according to
VA instructions or the corresponding military instructions. ***NOTE*:**
*DOD has established a Hotline, 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 as the veteran's Direct Hotline
(1-800-472-6719) for GW veterans to call with their recollection of
\"incidents\" that might be related to health problems.*

\(3\) Military facilities may obtain the pertinent VA administrative
issue and appropriate forms from the nearest VA site. The VA Medical
Center, 50 Irving Street, N.W., Washington, DC 20422, Attn:
Environmental Health Coordinator (136), is the processing center for all
active duty members of uniformed services stationed
[overseas]{.underline}. Military facilities must complete GWR
examination worksheets with exception of the facility number, suffix (if
applicable) and county and state. This information will be completed by
the VA EH Coordinator.

\(4\) Military facilities must provide completed copies of the code
sheets, physical examination, laboratory tests, etc., to the nearest VA
medical center or outpatient clinic. The EH Coordinator must:

\(a\) Complete the GWR data code sheets to include facility number (and
suffix, if applicable), and county and state codes.

\(b\) Transmit the code sheet data to the AAC via website:
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
.

\(c\) Establish a health record, if one does not already exist, and
maintain in the paper administrative health record or scanned and
attached to an appropriately titled CPRS Progress Note; and

\(d\) If requested, and only with a written authorization (release of
information) from an active duty member or other legal authority as
outlined in VHA Handbook 1605.1, VA may supply a copy of these medical
records to the military facility.

i\. **[Updating EH Clinician and EH Coordinator
Appointments.]{.underline}** Separate listings of EH Clinician and EH
Coordinators are maintained within EAS.

\(1\) In an effort to keep these listings current, facilities are
required to notify the EAS of any changes in the status of appointments
of the EH Clinician and/or the EH Coordinator at their respective
facilities.

\(2\) As changes in designation occur, submit in writing the name,
title, mail routing symbol, and telephone numbers including area code,
to the Environmental Health Coordinator (131), EAS, VA Central Office,
810 Vermont Avenue, N.W., Washington, DC 20420 (Facsimile Number
202-273-9080). ***NOTE:*** *In order to provide current GW information
to concerned VA Registry Staff, it is important that any changes in
designation of EH Clinicians and EH Coordinators at VA facilities be
provided to VA Central Office (131) as they occur.*

**6. GULF WAR UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)**

a\. **[Background]{.underline}**

\(1\) Many of the almost 690,000 personnel who served in the GW 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 that developed after their Gulf War service. These GW veterans
seen by VA EH Clinicians 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.

\(2\) VA and DOD working cooperatively developed a Uniform Case
Assessment Protocol (UCAP) for the evaluation of these GW veterans who
after a thorough routine medical evaluation are determined to have
unexplained illnesses (see App. F). ***NOTE:*** *This UCAP grew out of
the medical experience in diagnostic evaluation of GW veterans seen at
VA Referral Centers. (These Centers were discontinued and replaced with
War Related Illness and Injury Study Centers expanding their mission to
offer similar comprehensive clinical care to combat veterans of all
eras, as described in VHA Handbook 1303.5.) The protocol was then
further refined and adapted for use by both VA and DOD facilities. DOD's
similar protocol is identified as Comprehensive Clinical Evaluation
Program (CCEP).*

\(3\) The UCAP includes a group of supplemental baseline laboratory
tests and consultations which needs to be provided to every veteran with
debilitating unexplained illness. It gives guidelines for the minimum
diagnostic work-up for the most frequent complaints experienced by GW or
OIF veterans with unexplained illnesses. This protocol utilizes
validated and readily available diagnostic tests to thoroughly evaluate
each of the common symptoms reported by GW and OIF veterans.

\(4\) The concept behind the protocol was to identify previously
unrecognized major diagnostic entities which could provide an
explanation for the symptoms commonly reported in GW veterans with
unexplained illnesses. ***NOTE:** 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 EH or
Primary Care clinicians directing the work-up. The information gathered
by this process is to be entered into a computerized database at
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
.

b\. **[Authority.]{.underline}** The UCAP for GW veterans with
unexplained illnesses was administratively

established by the Under Secretary for Health to assist in addressing
the unique health concerns of the GW 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 GW veterans.

c\. **[Scope.]{.underline}** All VA health care facilities must examine
the available services for GW and OIF veterans to ensure that quality
outreach, diagnostic, and treatment services are furnished as intended.
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.

d\. **[Responsibilities]{.underline}**

\(1\) **EH Clinicians.** The responsibility of the EH Clinician is to:

\(a\) Conduct the Registry examination (Phase I), which is the first
step toward diagnosis of the health problems of a GW or OIF veteran; and

\(b\) If a diagnosis is not readily apparent after conducting routine
medical evaluations, to initiate the UCAP, (Phase II) using the protocol
provided in Appendix G.

\(2\) **EH Coordinators.** The EH Coordinator is responsible for:

\(a\) Following the reporting instructions as included in Appendix G.

\(b\) Providing accurate coding of both symptoms and diagnoses, and when
questions arise about these items consult with EH Clinician, or
designee.

\(c\) Completing and transmitting the UCAP to the AAC website at:
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)

**7. MEDIA AND OTHER EXTERNAL CONTACTS**

a\. **[Media Contacts.]{.underline}** Reports of Contact from various
media sources (e.g., radio, television, newspapers, etc.) concerning GWR
Program activities are to be referred by phone to the facility Public
Affairs Officer. Interviews are not to 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 Gulf
War-Related Illnesses.]{.underline}** Medical centers can expect, on
occasion, to be contacted by private sector physicians, researchers, and
the general public with information regarding "quick cures" for GW-\
related illnesses. Such individuals need to 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 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; 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.

\(6\) In general, VA cannot fund experimental treatments of veterans at
non-VA facilities.

**DEFINITIONS AND ACRONYMS**

1\. **AAC -** The Office of Financial Management, Austin Automation
Center (AAC) in Austin, TX. It is the location of the computerized
registry for code sheet data collection and database entry.

2\. **ANA -** Anti-Nuclear Antibody.

3\. **BAER -** Brainstem Auditory Evoked Response.

4\. **CAPS-PTSD -** Clinical Administered-Post Traumatic Stress
Disorder.

5\. **CARC -** Chemical Agent Resistant Compound paint.

6\. **CBC** - Complete Blood Count.

7\. **CHR** - Consolidated Health Record. A file containing medical
records relating to patient identity, diagnosis, prognosis or treatment
at Department of Veterans Affairs (VA) facility.

8\. **CPK** - Creatine Phosphokinase.

9\. **CPRS** - Computerized Patient Record System.

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 (131), VA Central
Office, has the responsibility to coordinate and monitor all VHA
activities, research and otherwise, relating to the Gulf War issue.

17\. **ECG** - Electrocardiogram.

18\. **EEG** - Electroencephalogram.

19\. **EGD** - Esophagastroduodenoscopy.

20\. **Environmental Health (EH) Clinician** - The EH Clinician is a
physician that is responsible for the clinical management of the Gulf
War (GW) Program at each VA medical facility.

21\. **EH Coordinator** - The EH Coordinator is a non-clinician staff
member responsible for the administrative management of the program at
each VA facility.

22\. **EMG** - Electromyogram.

23\. **ENG** - Electronystamogram.

24\. **Examinations**

a\. [Initial]{.underline}. The first physical examination which is
completed, transmitted and entered in the GW registry database, located
at the AAC, via website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
.

b\. [Follow-up]{.underline}. Examination performed subsequent to the
initial (first) examination and

entered in GW registry website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
.

25\. **Facility** - Any VA entity that provides GW Registry examinations
to GW veterans.

26\. **GI** - Gastrointestinal.

27\. **GW** - Gulf War.

28\. **GWR -** Gulf War Registry - is a computerized index of veteran
participants, is managed centrally by the EAS in VA Central Office. The
coded findings of GWR Program physical examinations and related
diagnostic results are entered into a database by the VA facility staff
via website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/).

29\. **GYN** - Gynecology.

30\. **Hct** - Hematocrit.

31\. **Hgb** - Hemoglobin.

32\. **HIV** - Human Immunodeficiency Virus.

33\. **IB-10-41** - VA Information Bulletin (IB) entitled "Gulf War
Veterans' Illnesses, Questions and Answers."

34\. **IB 10-42** - "Gulf War Research -- A Report to Veterans."

35\. **IB 10-166** - "Operation Iraqi Freedom/Enduring Freedom Review."

36\. **ICD-9-CM** - The current issue of the International
Classification of Diseases, 9th Edition, Clinical Modification provides
standardized classification of diseases.

37\. **IgG** - Immunoglobulin G.

38\. **KIA** - Killed in Action.

39\. **KTO** - Kuwait Theater of Operations.

40\. **LDH** - Lactic Acid Dehydrogenase.

41\. **LP** - Lumbar Puncture.

42\. **MIA** - Missing in Action.

43\. **MOS** - Military Occupational Specialty.

44\. **M.D.** - Doctor of Medicine.

45\. **MRI** - Magnetic Resonance Imaging.

46\. **MSLT** - Multiple Sleep Latency Test.

47\. **NCV** - Nerve Conduction Velocity.

48\. **OIF** - Operation Iraqi Freedom.

49\. **O&P** - Ova and Parasites.

50\. **P.A.** - Physician's Assistant.

51\. **PFT** - Pulmonary Function Test.

52\. **Plt** - Platelet.

53\. **PPD** - Purified Protein Derivative.

54\. **PTF** - Patient Treatment File.

55\. **PTSD** - Post-traumatic Stress Disorder.

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

57\. (**Persian) Gulf War Period of Service.** Public Law 102-25
established a (Persian) Gulf War period of service that affects persons
serving on active duty as of August 2, 1990. The wartime period of
service continues until terminated by Presidential proclamation or by
law.

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

59\. **RHP** - Reproductive Health Problems.

60\. **SCID** - Structured Clinical Interview for DSM-III.

61\. **SCUDS** - The common name for Soviet designed surface to surface
missiles.

62\. **SED** - Skin Erythema Dose.

63\. **SGPT(ALT)** - Serum Glutamic Pyruvate Transaminase.

64\. **SGOT (AST)** - Serum Glutamic Oxaloacetic Transaminase.

65\. **SMA (6/12)** - SMA is a Manufacturer's Trademark for a Chemistry
Analyzer.

66\. **SSN** - Social Security Number.

67\. **T4** - Thyroxine Total Serum.

68\. **TB** - Tuberculosis.

69\. **TSH** - Thyroid Stimulating Hormone.

70\. **UCAP -** Uniform Case Assessment Protocol.

71\. **UGI** - Upper Gastrointestinal.

72\. **VA** - Department of Veterans Affairs.

73\. **VBR** - Veterans Benefits Representative.

74\. **VDRL** - Venereal Disease Research Laboratory.

75\. **VHA** - Veterans Health Administration.

76\. **VA Form 10-9009B** - Identification Sticker entitled "Persian
Gulf."

77\. **WBC** - White Blood Cells.

**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: VA Form
10-9009a (July 1995), Gulf War Registry Code Sheet; dated follow-up
letters which must be maintained in the paper administrative health
record or scanned and attached to an appropriately titled CPRS Progress
Note; and all medical records of the registry examination, i.e.,
Standard Form (SF) 88, Report of Medical Examination, and SF 509,
Progress Notes (for follow-up) which must be maintained within CPRS.

***NOTE:*** *This should be accomplished by or under the direct
supervision of the Environmental Health (EH) Clinician. Examination data
will be recorded in the veteran's medical record as routinely as done
for any other medical examination.*

The complete medical history needs to address the following:

\(a\) Family history;

\(b\) Occupational history;

\(c\) Social history including tobacco, alcohol, drug use;

\(d\) 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.).

3\. When a GWR 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 EH Clinician or designee.

4\. The physician should be aware of the variety of exposures endemic to
the GW area. These are listed in Appendix C. There has been a wide
distribution of major categories of diagnosis reported by VA EH
Clinicians; 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
that should be considered:

***NOTE:*** *Recommended coding (refer to International Classification
of Diseases, Current Edition)*

*[Complaints]{.underline} [Symptom Code]{.underline}
[Diagnosis]{.underline} [Diagnostic Code]{.underline}*

***(If confirmed)***

######### (1) Other Symptoms involving:

#########  Nervous and Musculoskeletal 

#########  Systems for Pain in the joint 78199 Arthralgia 71940-71949

*(2) Malaise and Fatigue 78079 Chronic Fatigue Syndrome 78071*

*Fibromyalgia 7291*

*(3) Insomnia with sleep apnea 78051 Sleep Apnea 99001*

*or 78053*

**[DIAGNOSIS]{.underline}**

\(1\) Amebiasis

\(2\) Apnea, sleep

\(3\) Arthralgia

\(4\) Asthma

\(5\) Brill's Zinsser disease (recrudescent typhus)

\(6\) Bronchiectasis

\(7\) Bronchopneumonia, organism unspecified

\(8\) Brucellosis

(9) Chronic obstructive pulmonary disease, not elsewhere classified

\(10\) Chronic bronchitis

\(11\) Chronic Fatigue Syndrome

\(12\) Chronic Laryngotracheitis

\(13\) Chronic respiratory conditions due to fumes and vapors

\(14\) Emphysema

\(15\) Fibromyalgia

\(16\) Giardiasis

\(17\) Leishmaniasis

\(18\) Malaria

\(19\) Other and unspecified diseases of upper respiratory tract

\(20\) Pneumoconiosis due to other silica or silicates

\(21\) Pneumoconiosis, unspecified

\(22\) Unspecified chronic respiratory disease

\(23\) Respiratory conditions due to unspecified external agent

\(24\) Sandfly fever (phlebatomus fever)

\(25\) Schistosomiasis (bilharziasis)

\(26\) Toxoplasmosis

\(27\) Typhoid fever, also carrier - V02.1

\(28\) Tuberculosis, specify variant(s)

\(29\) Viral hepatitis

\(30\) Memory loss

\(31\) Polyneuropathy

\(32\) Skin rash

\(33\) Adjustment disorder, including Post Traumatic Stress

Disorder (PTSD)

\(34\) Alcohol dependence syndrome

\(35\) Drug dependence

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\. Blood and serum screening tests (SMA-6, SMA-12 or equivalent)
including glucose, electrolytes 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 conducted
according to the judgment of the EH Clinician or Primary Care Clinician
(see par. 9 and App. G, 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 and/or CPRS.

## INSTRUCTIONS FOR COMPLETING VA FORM 10-9009a

## GULF WAR REGISTRY CODE SHEET, PHASE 1

1\. General Instructions for completing Department of Veterans Affairs
(VA)

Form 10-9009 (July 1995).

a\. Electronic entry of Gulf War Registry (GWR) code sheet data should
be completed and

transmitted to the Austin Automation Center (AAC), Austin, TX database
via website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/).
Instructions for accessing this website are included on the home page.
The home page includes a User's Guide, Frequently Asked Questions,
Validation Reports, and Logon functions. Edits are automatically
accomplished at the time of entry. The completed registry code sheet
must be maintained in the paper administrative health record or scanned
and attached to an appropriately titled Computerized Patient Record
System (CPRS) progress note.

***NOTE**: As of September 30, 2003, the AAC no longer accepts hard
copies of code sheets mailed to their offices in Austin, TX.*

b\. Follow instructions carefully to ensure that all data fields are
accurately completed.

\(1\) Part I of the code sheet may 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 Environmental Health (EH) or Primary Care
Clinician and coded by appropriate staff, either the EH Coordinator and
Coding Clerk. ***NOTE:** Careful attention should be paid to assigning
the correct code for both complaints (symptoms) and diagnosis.
International Classification of Diseases, Clinical Modification, 9th
Edition (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.*

**2.** **Instructions for Completing Part I (Initial Examination)**

a\. **Item 1. Facility Number and Suffix.**
**Facility Number and Suffix.** Enter facility code as listed on website
<http://vaww.aac.va.gov/npcd/facility_quick_reference.asp> or
<http://vaww.aac.va.gov/npcd/new/Stations.php> .

b\. **Item 2. Last Name of Veteran.** Enter veteran's current last name.
Do not use apostrophe and/or hyphen in the name. If the last name is
followed with JR, SR, I, II, III, do not use commas, etc.

c\. **Item 3. First Name of Veteran**. Enter veteran's first name.

d\. **Item 4. Middle Name of Veteran**. Enter veteran's middle name or
initial.

e\. **Item 5. Type of Examination**. The following are transaction types
that appear at the registry logon:

A - Initial Examination. The veteran's first Gulf War (GW) examination.
If an initial examination code sheet has already been entered for the
veteran, "A" is not available.

B -- Deletes an entire initial examination that was originally submitted
through the manual batch process. Do not use this to delete an initial
examination that was entered via the website. If the transaction was
entered using the registries website, simply edit the original
transaction. This will automatically create a Type "B" that deletes the
original and adds the corrected transaction to the master file.

C - Follow-up Examination. The veteran's second and subsequent GWR
examination. Entering data for the first follow-up examination is
required. Data from subsequent follow-up code sheets will not be entered
or transmitted to the AAC unless a diagnostic code differs from
previously submitted code sheets.

***NOTE**: Consultations relating to the initial or first-time
examination are not considered follow-up examinations for the purpose of
this registry.*

D - Deletes an entire follow-up examination that was originally
submitted through the manual batch process. Do not use this to delete a
follow-up examination that was entered via the website. If the
transaction was entered using the registries website, simply edit the
original transaction.

E - Transmits a change in demographics, i.e., name, address, or date of
birth. Enter "E," and complete items with name, Social Security Number
(SSN), date of birth, and address. No other items need to be completed.

I - To include those veterans whose names are not on the GWR but would
like their name and address included on a mailing list for the "Gulf War
Review" newsletter.

P - To include diagnoses submitted by a private physician, on the
physician's letterhead paper, and signed by that physician, certifying
the accuracy of the diagnoses.

X - Identifies and verifies that a registry participant is deceased.
Complete items with the name, SSN, and date of birth. No other items
need to be completed.

f\. **Item 6. SSN**. The SSN that is entered at Registry Search via
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
, appears in these spaces.

g\. **Item 7. Date of Birth**. Enter numerical equivalent for the month,
day, and four-digit year (e.g., 01/19/1960).

h\. **Item 8. Permanent address**. Enter veteran's permanent street
address.

8a = Enter veteran's city or town.

8b = Enter County and State.

8c = Enter zip code of permanent residence (National Zip Code
Directory).

8d = Optional (Extended Zip Code).

8e = The user does not enter the County and State Code, as they are
entered automatically.

i\. **Item 9. Race or Ethnicity.** Enter from the pull-down menu.

j\. **Item 10. Marital Status**. Enter one of the following codes from
the pull-

down menu:

1 = Married

2 = Divorced

3 = Separated

4 = Widowed

5 = Single, Never Married

k\. **Item 11. Sex.** Enter one of the following codes from the
pull-down menu:

M = Male

####  F= Female {#f-female .unnumbered}

l\. **Item 12. Current Status**. Enter one of the following codes from
the pull-down menu:

1 = Inpatient

2 = Outpatient

3 = Incarcerated

4 = Active Duty (Outpatient)

5 = Active Duty (Inpatient)

m\. **Item 13. Branch of Service.** If veteran was in more than one
branch of service, enter the latest GW service. Enter one of the
following codes:

1 = Army (including Reserves and National Guard)

2 = Air Force (including Reserves and 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. Military Service in Persian Gulf.**

\(1\) Enter one of the following codes from the pull-down menu:

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 GWR 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
02/91 to 05/91).

\(3\) Item 14B. If veteran had two or more periods of service in Persian
Gulf, the longest period of service should be entered. If only one
period of service in Persian Gulf, enter in 14A and leave 14B blank.

o\. **Item 15, 15A, and 15B. In What Area(s) Did Veteran Serve?**

\(1\) Item 15A. Enter one of the following codes from the pull-down
menu:

1 = Combat Zone

2 = Other Land Area

3 = Sea Duty

\(2\) Item 15B. If other service is indicated or, if the response is
"Don't Know" enter appropriate code from pull-down menu.

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

5 = Don't Know

p\. **Item 16, 16A-16E. Military Units, Military Occupational Specialty
(MOS) and MOS-Different Duties.**

\(1\) Item 16A. Military Units. Enter the military unit in which the
veteran served. Specify complete unabbreviated title, i.e., 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. Were actual duties different from MOS? Enter one of the
following codes from the pull-down menu: If no, go to Item 16E.

Y = Yes

N = No

\(4\) Item 16D. If yes, enter actual duties that were different from
MOS.

\(5\) 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 and 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. 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
12/90 to 04/91 and 9/90 to 11/90). 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., 12/90) and enter nines (e.g.,
99/99) to indicate the veteran is still actively serving in the
military.

r**. Items 18, 18A-18Z1. Veteran's Exposure to Environmental Factors**.
Enter the following codes from pull-down menu:

Y = Yes

N = No

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

(2**)** Item 18B. If yes, how many years have you been smoking
cigarettes? Enter number of years.

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

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

\(5\) Item 18E**.** If yes, how many years did you smoke?

\(6\) Item 18F**.** If yes, on the average how many packs did you smoke
per day?

\(7\) Items 18G-Z1. While in the Persian Gulf do you believe you were
exposed to any of the following? Enter the following codes from the
pull-down menus:

Y = Yes

N = No

U = Unknown

\(8\) Item 18G**.** Smoke from oil fires?

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

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

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

\(12\) Item 18K. Exposure to burning trash and/or feces?

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

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

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

\(16\) Item 18O. Depleted uranium?

\(17\) Item 18P. Microwaves?

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

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

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

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

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

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

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

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

\(26\) Item 18Y. Immunization against anthrax?

\(27\) Item 18Z. Immunization against botulism?

\(28\) Item 18Z1. Enter other exposures.

s\. **Items 19A-F. Gulf War Experience.** Did you have any of the
following experiences while in the Persian Gulf? Enter codes from the
pull-down menus:

\(1\) Item 19A. Did you ever go on combat patrols or have other very
dangerous

duty? Enter one of the following codes:

1 = No

2 = 1-3 times

3 = 4-12 times

4 = 13-50 times

5 = 51 times, or more

6 = Unknown

\(2\) Item 19B. As far as you know, were you ever under enemy fire,
including Soviet designed surface to surface missiles (commonly known as
SCUDS)? Enter one of the following codes:

1 = Never

2 = less than 1 day

3 = less than 1 week

4 = 1-4 weeks

5 = 4 weeks or more

6 = Unknown

\(3\) Item 19C. What percentage of people in your unit (your immediate
group) were Killed in Action (KIA), wounded or Missing In Action (MIA)?
Enter one of the following codes:

1 = None

2 = 1-25 percent

3 = 26-50 percent

4 = 51-75 percent

5 = 76 percent or more

6 = Unknown

\(4\) Item 19D. How often did you see someone hit by incoming or
outgoing rounds? Enter one of the following codes:

1 = Never

2 = 1-2 times

3 = 3-12 times

4 = 13-50 times

5 = 51 times or more

6 = Unknown

\(5\) Item 19E. How often were you in danger of being injured or killed
(i.e., pinned down, overrun, ambushed, near miss, etc.)? Enter one of
the following codes:

1 = Never

2 = 1-2 times

3 = 3-12 times

4 = 13-50 times

5 = 51 times or more

6 = Unknown

\(6\) Item 19F. Witnessed chemical alarms? Enter one of the following
codes:

Y = Yes

N = No

U = Unknown

t\. **Item 20. Veteran's Health** (Veteran's evaluation) Item 20A. Enter
one of the following codes from pull-down menu that best describes
veteran's health after GW Service:

1 = Very good

2 = Good

3 = Fair

4 = Poor

5 = Very poor

u\. **Item 21. Veteran\'s Functional Impairment**

\(1\) Item 21A. Enter code that describes veteran's assessment of the
veteran's functional impairment, after GW Service, using one of the
following assessment codes from the pull-down menu:

1 = No impairment

2 = Slight impairment

3 = Moderate impairment

4 = Severe impairment

\(2\) Item 21B. How many workdays were lost by veteran due to illness in
the past 90 days? Enter number of days lost.

v\. **Item 22. Evidence of Birth Defects and Infant Death(s) among
veteran's children and problems with pregnancy and infertility**
***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*.

\(1\) Item 22A. How many children does the veteran have? If none, go to
22C.

\(2\) Item 22B. Birth Defects. How many of these children were born with
birth defects? Enter number of children. If none, go to Item 22C.

\(a\) Item 22B1. How many of these children were conceived before and/or
after the veteran's GW service? If none, go to Item 22B2.

\(b\) Item 22B1(a). If yes, enter the maternal age at conception of
first child conceived before GW service.

\(c\) Item 22B2. How many children were conceived during or after the
veteran's GW service? If none, go to Item 22C.

(d). Item 22B2(a) If yes, Enter the maternal age at conception of first
child conceived during or after the veteran's GW service.

\(3\) Item 22C. 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:

Y = Yes

N = No (If No, go to Item 22D.)

\(a\) Item 22C1. Has veteran or spouse had infertility before GW
service? Enter one of the following codes:

Y = Yes

N = No (If No, go to Item 22C2.)

\(b\) Item 22C1(a). Enter the maternal age during first attempts to
conceive.

\(c\) Item 22C2. Has veteran or spouse had infertility after return from
GW service? Enter one of the following codes:

Y = Yes

N = No (If No, go to Item 22D.)

\(d\) Item 22C2(a). Enter the maternal age during first attempts to
conceive.

\(4\) Item 22D. 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:

Y = Yes

N = No (If No, go to Item 22E.)

\(a\) Item 22D1. If yes, has veteran or spouse had miscarriage(s) before
GW service? Enter one of the following codes:

Y = Yes

N = No (If No, go to Item 22D2.)

\(b\) Item 22D1(a). If yes, enter the maternal age at conception.

\(c\) Item 22D2. Has veteran or spouse had miscarriage(s) after return
from GW service? Enter one of the following codes:

Y = Yes

N = No (If No, go to Item 22E.)

\(d\) Item 22D2(a). If yes, enter the maternal age at conception.

\(5\) Item 22E. 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:

#####  {#section-1 .unnumbered}

#####  Y = Yes {#y-yes .unnumbered}

N = No (If No, go to Item 22F.)

\(a\) Item 22E1. Has veteran or spouse had still birth(s) before GW
service? Enter one of the following codes:

Y = Yes

N = No (If No, go to Item 22E2.)

\(b\) Item 22E1(a). Enter the maternal age at conception of the still
born child.

\(c\) Item 22E2. Has veteran or spouse had still birth(s) after return
from GW service? Enter one of the following codes:

Y = Yes

N = No (If No, go to Item 22F.)

\(d\) Item 22E2(a). If yes, enter the maternal age at conception of the
still born child. Enter age.

\(6\) Item 22F. 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:

Y = Yes

N = No (If No, go to Item 22G.)

\(a\) Item 22F1. Has veteran or spouse had babies with infant death(s)
before GW service? Enter one of the following codes:

Y = Yes

N = No (If No, go to Item 22F2.)

\(b\) Item 22F1(a). If yes, enter maternal age at conception of the
infant who died.

\(c\) Item 22F2. Has veteran or spouse had babies with infant death(s)
after return from GW service? Enter one of the following codes:

Y = Yes

N = No (If No, go to Item 22G.)

\(d\) Item 22F2(a) Enter the maternal age at conception of the infant
who died.

\(7\) Item 22G. If applicable and the woman veteran reports she was
pregnant in the Persian Gulf, record the date of child\'s birth and
hospital of birth to facilitate follow-up, if needed.

**3.** **Instructions for Completing GWR Code Sheet, Part II (Initial
Examination**). (*To be completed by the examining clinician)* List up
to ten major and current symptoms and/or complaints. If veteran has more
than ten, enter most severe. Any additional symptoms should be entered
under Remarks, Item 32.

***NOTE***: C*oders, use ICD-9-CM "Symptom" codes from the current
ICD-9-CM codebook. For uncodable symptoms use "78999." For no known
complaints, use "78000." However, ICD-9-CM code 78999 should
[only]{.underline} be used if all possible codes have been reviewed; if
necessary, seek physician consultation to make a correct choice.*

a\. **Item 23. Date of Examination**. Enter the numerical equivalent for
the month, day, and year in that order (e.g., 9/22/1992).

b\. **Item 24. Total Number of Veteran's Complaints**.

c\. **Item 25, 25A-M. Veteran's Complaints, Month and Year of Onset,
Duration in Months, Whether Symptom is Currently Present, and Most
Severe Complaint**.

\(1\) **Items 25A-J.**

\(a\) Describe veteran's complaints/symptoms.

\(b\) State ICD-9-CM codes.

\(c\) State duration in Months.

\(d\) State whether the symptom is still present, using the following
codes: Y=Yes or N=No from the pull-down menu.

\(e\) State month and year of onset.

\(2\) **Item 25K.** Most Severe Symptom/Complaint. Enter the Item code
from pull-down menu for most severe symptom (Symptom from Items A-J,
which the [veteran]{.underline} considers the most severe; i.e., the
chief complaint).

d\. **Item 26, A-S. Diagnostic workup/consultation.** Enter one of the
following codes from pull-down menus:

1 = No workup. No consultation done.

2 = Workup and/or consultation done. Unexplained illness.

3 = Workup and/or consultation done. Diagnosis established.

4 = Workup and/or consultation done. No diagnosis.

\(1\) Item 26A. Allergy and/or Immunology.

\(2\) Item 26B. Audiology.

\(3\) Item 26C. Cardiology.

\(4\) Item 26D. Dentistry.

\(5\) Item 26E. Dermatology.

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

\(7\) Item 26G. Endocrinology.

\(8\) Item 26H. Gastroenterology.

\(9\) Item 26I. Hematology and/or Oncology.

\(10\) Item 26J. Infectious Diseases and/or Parasitology.

\(11\) Item 26K. Nephrology.

\(12\) Item 26L. Neurology.

\(13\) Item 26M. Occupational Medicine.

\(14\) Item 26N. Pulmonary.

\(15\) Item 26O. Psychiatry.

\(16\) Item 26P. Psychology and/or Psychometric Testing.

\(17\) Item 26Q. Rheumatology.

\(18\) Item 26R. Other. Were any additional workups and/or consultations
performed as part of GWR examination which were not listed in Items
26A-Q. Enter one of the following codes from pull-down menu:

Y = Yes

N = No

\(19\) Item 26S. Specify on code sheet any additional workups and/or
consultations performed as part of GWR registry examination that were
not listed in Item 26A-Q.

e\. **Item 27, 27A-B. Diagnoses.** Item 27A. List up to ten major
definite medical diagnoses on lines 27A-J. The examining physician will
select the ten most significant and/or serious in the examining
physician's opinion, **listing the primary diagnosis in Item A**. Any
additional diagnosis(es) must be included in patient's medical record.
Coders are to code each diagnosis listed from the current ICD-9-CM
codebook. Leave blank if no diagnosis is made. Do not repeat or enter
symptom codes already listed under Item 25A-J.

f\. **Item 28. No Diagnosis Made.** If no diagnosis is made, enter a
"1,"otherwise leave this block blank. This item must be considered in
conjunction with Item 27, "Diagnoses." A "1" needs to 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. Disposition.** Enter one of the following codes
from the pull-down menu: Y = Yes, or N = No.

\(1\) Item 29A. Examination completed?

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

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

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

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

\(6\) Item 29F. Biopsy?

h\. **Item 30. 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 from the pull-down menu: Y =
Yes; or N = No.

i\. **Item 31. Has Phase II examination been initiated?** Enter the
following codes from the pull-down menu: Y = Yes; N = No.

j\. **Item 32. Remarks**. Utilize this section for any additional
information.

k\. **Item 33. Name of Examiner**. Enter full name of examiner.

l\. **Item 34. Title of Examiner.** Full title of examiner.

m\. **Item 35. Signature of Examiner.** Signature of examiner, if
electronic signature is available. Item 35a**. Signature of Physician.**
Signature of EH Clinician, if electronic signature is available.

**4. Follow-up Examinations**. Follow-up examinations should be entered
into the GWR using Type C. The instructions for completing Parts I, II
and III are available via website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
. Only the first follow-up examination is entered into the GWR unless
subsequent follow-up examination data contains new diagnoses.

**EXAMPLE GULF WAR REGISTRY FOLLOW-UP LETTER**

**(MEDICAL PROBLEMS INDICATED)**

> ![](media/image1.png){width="0.9895833333333334in"
> height="0.9243055555555556in"} **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) Gulf War 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 that may have resulted
> from service in Southwest Asia during the Gulf War and/or Operation
> Iraqi Freedom.
>
> 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]{.underline}). If for any reason you cannot keep
> this appointment, please call ([telephone number]{.underline}) 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 Gulf War Registry examination, please contact the
> Veterans' Environmental Health Coordinator at ([telephone
> number]{.underline}) for assistance.
>
> Whether you are eligible for cost-free treatment or will be
> responsible for co-payments 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
> the nearest VA Regional Office. In your area, the Regional Office is
> located at ([address]{.underline}). Their telephone number is
> ([telephone number]{.underline}). If you need any further assistance,
> you may contact one of the following toll-free numbers:

(1) Veterans Benefits Representative: 1-800-827-1000 (for information on
    filing claims);

(2) Veterans Health Benefits Service Center: 1-877-222-VETS (8387) or

(3) VA Helpline: 1-800-749-8387.

> 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 Gulf War
> theater of operations during the Gulf War or Operation Iraqi Freedom.
> You will be receiving a "Gulf War Review" which is published
> periodically by VA's Environmental Agents Service. A copy of this
> "Review" is enclosed for your reference.
>
> For other veterans who served on active duty in a designated theater
> of combat operations after the Persian Gulf War or in combat against a
> hostile force during a period of hostilities after November 11, 1998,
> VA is authorized to provide a broad range of health care services to
> them for a 2-year period following separation from military service.
>
> We trust this information is helpful to you. Once again, your
> participation in the registry is appreciated.
>
> Sincerely yours,
>
> [(Signature)]{.underline}
>
> Name of Environmental Health Clinician
>
> Enclosure

**EXAMPLE GULF WAR REGISTRY FOLLOW-UP LETTER**

**(NO MEDICAL PROBLEMS INDICATED)**

> ![](media/image1.png){width="0.9895833333333334in"
> height="0.9243055555555556in"} **DEPARTMENT OF VETERANS AFFAIRS**
>
> **VA 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) Gulf War (GW) 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 that may have resulted
> from service in Southwest Asia during the Gulf War or Operation Iraqi
> Freedom (OIF).
>
> 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 Environmental
> Health Clinicians or Coordinators at the nearest VA medical center or
> outpatient clinic. You may reach us at ([telephone
> number)]{.underline}.
>
> 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 for compensation
> to establish possible service-connection, please contact your nearest
> VA Regional Office. In your area, the Regional Office is located at
> (address). Their telephone number is (phone number). VA may pay
> compensation for current disability due to any injury or disease that
> was incurred or aggravated during military service. The condition does
> not have to be related to combat.
>
> If you need any further assistance, you may call one of the following
> toll-free numbers:

(1) Veterans Benefits Representative: 1-800-827-1000 (for information on
    filing claims)

(2) Veterans Health Benefits Service Center: 1-877-222-VETS (8387) or

(3) VA Helpline: 1-800-749-8387

> 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 Gulf War
> theater of operations during the Gulf War. You will be receiving a
> "Gulf War Review" which is published periodically by VA's
> Environmental Agents Service. A copy of this "Review" is enclosed for
> your reference.
>
> For other veterans who served on active duty in a designated theater
> of combat operations after the Persian Gulf War or in combat against a
> hostile force during a period of hostilities after November 11, 1998,
> VA is authorized to provide a broad range of health care services to
> them for a 2-year period following separation from military service.
>
> We trust this information is helpful to you. Once again, your
> participation in the registry is appreciated.
>
> Sincerely yours,
>
> \_\_\_\_\_\_[(Signature)\_\_\_\_\_\_\_\_\_]{.underline}\_\_\_[\_\_\_\_\_\_\_\_\_]{.underline}
>
> Name of Environmental Health Clinician
>
> Enclosure

**UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)**

1\. **Phase I-Level Laboratory Evaluations**

a\. Complete Blood Count (CBC),

b\. Urinalysis, and

c\. Blood Chemistry - SMA-6. (SMA is a Manufacturer's Trademark for a
Chemistry Analyzer)

2\. **Phase II-Level Evaluation Protocol.** Phase II-Level Evaluations
are recommended for those veterans after complete clinically-indicated
evaluations are conducted and the clinician 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 Immunodeficiency (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.

\(a\) Structured Clinical Interview for the Diagnostic and Statistical
Manual of Mental Disorders, Third Edition, Revised (DSM III-R).
***NOTE:** Delete modules 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 need to have the listed minimum work-up.

\(1\) **Diarrhea,** to include**:**

\(a\) Gastrointestinal (GI) consult,

\(b\) Stool for Ova and Parasites (O&P),

\(c\) Stool Leukocytes,

\(d\) 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,

\(c\) Colonoscopy with biopsy,

\(d\) 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]{.underline}. Glucose,

[2]{.underline}. Protein,

[3]{.underline}. Cell Count,

[4]{.underline}. VDRL,

[5]{.underline}. Oligoclonal (lgG),

[6]{.underline}. Myelin basic protein,

[7]{.underline}. Opening pressure, and

[8]{.underline}. 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.*

\(c\) Neurology consult,

\(d\) Neuro-psychological testing,

\(6\) **Vertigo and/or Tinnitus**, to include:

\(a\) Audiogram,

\(b\) Electronystamogram (ENG), and

\(c\) Brainstem Auditory Evoked Response (BAER).

\(7\) **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),

\(c\) If routine PFT's are negative, perform Methacholine challenge
test, and

\(d\) 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

\(c\) Holter monitor.

\(10\) **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.

\(c\) Additional elements recommended for the evaluation of Gulf War
veterans with complaints of Reproductive Health Problems (RHP):

[1]{.underline}. Detailed genitourinary history and/or problems, e.g.,:

[a]{.underline}. Sexual,

[b]{.underline}. Genitourinary symptoms,

[c]{.underline}. Menstrual,

[d]{.underline}. Contraceptive practices,

[e]{.underline}. Pregnancy-related,

[f]{.underline}. Conception,

[g]{.underline}. Birth defects,

[h]{.underline}. Congenital disorders,

[i]{.underline}. Menopause,

[j]{.underline}. Prior infections,

[k]{.underline} Prior surgery, and

[l]{.underline}. Exposures to toxic agents, etc.

[2]{.underline}. Detailed genital and/or pelvic examination.

[3]{.underline}. Laboratory and ancillary testing, e.g.;

[a]{.underline}. Pap tests; and

[b]{.underline}. Tests for genitourinary infections.

[4]{.underline}. Urologist consultation for male veterans who have RHP
that cannot be diagnosed or managed successfully by primary care
practitioners.

[5]{.underline}. Gynecology consultation for female veterans who have
RHP that cannot be diagnosed or managed successfully by primary care
practitioners.

\(d\) Additional elements for evaluation of Gulf War veterans with
complaints of infertility.

[1]{.underline}. Detailed menstrual and reproductive history (such as
the Infertility Questionnaire utilized by Walter Reed Army Medical
Center).

[2]{.underline}. Semen analysis, e.g.:

[a]{.underline}. Volume,

[b]{.underline}. pH,

[c]{.underline}. Liquefaction,

[d]{.underline}. Sperm concentration,

[e]{.underline}. Motility,

[f]{.underline}. Progressive motility,

[g]{.underline}. Sperm viability,

[h]{.underline}. Leukocytes, and

[i]{.underline}. Morphology.

[3]{.underline}. Referral to an infertility specialist or program.

\(e\) Additional elements for evaluation of GW veterans with complaints
related to birth defects or genetic disorders in offspring conceived
during or after GW service.

[1]{.underline}. Detailed history of congenital or genetic disorders
(such as the Patient Genetic Screen Questionnaire utilized by Walter
Reed Army Medical Center).

[2]{.underline}. Detailed occupational exposures questionnaire (such as
Worker and Supervisor Questionnaires utilized by National Naval Medical
Center).

[3]{.underline}. Referral to a genetic disease specialist or program.

**INSTRUCTIONS FOR COMPLETING GULF WAR**

**UNIFORM CASE ASSESSMENT PROTOCOL (UCAP), PHASE II, PART III**

1\. **General Instructions for Completing Department of Veterans Affairs
(VA) Gulf War Registry Examination,** Uniform Case Assessment Protocol
(UCAP), Phase II**.**

a\. The Phase II examination needs to be offered to all eligible Gulf
War (including Operation Iraqi Freedom) veterans with unexplained
illnesses. The Phase II examination needs to 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 needs to 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 War Related Illness and
Injury Study Center (WRIISC). ***NOTE:** Refer to VHA Handbook 1303.5 or
website [www.va.gov/environagents](http://www.va.gov/environagents) and
video entitled War and Health: Treating War-Related Illnesses at VA's
WRIISCs.*

**2.** **Instructions for Completing Part III, Phase II**

a\. **Tests and Consultations.** Only those entries which are related to
the veteran's symptoms and deemed necessary by the examining physicians
need to be completed; leave test and consult questions that are not
applicable blank Select either (Y)es or (N)o from the pull-down menu.
***NOTE:** Refer to website
[http://vaww.registries.aac.va.gov](http://vaww.registries.aac.va.gov/)
for instructions.*

\(1\) **Item 1**. Were the following tests performed? Enter one of the
following codes from the pull-down menu:

\(2\) **Item 2.** **Blood Tests**

\(a\) Complete Blood Count (CBC)?

\(b\) Skin Erethyma Dose (SED) Rate?

\(c\) C-Reactive Protein?

\(d\) Rheumatoid Factor?

\(e\) Fluorescent Anti-Nuclear Antibody (ANA)?

\(f\) SGOT (AST) (Glutamic Oxaloacetic Transaminase)?

\(g\) SGPT (ALT) (Transaminase Glutamic Pyruvate)?

\(h\) Lactic Acid Hydrogenase (LDH)?

\(i\) Alkaline Phosphatase?

\(j\) Creatine Phosphokinase (CPK)?

\(k\) Hepatitis B Surface Antibody?

\(l\) Hepatitis B Core Antigen?

\(m\) Venereal Disease Research Laboratory (VDRL)?

\(n\) Vitamin B-12?

\(o\) Folate?

\(p\) Human Immuno-deficiency (HIV)?

\(q\) Thyroxine Total Serum (T4)?

\(r\) Thyroid Stimulating Hormone (TSH)?

\(3\) **Item 3**. **Urinalysis?**

\(4\) **Item 4**. **Tuberculosis (TB) Skin Test Purified Protein
Derivative (PPD)?**

\(5\) **Item 5**. **Chest X-ray?**

\(6\) **Item 6. Psychiatric Consultation?**

\(a\) **Item 6A.** Structured Clinical Interview for Diagnosis (SCID)
for Diagnostic and Statistical Manual of Mental Disorders, Third
Edition, Revised (DSM-III-R). Was the SCID interview given?

\(b\) **Item 6B.** Clinical Administered Post-traumatic Stress Disorder
(PTSD) Scale (CAPS). Was the CAPS performed?

\(c\) **Item 7**. **List of Diagnoses**. Designated physician staff or
clinical staff are to provide narrative description of diagnoses. If
none, leave blank. ***NOTE:*** C*oders: Enter International
Classification of Diseases, Clinical Modification, 9th Edition (ICD-9)
codes as required.*

b\. **SYMPTOM-SPECIFIC EXAMINATIONS, PHASE II *NOTE:*** *Complete only
those questions which are appropriate to the veteran's symptoms;
otherwise leave these blank.*

\(1\) **Item 8. Psychology-Neuropsychological Test**.

\(a\) Was this test performed?

\(b\) List of Diagnoses and ICD-9 codes.

\(2\) **Item 9. Infectious Disease-Screening Examination**.

\(a\) Was this examination performed?

\(b\) List of Diagnoses and ICD-9 codes.

\(3\) **Item 10.** **Dental Examination**.

\(a\) If there was a medical indication, was this examination performed?

\(b\) List of Diagnoses and ICD-9 codes.

\(4\) **Item 11. Diarrhea and/or Abdominal Pain.**

\(a\) Did patient receive a GI (Gastroenterology) consult?

\(b\) List Diagnoses and ICD-9 codes.

\(5\) **Item 12.** **Headache and/or Memory Loss.**

\(a\) Did patient receive neurology consult?

\(b\) List Diagnoses and ICD-9 codes

\(6\) **Item 13. Muscle Aches or Numbness.**

\(a\) Did patient receive a neurology consult?

\(b\) List Diagnoses and ICD-9 codes.

\(7\) **Item 14. Chronic Fatigue.**

\(a\) Did patient receive consult(s) relating to chronic fatigue?

\(b\) List Diagnoses and ICD-9 codes.

\(8\) **Item 15**. **Joint Pain.**

\(a\) Rheumatology Consult. Did patient receive rheumatology consult?

(b). List Diagnoses and ICD-9 codes.

\(9\) **Item 16.** **Chronic Cough and/or Shortness of Breath.**

\(a\) Pulmonary Consult. Did patient receive pulmonary consult?

\(b\) List Diagnoses and ICD-9 codes.

\(10\) **Item 17.** **Skin Rash.**

\(a\) Dermatology Consult. Did patient receive a dermatology consult?

\(b\) List Diagnoses and ICD-9 codes.

\(11\) **Item 18.** **Vertigo and/or Tinnitus.**

\(a\) Audiology consult? Did patient receive an audiology consult?

\(b\) List Diagnoses and ICD-9 codes.

(12**) Item 19.** **Chest Pain and/or Palpitations.**

\(a\) Cardiology Consult. Did patient receive a cardiology consult?

\(b\) List Diagnoses and ICD-9 codes.

\(13\) **Item 20. Reproductive Concerns.**

\(a\) Did male patient receive a urology consult?

\(b\) Did female patient receive a gynecology consult?

\(c\) List Diagnoses and ICD-9 codes.

\(14\) **Item 21.** **Final Diagnoses.** List up to ten major definite
medical diagnoses, with the primary diagnosis listed on line 21A with
ICD-9 codes. If no diagnosis is made, leave these lines blank as well as
the ICD-9 codes*.*

\(15\) **Item 22.** After completing the Uniform Case Assessment
Protocol (UCAP), Phase II, Part III, does the physician feel that the
veteran has an unexplained illness? Enter either Y(es) or N(o) from the
pull-down menu.