+-------------------------------------+--------------------------------+
| #                                   | ###  VHA HANDBOOK 1303.4       |
| ### Department of Veterans Affairs  |                                |
+-------------------------------------+--------------------------------+
| **Veterans Health Administration**  | **Transmittal Sheet**          |
+-------------------------------------+--------------------------------+
| **Washington, DC 20420**            | **March 30, 2004**             |
+-------------------------------------+--------------------------------+

EVALUATION PROTOCOL FOR NON-GULF WAR VETERANS WITH POTENTIAL EXPOSURE TO
DEPLETED URANIUM (DU)

**1. PURPOSE:** This Veterans Health Administration (VHA) Handbook
outlines the procedures for evaluating non-Gulf War (GW) veterans with
possible exposure to depleted uranium (DU). ***NOTE:*** *For GW
veterans, including those who served in Operation Iraqi Freedom (OIF),
refer to VHA Handbook 1303.1.*

**2. SUMMARY OF CHANGES:** Service personnel from non-Gulf War
conflicts, such as Bosnia, may have possible inhalation exposure to DU.
According to Public Law 102-585, Section 703(b)(2), each Department of
Veterans Affairs (VA) facility must offer a DU screening evaluation to
veterans of these conflicts using the DU Evaluation Protocol. Veterans
eligible for this evaluation and inclusion in VA's DU Registry Program
([not]{.underline} the Gulf War Registry Program) are identified and
referred by the Department of Defense or are self-referred.

**3. RELATED ISSUES:** VHA Handbook 1303.1.

**4. RESPONSIBLE OFFICE:** The Chief Public Health and Environmental
Hazards Officer (13) is responsible for the contents of this Handbook.
Questions about DU must be addressed to the Baltimore DU Follow-up
Program at 1-800-815-7533; general questions about the protocol may be
addressed to the Environmental Agents Service at (202) 273-8580.

**5**. **RESCISSIONS:** None.

**6. RECERTIFICATION:** This VHA Handbook is scheduled for
recertification on or before the last working day of March 2009.

  ------------------------------- ---------------------------------------
                                  S/ Art Hamerschlag for

                                  Robert H. Roswell, M.D.

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

  --------------- ------- ------------------------------------------------
  DISTRIBUTION:   CO:     E-mailed 3/31/04

                  FLD:    VISN, MA, DO, OC, OCRO, and 200 -- E-mailed
                          3/31/04
  --------------- ------- ------------------------------------------------

##### CONTENTS

**EVALUATION PROTOCOL FOR NON-GULF WAR VETERANS WITH POTENTIAL EXPOSURE
TO DEPLETED URANIUM (DU)**

######## PARAGRAPH PAGE

1\. Purpose 1

2\. Background 1

3\. Scope 1

4\. The Procedure 2

5\. Responsibilities of the Baltimore DU Program Staff 2

6\. References 3

######## APPENDICES

A VA Form 10-9009D, Depleted Uranium (DU) Questionnaire A-1

B VA Form 10-9009E, Depleted Uranium Program Checklist 24-Hour Urine

Uranium Collection Baltimore Department of Veterans Affairs (VA) Medical
Center B-1

**EVALUATION PROTOCOL FOR NON-GULF WAR VETERANS WITH POTENTIAL EXPOSURE
TO DEPLETED URANIUM (DU)**

**1. PURPOSE**

This Veterans Health Administration (VHA) Handbook outlines the
procedures for evaluating non-Gulf War (GW) veterans with possible
exposure to DU. ***NOTE:** For GW veterans, including those who served
in Operation Iraqi Freedom (OIF), refer to VHA Handbook 1303.1.*

**2.** **BACKGROUND**

a\. DU is natural uranium left over after most of the U-235 isotope has
been removed, such as that used as fuel in nuclear power plants. DU
possesses about 60 percent of the radioactivity of natural uranium; it
is a radiation hazard primarily if internalized, such as in shrapnel,
contaminated wounds, and inhalation. In addition to its radioactivity,
DU has some chemical toxicity related to being a heavy metal (similar to
lead).

b\. Testing of DU for possible military use began in the early 1960's
and was first used by the United States military in projectiles and
armor for tanks during the Gulf War, which began in 1990, and continues
to the present (see Title 38 United States Code (U.S.C.) § 101(33)). DU
has also been used in other conflicts, such as OIF and Bosnia. Service
personnel who may have had potential inhalation exposure to DU include
those on, in, or near vehicles hit with \"friendly fire;\" rescuers
entering burning vehicles; individuals near fires involving DU
munitions; individuals salvaging damaged vehicles; and those near
burning vehicles.

c\. The medical effects of DU exposure are continuing to be evaluated. A
group of GW veterans with retained DU fragments or DU-contaminated
wounds is being followed at a special DU Program at the Department of
Veterans Affairs (VA) Medical Center, Baltimore, MD. While no clinically
significant adverse effects of DU have been evident to date in this
group, some abnormalities have been detected on specialized testing.
***NOTE:** As of year 2003 the Baltimore DU Follow-up Program has seen
70 veterans.*

d\. The Baltimore DU Follow-up Program has determined that for
friendly-fire victims, a 24-hour urine determination for uranium is a
more sensitive screening test for DU than whole-body counting.

e\. The Austin Automation Center (AAC) functions as the "contractor" to
VHA in providing national level computer support for this DU program.

***NOTE:** For additional background information on DU, see the
references in paragraph 6.*

**3. SCOPE**

Each VHA facility must offer a DU screening evaluation using the DU
Evaluation Protocol (App. A and App. B) to any veteran eligible for
listing, or inclusion, in VA's DU Registry Program (for authority see
Public Law 102-585, § 703(b)(2)). Veterans eligible for listing, or
inclusion, in this Registry include veterans identified and referred by
the Department of Defense (DOD) because of possible DU exposure, or
veterans who self-refer because they are concerned about their potential
exposure to DU.

**4. THE PROCEDURE**

a\. Evaluation of veterans for potential DU exposure must be provided by
either a primary care clinician, or the Environmental Health Clinician,
utilizing the DU Evaluation Protocol described in Appendix A, VA Form
10-9009D, DU Questionnaire, and Appendix B, DU Consult Urine
Instructions. Components of the DU evaluation include the DU exposure
questionnaire and a 24-hour urine collection for creatinine and uranium.

b\. Any positive responses to the DU exposure questionnaire must be
followed-up with a more detailed history-taking by the VA primary care
provider. The full-exposure history must be recorded in the veteran's
consolidated health record (CHR) and/or the computerized patient record
system (CPRS). All free text on the DU exposure questionnaires must be
included in the CHR or CPRS. Completed DU exposure questionnaires are to
be transmitted to the AAC via website
<http://vaww.registries.aac.va.gov/index.asp>.

c\. The health care provider must contact the DU Follow-up Program at
the Baltimore VA Medical Center (1-800-815-7533) to discuss obtaining a
24-hour urine collection for uranium. ***NOTE:** The 24-hour urine
collection for uranium must be performed in accordance with instructions
in Appendix B.*

d\. Upon completion of the evaluation protocol, the DU exposure
questionnaire must be transmitted by the Environmental Health
Coordinator (EHC) via website
<http://vaww.registries.aac.va.gov/index.asp> to the DU Registry
database**.**

e\. Results of the 24-hour urine for uranium are communicated directly
to the veteran by letter from the Baltimore DU Follow-up Program with a
copy to the VA referring physician for the veteran\'s CHR and/or CPRS.
The Baltimore DU program staff transmits the urine uranium results to
AAC via website <http://vaww.registries.aac.va.gov/index.asp> .

f\. Follow-up actions for any veteran with an elevated 24-hour urine
uranium determination must be individualized based on discussion between
the veteran\'s primary VA clinician and the staff at the Baltimore DU
Follow-up Program.

**5. RESPONSIBILITIES OF THE BALTIMORE DU PROGRAM STAFF**

The Baltimore DU program staff is responsible for:

\(1\) Arranging for testing of urine samples for uranium.

\(2\) Sending, by letter, the results of the 24-hour urine for uranium
directly to the veteran with a copy to the VA referring clinician.

\(3\) Transmiting the urine uranium results to AAC via registry website
<http://vaww.registries.aac.va.gov/index.asp>

\(4\) Providing consultative advice to VA clinicians regarding DU
testing.

***NOTE:** Active-duty service members concerned about DU exposure, or
other health issues related to service in the Gulf or other conflicts,
need to be advised to contact a military health treatment facility or
call the DOD Gulf War Veteran's Hotline at 1-800-796-9699. Additional
information about DOD's post-deployment health care program initiatives
is available on its Deployment LINK website:
<http://deploymentlink.osd.mil/>.*

**6.** **REFERENCES**

a\. Voelz, George L., Chapter 13 - "Uranium," in [Hazardous Material
Toxicology]{.underline}, Eds. Sullivan, John B. and Krieger, Gary R.,
Williams and Wilkins, Baltimore, MD, 1992.

b\. Health Effects of Depleted Uranium - Fact Sheet, DOD, June 11, 1993.
***NOTE**: Copies may be obtained by calling (703) 697-3189.*

c\. "Agency for Toxic Substances and Disease Registry," United States
Public Health Service, 1990.

d\. [Toxicologic Profile for Uranium]{.underline}. PB91-180 471, U.S.
Department of Commerce, National Technical Information Service.
***NOTE:** The Customer Service number is (703) 487-4660.*

e\. McDiarmid, et al., "Health Effects of Depleted Uranium on Exposed
Gulf War Veterans," [Environmental Research]{.underline}. Section A,
Vol. 82, pages 168-180, 2000.

f\. McDiarmid, et al., "Urinary Uranium Concentrations in an Enlarged
Gulf War Veterans Cohort," [Health Physics]{.underline}, Vol. 80, No. 3,
pages 270-273. 2001.

g\. McDiarmid, et al., "Surveillance of Depleted Uranium Exposed Gulf
War Veterans: Health Effects Observed in an Enlarged "Friendly Fire"
Cohort," [Journal of Environmental Medicine.]{.underline} Vol. 4, No.
12, pages 991-1000, December 2001.

h\. VHA website:
[http://va]{.underline}[ww.va.gov/gulfwar](http://www.va.gov/gulfwar)/

**VA FORM 10-9009D, DEPLETED URANIUM (DU) QUESTIONNAIRE**

Below is an embedded copy of Department of Veterans Affairs (VA) Form
10-9009D, Depleted Uranium (DU) Questionnaire. This form can also be
found on the Veterans Health Administration (VHA) Forms at
<http://www.va.gov/vaforms> *.* This is to be used for local
reproduction. Since this is a low use form, it will not be stocked by
the Hines Service and Distribution Center (formerly known as the Forms
and Publications Depot).

You should use Adobe Acrobat 5.05 or later to view this form. To print
this form, your printer must be set to "print as image" and "fit to
page."

![](media/image1.wmf)

**DEPARTMENT OF VETERANS AFFAIRS (VA) FORM 10-9009F, DEPLETED URANIUM
(DU) PROGRAM CHECKLIST**

**24-HOUR URINE URANIUM COLLECTION**

**BALTIMORE VA MEDICAL CENTER**

**CONSULT URINE INSTRUCTIONS (REVISED 03/04)**

**Social Security**

**PATIENT
NAME:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Number: \_\_\_\_\_\_\_\_\_**

**ADDRESS :
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Specimen Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**TELEPHONE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date of Birth: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Referring VA Medical Center:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Mail Code:
\_\_\_\_\_\_\_\_\_\_\_**

**Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Referring Physician:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Beeper Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Telephone Number
: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**FAX Number (to receive report):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**■** Call DU Program at 1-800-815-7533 to obtain the specimen
collection kit, including the 24-hour specimen collection containers and
shipping materials from DU Program. Only 32 ounce Fischer wide-mouth
jugs will be accepted. [Specimens received in any other container will
be returned. Leaking containers will be returned.]{.underline}

**■** FAX a copy of this checklist with the top portion completed, and a
completed copy of VA Form 10-9009D, Depleted Uranium (DU) Questionnaire,
to 410-605-7943 [PRIOR TO SENDING THE SPECIMEN.]{.underline}

**■** Schedule patient for 24-hour urine collection.

Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

a\. Time of first void (discarded) urine DAY
1:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b\. Time of first void urine DAY
2:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**VA Form 10-9009F REPRODUCE LOCALLY Page 1**

**March 2004**

**DU PROGRAM CHECKLIST - CONSULT URINE INSTRUCTIONS (Continued)**

**■** Instruct the patient to urinate directly into the collection
container(s). Uranium sticks to the sides of the container. Therefore,
[do not transfer urine]{.underline} due to potential loss of analyte.
Issue 3 containers to patient to insure full 24-hour collection in
approved containers.

**■** Instruct the patient to [collect urine beginning after first
morning]{.underline} [void of Day 1, and end collection after first
morning void on Day 2 (the next day)]{.underline}.

**■** [Seal containers as tightly as possible]{.underline}. Double bag
each urine container with absorbent material. Make sure each plastic bag
is sealed tightly. [Stabilize container inside the box]{.underline} with
more absorbent packing material to prevent movement. The sample must be
mailed in the package provided. *TIP: YOU CAN CONTACT YOUR LABORATORY
SERVICES SUPERVISOR TO ASSIST IN PACKAGING.*

**■** A copy of this VA Form 10-9009E [sealed in a separate ziplock
plastic bag]{.underline} is to be enclosed with the sample for
identification purposes and also is to be faxed with the completed copy
of VA Form 10-9009D to the DU office at 410-605-7943.

**■** [SEND SPECIMEN VIA FEDEX]{.underline}. [Call the DU Program
Office]{.underline} at 1-800-815-7533 as soon as specimen has been
shipped.

**FEDEX Tracking
Number:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**■** SEND TO:

> **PATHOLOGY AND LABORATORY MEDICINE SERVICE (113)**
>
> **BALTIMORE VA MEDICAL CENTER**
>
> **10 N. GREENE STREET**
>
> **BALTIMORE, MARYLAND 21201**
>
> **ATTN: DR. LAWRENCE BROWN (FOR DU PROGRAM)**

**■** Before sending this sample, [call the DU program office at
1-800-815-7533]{.underline} so that they can anticipate delivery. A
[copy of this checklist, and a completed copy of VA Form 10-9009D, must
be faxed to 410-605-7943]{.underline}.

**■** Notification of the results can be expected in approximately 45
days.

**VA Form 10-9009F REPRODUCE LOCALLY Page 2**

**March 2004**