**Department of Veterans Affairs M-10, Part III**

**Veterans Health Administration**

**Washington, DC 20420 August 8, 1995**

1\. Transmitted is a revision to the Department of Veterans Affairs,
Veterans Health Administration M-10, "Environmental Agents Service,\"
Part III, "Persian Gulf Program."

2\. This revision provides the following:

a\. **Chapter 1:** States the authority for providing health care and
describes the services authorized.

b\. **Chapter 2:** Defines the Persian Gulf Registry (PGR) and describes
eligibility criteria and program management.

c\. **Chapter 3**: Provides an uniform case assessment protocol for
veterans that have unexplained illnesses after their Persian Gulf
Service.

d\. **Chapter 4:** Defines the clinical and administrative policies
concerned with the program management of Persian Gulf Referral Centers
(PGRC) and PGRC reporting requirements.

3\. **Filing Instructions**

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4\. **RESCISSIONS**: M-10, Part III, Chapters 1 and 2, dated December 7,
1992, and VHA Directive 10-95-053.

Signed by Mike Hughes

for 8/10/95

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

Under Secretary for Health

Distribution: **RPC: 1323**

FD

Printing Date: 8/95

(Logo) **Department of Veterans Affairs**

**ENVIRONMENTAL AGENTS SERVICE**

**Persian Gulf Program**

**M-10, Part III Veterans Health Administration**

**August 8, 1995 Washington, DC 20420**

**August 8, 1995 M-10, Part III**

**Department of Veterans Affairs**

**Veterans Health Administration**

**Washington, DC 20420**

The Department of Veterans Affairs, Veterans Health Administration
Manual M-10, "Envioronmental Agents Service," Part III, "Persian Gulf
Program," is published for the compliance of all concerned.

Signed by Mike Huges

for

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

Under Secretary for Health

Distribution: **RPC: 1323**

FD

Printing Date: 8/95

**CONTENTS**

**CHAPTERS**

1\. PERSIAN GULF PROGRAM

2\. PHASE I, PERSIAN GULF REGISTRY EXAMINATION

3\. PHASE II, PERSIAN GULF UNIFORM CASE ASSESSMENT PROTOCOL

4\. PERSIAN GULF REFERRAL CENTERS

**RESCISSIONS**

The following material is rescinded:

1\. **Manuals**

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

2\. **Directives**

10-95-053

**CONTENTS**

**CHAPTER 1. PERSIAN GULF REGISTRY (PGR) PROGRAM**

**PARAGRAPH PAGE**

1.01 Purpose 1-1

1.02 Background 1-1

1.03 Authority and Healthcare Services Provided 1-2

1.04 Health Evaluation 1-3

1.05 Exceptions to Services 1-3

1.06 Responsibilities 1-4

1.07 Media and Other External Contacts 1-4

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

**RESCISSIONS**

The following material is rescinded:

1\. **Manuals**

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

**CHAPTER 1. PERSIAN GULF REGISTRY (PGR) PROGRAM**

**1.01 PURPOSE**

a\. This chapter provides procedures to establish a Persian Gulf
Registry (PGR) Program at all Department of Veterans Affairs (VA) health
care facilities for concerned participants of "Operation Desert Shield
/Storm."

**1.02 BACKGROUND**

a\. According to the Department of Defense (DOD) approximately 690,000
American servicemen and women were involved in the Persian Gulf War.
There may be a substantial number of troops actually exposed to
unignited petroleum and/or smoke from the sabotage of Kuwaiti oil wells
by retreating Iraqi forces as well as other industrial and environmental
hazards.

b\. Establishment of a PGR will assist VA in initiating a program to
identify possible diseases which may result from service of United
States (U.S.) military personnel in certain areas of Southwest Asia (see
par. 2.02). These diseases may be endemic to the area or due to
hazardous exposures, including heavy metals. Furthermore, air
pollutants, i.e., carbon monoxide sulfur oxides, hydrocarbons,
particulate matter, and nitrogen oxides, singly or in combination, can
cause chronic as well as acute health problems.

\(1\) These health problems may include:

\(a\) Chronic bronchitis,

\(b\) Chronic obstructive pulmonary disease,

\(c\) Pulmonary emphysema,

\(d\) Bronchial asthmas, and

\(e\) Lung cancer.

**NOTE:** *U.S. veterans who served in the Persian Gulf [theatre of
war]{.underline} are henceforth in M-10. Part III, referred to as
Persian Gulf veterans.*

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

\(a\) Oil, smoke and other petrochemical agents;

\(b\) Leishmaniasis (Sand flies);

\(c\) Pyridostigmine bromide, malaria prophylaxis and other prophylactic
drug treatments;

\(d\) Depleted Uranium (DU);

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

\(f\) Pesticides;

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

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

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

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

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

\(a\) Gastrointestinal problems;

\(b\) Flu-like conditions;

\(c\) Skin rashes;

\(d\) Sinus congestion, post nasal drip;

\(e\) Joint pains and/or muscle soreness;

\(f\) Hair loss;

\(g\) Headaches;

\(h\) Memory loss;

\(i\) Chronic fatigue;

\(j\) Thickened saliva;

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

\(l\) Dizziness, vertigo;

\(m\) Sleep disturbance; and

\(n\) Other symptoms and/or exposures.

\(4\) During the examination process, these exposures and health
conditions will be identified and documented in the Consolidated Health
Record (CHR) and VA Form 10-9009A (July 1995), Persian Gulf Registry
Code Sheet.

c\. The creation of a registry containing medical and other data on
exposed veterans will signal VA's commitment to address questions
concerning possible future effects of air pollutant exposure, other
environmental agents, and serve as the basis for future medical
surveillance. **NOTE:** *VA is in the process of requesting support for
future computerization of this registry.*

**1.03 AUTHORITY AND HEALTH CARE SERVICES PROVIDED**

Title 38, United States Code (U.S.C.) Chapter 17, Section 1710, provides
for health care only, and a determination that the veteran is eligible
for such care does not constitute a basis for service-connection or in
any way affect determinations regarding service-connection.

a\. Health care services will be provided to veterans who while serving
on active duty in the Southwest Asia theater of operations during the
Persian Gulf War may have been or were exposed to a toxic substance or
environmental hazard. Verification of service in the Persian Gulf during
the Persian Gulf era (August 2, 1990 - no ending data established by
law) will be required. Inasmuch as VA presumes that a veteran was
exposed to a toxic substance or environmental hazard during any service
in the Persian Gulf, a verified claim of such in-country service
constitutes the required contention of exposure and establishes
eligibility for medical care within these provisions.

b\. Authorized health care services are limited to:

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

\(2\) Such health care services will be provided without regard to the
veteran's age, service-connected status or ability of the veteran to
defray the expenses of such care.

\(3\) Veterans furnished outpatient care under this authority will be
accorded priority ahead of most other non service-connected veterans and
equal to former Prisoners of War who are receiving care for non
service-connected conditions.

\(4\) Congress made it clear that this authority provides for health
care only, and that a determination that the veteran is eligible for
such care does not constitute a basis for service-connection or in any
way affect determinations regarding service-connection.

**NOTE:** *Health care services may not be provided under this authority
for the care of conditions which are found to have resulted from a cause
other than the specified exposures*.

**1.04 HEALTH EVALUATION**

a\. Veterans claiming health conditions related to exposure to toxic
substance or environmental hazard will be evaluated clinically by means
of a physical examination and appropriate diagnostic studies (see Ch. 2,
App. 2B). Where findings reveal a condition requiring treatment, the
responsible staff physician shall make a determination as to whether the
conditions resulted from a cause not related to Persian Gulf Service.

b\. In making this determination, the physician will consider the
following types of conditions which are not ordinarily considered to be
due to toxic substances or environmental hazards:

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

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

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

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

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

**1.05 EXCEPTIONS TO SERVICES**

a\. Although the types of conditions listed in paragraph 1.04 are not
ordinarily considered to be due to a toxic substance or environmental
hazard, if the staff physician finds that a veteran requires care under
this provision for one or more of those conditions, the physician should
seek guidance from the Chief of Staff (COS) and the Veterans' Registry
Physician (VRP) regarding the authorization for treatment.

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

c\. Veterans who are not provided needed medical care under these
provisions may be furnished care if they are eligible under other
statutory authority.

d\. All non service-connected Persian Gulf veterans who respond
affirmatively to the exposure question are means tested before being
seen by a physician.

**1.06 RESPONSIBILITIES**

a\. A PGR will be established modeled after the Agent Orange and
Ionizing Radiation Registries. All VA facility staff are to be alerted
of the PGR through appropriate internal communications, e.g., medical
center memoranda providing names, locations, and office telephone
numbers of the Veterans' Registry Physician (VRP) and the Veterans'
Registry Coordinator (VRC).

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

\(a\) VRPs;

\(b\) VRCs; and

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

\(2\) It will consist of medical examinations and other data of
concerned Persian Gulf War participants. The PGR will be the most
effective means of identifying such concerned veterans.

b\. The EAS has the responsibility to develop, coordinate, and monitor
Veterans Health Administration (VHA) activities relating to the Persian
Gulf issue. All policy and clinical questions relating to the identity
of possible diseases which may result from service of U.S. (United
States) military personnel in certain areas of Southwest Asia should be
referred to EAS.

c\. The VRP and VRC at each VA facility will assume respective
responsibility for coordinating the medical and administrative aspects
of the registry. The VRP, VRC, and other medical center staff, will play
a key role, beginning with the initial contact in:

\(1\) Providing registry participants with medical examinations and
necessary treatment where medically indicated for eligible veterans;

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

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

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

**1.07 MEDIA AND OTHER EXTERNAL CONTACTS**

a\. **Media Contacts.** Reports of Contact from various media sources
(e.g., radio, television, newspapers, etc.) concerning PGR Program
activities will be referred by phone to the facility Public Affairs
Officer. Interviews should not be given unless approved by the medical
center Public Affairs Officer who may appropriately coordinate response
with the regional VA public affairs representative.

b\. **Contacts to Advise Centers of "Special Cures" for Persian
Gulf-Related Illnesses.** Medical centers can expect, on occasion, to be
contacted by private sector physicians, researchers, and the general
public with information regarding "quick cures" for Persian Gulf-related
illnesses. Such individuals should be advised that:

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

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

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

\(4\) Provisions exist to permit the originator of new therapies to
retain professional credit and be appropriately compensated; and/or

\(5\) The individual might want to consider presenting the "new
approach" at a VA or medical school Grand Rounds or Staff Review
Committee meeting.

**1.08 SPECIAL HEALTH NEEDS OF PERSIAN GULF FEMALE VETERANS**

VHA is committed to providing for the physical and psychological
treatment needs of women veterans who have been sexually or physically
abused, or engaged in combat.

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

\(1\) Raped;

\(2\) Otherwise sexually assaulted;

\(3\) Sexually harassed;

\(4\) Combatants during military service; or

\(5\) Prisoners of War.

b\. This can lead to long-term psychiatric and psychosomatic sequelae.
When a problem is detected, appropriate counseling and psychotherapy
must be provided.

**NOTE:** *Since this is a highly specialized area, it may be necessary
to make appropriate referral to other VA or private sector providers.
This should be reported on the CHR as well as under Item 32, Part II of
VA Form 10-9009A (July 1995)*, *Persian Gulf Registry Code Sheet, Phase
I.*

**CONTENTS**

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

**PARAGRAPH PAGE**

2.01 Purpose 2-1

2.02 Eligibility Criteria 2-1

2.03 Program Management 2-2

2.04 Responsibilities 2-2

2.05 Consolidated Health Report (CHR) 2-5

2.06 Incarcerated Veterans 2-5

2.07 Veterans with other than Honorable Discharges 2-5

2.08 Active Duty Military Personnel 2-5

2.09 Updating VRP and VRC Appointments 2-6

2.10 Report to AAC 2-6

**APPENDICES**

2A Definitions and Acronyms 2A-1

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

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

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

2D Reporting Requirements 2D-1

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

for Use in Shipment of Tabulated Data 2E-1

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

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

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

**RESCISSIONS**

The following material is rescinded:

1\. **Manuals**

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

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

**2.01 PURPOSE**

This chapter sets forth clinical and administrative policies related to
the maintenance of Veterans Health Administration's (VHAs) Persian Gulf
Registry (PGR) Program for physical examinations of concerned veterans.

**2.02 ELIGIBILITY CRITERIA**

The Department of Veterans Affairs (VA) will provide a PGR examination
to veterans who served on active military duty in Southwest Asia during
the Persian Gulf War between August 2, 1990, and the official
termination date (to be established). Active duty military personnel who
served in Southwest Asia are encouraged to participate in the PGR
program, (see par. 2.07).

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

\(1\) Iraq;

\(2\) Kuwait;

\(3\) Saudi Arabia;

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

\(5\) Bahrain;

\(6\) Qatar;

\(7\) The United Arab Emirates:

\(8\) Oman;

\(9\) Gulf of Aden,

\(10\) Gulf of Oman; and

\(11\) Waters of the:

\(a\) Persian Gulf,

\(b\) Arabian Sea; and

\(c\) Red Sea.

**NOTE:** M*edical Administration Service (MAS) should be consulted to
determine whether each veteran applying for this examination meets
pertinent eligibility requirements.*

b\. Eligible Persian Gulf veterans applying for treatment in a VA
medical center and/or outpatient clinic should be encouraged to undergo
an initial (i.e., "first-time") PGR examination. The protocol for
conducting the physical examination and ordering diagnostic studies is
contained in Appendix 2B.

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

\(1\) Although the results of a PGR examination may be used to support a
compensation claim, the examination will not in and of itself be
considered such a claim.

**NOTE:** *If a compensation examination is performed for a Persian Gulf
War veteran and the veteran requests inclusion in the PGR, it is not
necessary to schedule an additional registry examination as long as the
information is sufficient to adequately complete the PGR code sheet for
submission to the Austin Automation Center (AAC).*

\(2\) Veterans who wish to submit a claim for conditions possibly
related to Persian Gulf service should do so via the normal claims
process through a Veterans Benefits Counselor (VBC) at the nearest VA
medical center or regional office.

**2.03 PROGRAM MANAGEMENT**

For current information and program activities, Veterans' Registry
Physicians (VRPs), Veterans' Registry Coordinators (VRCs) and MAS
employees should receive and familiarize themselves with quarterly
mailouts and various materials distributed by VA Central Office. In
addition, all program officials should attend the periodic Environmental
Agents Service (EAS) conference calls from VA Central Office.

**2.04 RESPONSIBILITIES**

The VRP, or designee, VRC and MAS staff play a significant role in
determining the perceptions veterans have concerning the quality of VA
health care services and of their individual treatment by VA health care
providers.

a\. **[VRP Responsibilities]{.underline}.** The VRP, or designee, is
responsible for clinical management of the veteran on the registry and
will serve as their primary health care provider unless another has been
assigned. The VRP serves in an advisory capacity for the administrative
management of the program. The VRP should be the person to discuss with
the patient the results of the examination(s) as well as providing
follow-up visits and/or possible referrals to other tertiary medical
centers or Persian Gulf Referral Centers (PGRC). Major essential
responsibilities include:

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

\(2\) Providing focused initial examination and continuum of care to
those symptomatic veterans experiencing multiple symptoms after their
Persian Gulf experience;

\(3\) Conducting and documenting the physical examination in the medical
record or Consolidated Health Record (CHR) at the time of the visit;

\(4\) Providing a complete medical history including:

\(a\) Family;

\(b\) Occupation;

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

\(d\) Civilian exposure to possible toxic agents;

\(e\) Psychosocial condition; and

\(f\) Review of systems.

\(5\) Completing Part II (Phase I) and III (Phase II) of VA Form
10-9009A (July 1995), Persian Gulf Registry Code Sheet, and reviewing
Part I and completing that section, if necessary.

\(a\) Reviewing the code sheet to further ensure the form's
completeness, the clinical examiner will review the code sheet and, if
necessary, obtain and record any missing information from the veteran.
**NOTE:** *Code sheets should be transmitted to AAC no later than 25
working days after initial examination.*

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

\(6\) Reviewing records of every Persian Gulf veteran examined to ensure
that a complete physical examination was performed and documented;

\(7\) Personally discussing with each veteran the findings of the
physical examination and completed diagnostic studies. The interview
will be conducted in such a way as to encourage the veteran to discuss
any health concerns, as well as concerns expressed by family members;

\(8\) Personally discussing each veteran's need for a follow-up
examination either recommended by VRP or requested by the veteran;

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

\(10\) Encouraging the veteran to contact VA medical center to include
additional diagnoses in CHR and PGR if the veteran is subsequently
diagnosed with a significant health problem by non-VA doctor. This new
diagnosis must be submitted under non-VA physician's signature and
official letterhead. A code sheet identified as, follow-up examination,
Type C, will be completed with this diagnosis and subsequently forwarded
to AAC for inclusion in PGR.

\(11\) Preparing and signing a follow-up letter to each veteran
explaining the results of the examination and associated laboratory
tests. **NOTE:** *Sample follow-up letters are provided in Appendix 2G.*

\(a\) These letters are to be mailed to the veteran within 2 weeks of
the initial examination appointment and follow-up examination when a new
diagnosis is determined. The only exception to this timeframe will be
when a consultation at a specialty clinic is requested as part of the
initial examination process. This exception suspends, but does not
remove the requirement for the follow-up letter. The follow-up letter is
to be sent no later than 2 weeks after the consultation.

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

\(c\) 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. A great deal of sensitivity and care
should be exercised in the preparation of this correspondence.

\(d\) The letter will explain that:

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

[2]{.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.

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

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

[5]{.underline}. If the veteran is not eligible for treatment, the
letter should so advise and recommend that the veteran seek appropriate
medical care elsewhere.

[6]{.underline}. The examination does not automatically initiate a claim
for VA benefits. For information relating to claims, refer the Persian
Gulf veterans to a VBC at the nearest VA medical center or regional
office.

[7]{.underline}. The results of the examination will be maintained by VA
and will be available for future use as needed; and

[8]{.underline}. If the veteran changes place of residence, the veteran
should provide the new address to the VRC to be recorded on a
computerized record or card file and included on a corrected code sheet
(Type \"E\" examination code) for submission to AAC.

b\. **[Veterans' Registry Coordinator (VRC)
Responsibilities]{.underline}**

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

\(a\) Scheduling of appointments;

\(b\) Monitoring timeframe compliance;

\(c\) Reviewing records for accuracy and completeness; and

\(d\) Collecting data for reporting purposes.

\(2\) The VRC is responsible for the following:

[1]{.underline}. [Scheduling]{.underline}. Facilities should make every
effort to give each veteran a PGR examination within 30 days of the
request date. If numerous consultations are required, all of these
should be scheduled on the same day, whenever possible, so that the
veteran will not be unduly inconvenienced. When it is not possible to
provide all consultations on the same day, the VRC/scheduler should work
with the veteran to minimize disruptions in the veteran's life. If a
medical center fails to meet the time standard of 30 calendar days from
date of request, the medical center Director in coordination with the
Regional Office Director shall work together to explore all
alternatives, i.e., referrals to other VA facilities, additional staff
hours to perform these examinations; and the possibility of the use of
fee-basis sources or contracting out some or all examinations with
volume health care providers, to bring the medical center in line with
the time standard.

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

[a]{.underline}. Upon distribution by VA EAS, provide each Persian Gulf
veteran reporting to the outpatient area, with a VA Central Office
(103A) handout, "VA Persian Gulf Veterans' Illnesses, Questions and
Answers," Information Bulletin IB-10-41, describing the purpose of the
examination and its limitations. This can be further clarified by the
examining physician prior to and during the course of the physical
examination;

[b]{.underline}, VRCs will also provide each veteran with a brief oral
explanation of the purposes of the PGR and the examination process and
respond to any questions the veteran might have. This can be
accomplished during the VRCs initial contact with the veteran.

[c]{.underline}. Computerized Record or Card File. A computer record or
card file will be established to include data on all registry
participants. Each computer record or card file should include veteran's
full name, address, telephone number, date of birth, Social Security
Number (SSN), date of initial examination and date(s) of subsequent
follow-up examination(s). **NOTE** : *This record will support the
statistics included in the Bi-monthly Report of Persian Gulf War Veteran
Registry Examinations (RCS 10-0875). In addition to other information
updates, every effort should be made by the VRC to maintain the
veteran's current address in the computer record or card file for
outreach purposes. VA Central Office is in the process of establishing a
VA system-wide computerization of this card file.*

[3]{.underline}. [Code Sheet Completion]{.underline}

[a]{.underline}. The VRC, or designee, will complete Part I of VA Form
10-9009A (July 1995) and will ensure that all information is entered on
the code sheet before the veteran is referred to the clinician for the
examination.

[b]{.underline}. The VRP will complete Part II and III of VA Form
10-9009A (July 1995). (Refer to instructions and sample code sheet in
App. 2C).

[c]{.underline}. In the event that a veteran requests a PGR examination
but does not wish to be included in the registry database, a registry
examination should be performed. Item 32, "Remarks," should indicate the
current date and note that the veteran chose not to participate in the
registry. This code sheet should be filed in veteran's CHR. Do not
submit this code sheet to the AAC.

**2.05 CONSOLIDATED HEATH RECORD (CHR)**

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

a\. All Persian Gulf veterans participating in the registry will have a
VA Form 10-9009B (Persian Gulf Identification Sticker) affixed to their
CHR. VA Form 10-9009B should be affixed to the front of the record in
the lower left-hand corner of the "service connected" block.

b\. These Persian Gulf registry records are subject to the same
retention and disposition policies as other medical record files, i.e.,
Records Control Schedule 10-1.

**2.06 INCARCERATED VETERANS**

VA medical facilities can provide assistance to penal authorities or
institutions, which agree to provide examinations to veterans, without
reimbursement from VA, for purposes of entry in the PGR.

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

b\. Penal authorities must be advised at the time of such requests that
the results of the examinations provided at their institutions must be
returned to the VA medical facility of jurisdiction for inclusion, in
the veteran's behalf, in PGR and in the veteran's CHR.

**2.07 VETERANS WITH OTHER THAN HONORABLE DISCHARGES**

The requirements of M-1, Part I, Chapter 4, applies to veterans with
less than honorable discharges applying for PGR examinations.

**2.08 ACTIVE DUTY MILITARY PERSONNEL**

When active duty members of the uniformed services apply to VA
facilities for a PGR examination, Department of Defense (DOD) must
authorize and provide the appropriate DOD Form 2161, Referral for
Civilian Care, requesting this examination or provide services under
existing DOD/VA sharing agreement. The requirements of M-1, Part I,
Chapter 15, regarding the authorization and billing from the appropriate
branch of service will apply. Facilities should also reference the
current directive providing the interagency billing rates.

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

b\. A military facility may perform the PGR examination according to VA
instructions or the corresponding military instructions. **NOTE:** *DOD
has established a Persian Gulf Hot Line #1-800-796-9699 to direct active
duty personnel to military hospitals for medical examinations and
provide other related information. An additional telephone number has
been established (1-800-472-6719) for Persian Gulf War veterans to call
with their recollection of \"incidents\" that might be related to health
problems.*

c\. Military facilities may obtain the pertinent VA administrative issue
and appropriate forms from the nearest VA facility. The VA Medical
Center, 50 Irving Street, N.W., Washington, DC 20422, Attn: Persian Gulf
Coordinator (136) is the processing center for all active duty members
of uniformed services stationed [overseas]{.underline}. Military
facilities will complete code sheets with exception of the following
which will be filed in by VA coding clerks:

**[Blocks]{.underline} [Code Identifier]{.underline}**

**[Part I]{.underline}** 2 to 7 Facility number and suffix

137 to 141 County and State

d\. Military facilities will provide completed copies of the code sheet,
physical examination, laboratory tests, etc., to the nearest VA medical
center or outpatient clinic. The VRC will:

\(1\) Prepare a colored card (or computerized facsimile) for the file
with similar data as for a veteran and label the card "Active Duty";

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

\(3\) Submit code sheet to the VA Office of Financial Management, AAC,
1615 Woodward Street, Austin, TX 78722-0001, in accordance with
instructions;

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

\(5\) If requested, and only with written authorization (release of
information) from active duty member, VA may supply a copy of these
medical records to the military facility.

**2.09 UPDATING VRP AND VRC APPOINTMENTS**

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

a\. In an effort to keep these listings current, facilities are required
to notify the EAS of any changes in the status of appointments of VRP\'s
and/or VRC\'s at their respective facilities.

b\. As changes in designation occur, submit in writing the name, title,
mail routing symbol, FTS and commercial numbers including area code, to
the VRC (103A), EAS, VA Central Office, 810 Vermont Avenue, N.W.,
Washington, DC 20420 (Facsimile Number FTS 700-565-7572). **NOTE:** *In
order to provide current Persian Gulf information to concerned VA
Registry Staff, it is important that any changes in designation of VRPs
or VRCs at VA facilities be provided to VA Central Office (103A) as they
occur.*

**2.10 REPORT TO AAC**

The PGR report should be prepared monthly and submitted to the AAC as
per instructions contained in Appendix 2D:

a\. VA Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet, and
VA Form 7252, (originally 30-7252) Transmittal Form for the Use in
Shipment of Tabulating Data, should be prepared monthly and submitted

to AAC as per instructions contained in Appendix 2D. **NOTE:** *These
code sheets should be submitted, based on the following schedule, but no
later than 25 working days following initial examination.*

b\. The schedule of mailing dates is:

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

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

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

\(4\) Region 4 \-- l8th of month.

**DEFINITIONS AND ACRONYMS**

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

2\. **AMIS -** Automated Management Information System.

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

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

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

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

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

8\. **CHR** - Consolidated Health Record - A file containing medical
records relating to patient identity, diagnosis, prognosis or treatment
at VA facility.

9\. **CPK** - Creatine Phosphokinase.

10\. **CT** - Computed Tomography.

11\. **D.O.** - Doctor of Osteopathy.

12\. **DOD** - Department of Defense.

13\. **DOD Form 2161**, "Referral for Civilian Care."

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

15\. **DU** - Depleted Uranium.

16\. **EAS** - Environmental Agents Service - EAS (103A), VA Central
Office, has the responsibility to coordinate and monitor all VHA
activities, research and otherwise, relating to the Persian Gulf issue.

17\. **ECG** - Electrocardiogram.

18\. **EEG** - Electroencephalogram.

19\. **EGD** - Esophagastroduodenoscopy.

20\. **EMG** - Electromyogram.

21\. **ENG** - Electronystamogram.

22\. **Examinations**

a\. [Initial]{.underline}. The first physical examination which is
completed and sent to the AAC for the purpose of entering a veteran into
the Persian Gulf Registry system.

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

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

24\. **GI** - Gastrointestinal.

25\. **GYN** - Gynecology.

26\. **HcT** - Hematocrit.

27\. **HgB** - Hemoglobin.

28\. **HIV** - HumanImmuno-deficiency.

29\. **IB-10-41** - VA Information Bulletin entitled "Persian Gulf
Veterans' Illnesses, Questions and Answers."

30 **ICD-9-CM** - The International Classification of Diseases, Clinical
Modification, 9th Edition provides standardized classification of
diseases.

31\. **IgG** - Oligoconal.

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

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

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

35\. **LP** - Lumbar Puncture.

36\. **MAS** - Medical Administration Service.

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

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

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

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

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

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

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

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

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

46\. **PGR** - Persian Gulf Registry - The PGR is a computerized index
of veteran participants, is managed centrally by the EAS in VA Central
Office. The coded findings of Persian Gulf Program physical examinations
and related diagnostic results are entered into a database by the AAC.

47\. **PGRC** - Persian Gulf Referral Centers - Selected tertiary VA
Medical Centers (Birmingham, AL, Houston, TX; , Washington, DC; and West
Los Angeles, CA), with clinical and academic expertise in such areas a

pulmonary and infectious diseases, immunology, neuropsychology, and
toxicology, where medical assistance is provided for those Persian Gulf
veterans with symptoms which defy explanation.

48\. **Plt** - Platelet.

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

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

51\. **PTSD** - Post Traumatic Stress Disorder.

52\. **Persian Gulf Area of Service.** For eligibility purposes, active
military duty in Southwest Asia during the Persian Gulf War would
include service in one or more of the following areas: Iraq, Kuwait,
Saudi Arabia, the neutral zone (between Iraq and Saudi Arabia), Bahrain,
Qatar, the United Arab Emirates, Oman, waters of the Persian Gulf, Red
Sea, Arabia Sea, and Gulfs of Aden and Oman.

53\. **Persian Gulf War Period of Service.** Public Law 102-25
established a Persian Gulf War period of service which will affect
persons serving on active duty as of August 2, 1990, with no ending date
established by law.

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

55\. **Reports Control Symbol (RCS) 10-0860.** Reflects the reporting
requirements for VA Form 10-9009A (July 1995), Persian Gulf Registry
Code Sheet, Persian Gulf Referral Center Monthly Report, and Bi-monthly
Report on Persian Gulf Uniform Case Assessment Protocol.

56\. **RCS 10-0875.** The reporting requirements for the Bi-monthly
Report on Persian Gulf War Veteran Registry Examinations, under
Directive 10-95-053 are rescinded by this manual change.

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

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

59\. **SCUDS** - Soviet designed surface to surface missiles.

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

61\. **SGPT(ALT)** - Transaminase Glutamic Pyruvate.

62\. **SGOT(AST)** - Glutamic Oxaloacetic Transaminase.

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

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

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

66\. **TB** - Tuberculosis.

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

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

69\. **UGI**- Upper Gastrointestinal.

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

71\. **VBC** - Veterans Benefits Counselor.

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

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

74\. **VRC** - Veterans' Registry Coordinator - A non-physician staff
member responsible for the administrative management of the program at
each VA facility.

75\. **VRP** - Veterans' Registry Physician - The VRP is a physician
responsible for the clinical management of the Persian Gulf Program at
each VA medical facility.

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

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

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

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

**PROTOCOL FOR CONDUCTING THE PHYSICAL EXAMINATION**

**AND ORDERING DIAGNOSTIC STUDIES**

1\. It is essential that a complete medical history, physical
examination and interview be performed and documented on appropriate
forms . The required forms that must be fully completed are: Standard
Form (SF) 88, Report of Medical Examination, Department of Veterans
Affairs (VA) Form 10-9009A (July 1995), Persian Gulf Registry Code
Sheet, and SF 509, Progress Notes (for follow-up). These are to be
maintained in the veteran\'s Consolidated Health Record (CHR). **NOTE:**
*This should be accomplished by or under the direct supervision of the
Veterans' Registry Physician (VRP). Examination data will be recorded in
the veteran's medical record as routinely as done for any other medical
examination.* The complete medical history should address the following:

\(a\) Family history;

\(b\) Occupational history;

\(c\) 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.). A physician's
countersignature is required if the examiner is other than a physician.
Under normal circumstances, VRP will provide such countersignatures.

3\. When a Persian Gulf Registry (PGR) examination is done as part of a
compensation and pension examination, the physical examination will be
done by/or under the direct supervision of the VRP.

4\. The physician should be aware of the variety of exposures endemic to
the Persian Gulf area. These are listed in Appendix 2C and on VA Form
10-9009A (July 1995),. There has been a wide distribution of major
categories of diagnosis reported by VA VRPs; however, no significant
variation in occurrence of major categories of medical problems has been
identified. We are listing below (for informational purposes) some of
the health problems and/or diseases which should be considered:

**[International Classification of Diseases]{.underline}**

**[DIAGNOSIS]{.underline} [Clinical Modification, 9th
Edition]{.underline} ([ICD-9-CM)]{.underline}**

\(1\) Amebiasis 006

\(2\) Asthma 493

\(3\) Brill's Zinsser disease (recrudescent typhus) 0811

\(4\) Bronchiectasis 494

\(5\) Bronchopneumonia, organism unspecified 485

\(6\) Brucellosis 023

**[International Classification of Diseases]{.underline}**

**[DIAGNOSIS]{.underline} [Clinical Modification, 9th
Edition]{.underline} ([ICD-9-CM)]{.underline}**

\(7\) Chronic obstructive pulmonary disease,

not elsewhere classified 496

\(8\) Chronic bronchitis 491

\(9\) Chronic Laryngotracheitis 4761

\(10\) Chronic respiratory conditions due to fumes and vapors 5064

\(11\) Emphysema 492

\(12\) Giardiasis 0071

\(13\) Leishmaniasis 085

\(14\) Malaise and Fatigue 7807

(l5) Malaria 084

\(16\) Neurasthenia (chronic fatigue syndrome) 3005

\(17\) Other and unspecified diseases of upper respiratory tract 4789

\(18\) Pain in Joint (arthralgia) 7194

\(19\) Pneumoconiosis due to other silica or silicates 502

\(20\) Pneumoconiosis, unspecified 505

\(21\) Unspecified chronic respiratory disease 5199

\(22\) Respiratory conditions due to unspecified external agent 5089

\(23\) Sandfly fever (phlebatomus fever) 0660

\(24\) Schistosomiasis (bilharziasis) 120

\(25\) Toxoplasmosis 130

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

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

\(28\) Viral hepatitis 070

\(29\) Memory loss 310

\(30\) Polyneuropathy 356-357

\(31\) Skin rash 680-709

\(32\) Adjustment disorder, including Post Traumatic Stress

**[International Classification of Diseases]{.underline}**

**[DIAGNOSIS]{.underline} [Clinical Modification, 9th
Edition]{.underline} ([ICD-9-CM)]{.underline}**

Disorder (PTSD) 309

\(33\) Alcohol dependence syndrome 303

\(34\) Drug dependence 304

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

a\. Time of onset of the symptoms or conditions,

b\. Intensity,

c\. Degree of physical incapacitation, and

d\. Details of any treatment received.

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

a\. Complete Blood Count (CBC);

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

c\. Urinalysis.

7\. Appropriate additional diagnostic studies should be performed and
consultations obtained as indicated by the patient's symptoms and the
physical and laboratory findings. **NOTE:** *If individuals have
unexplained illnesses, after a Phase I registry examination is
performed, a Phase II examination is mandated. (See Ch. 3, App 3A, for
instructions.)*

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

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

**SAMPLE AND INSTRUCTIONS FOR COMPLETING**

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

1\. **General Instructions for completing Department of Veterans Affairs
(VA) Form 10-9009A (July 1995).**

a\. An original code sheet should be prepared and a legible copy
submitted to the Office of Financial Management Austin Automation Center
(AAC) in accordance with instructions for the initial and first
follow-up examinations (if required). After code sheet data has been
reviewed and entered into the computerized database at AAC, the AAC will
forward these code sheets to the Senior Registry Coordinator (103A),
Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC
20420, for disposition. These code sheets will not be returned to the
medical center of origin unless corrections are required.

\(1\) The original code sheet will be filed in the medical record with
any corrections required by AAC. Additional follow-up examinations, as
required, will continue to be documented in the Consolidated Health
Record (CHR).

\(2\) A code sheet for [additional]{.underline} follow-up examinations
will not be prepared or submitted to the AAC with the exception that if
a diagnostic code differs from previously submitted code sheets, then a
code sheet will be prepared and submitted for entry into the Persian
Gulf Registry (PGR).

b\. Print clearly using a BLACK ball-point pen or a BLACK felt-tipped
pen. Follow instructions carefully to ensure that all data fields are
accurately completed. Enter one letter or number per block. **The
numeric zero must be slashed "∅."** For registry coding purposes, use
the International Classification of Diseases - Clinical Modification,
9th Edition, (ICD-9-CM) codes. These must be the codes currently in use
by AAC.

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

\(2\) Parts II and III of the code sheet should be completed at the time
of the examination by the Veterans' Registry Physician (VRP). A
completed Parts II and III will be returned to Medical Administration
Service (MAS) for assignment of the ICD-9-CM codes in appropriate
blocks. **NOTE:** *Careful attention should be paid to assigning the
correct code for both complaints (symptoms) and diagnosis. ICD-9-CM code
78999, for uncodable complaints (symptoms), should be assigned only
after all coding possibilities have been thoroughly explored. The
indiscriminate use of ICD-9-CM code 78999 may result in skewed or
misleading statistics of minimal value.*

\(3\) Date all code sheets with current date in the upper right hand
corner of VA Form 10-9009A (July 1995).

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

a\. **Item 1. Blocks 2-7. Facility Number and Suffix.** Enter facility
code as listed in MP-6, Part XVI, Supplement No. 4.1, Appendix A. Use
the AMIS suffix (BY, BZ, etc.) to indicate your satellite facility. DO
NOT USE Q, R, OR S. **NOTE:** *If veteran requests the inclusion of his
Department of Defense (DOD) registry examination records in VA PGR,
submit code sheet with Facility Number as 999 in Blocks 2, 3 & 4 and
indicate actual VA facility number in upper left margin of codesheet.*

b\. **Item 2. Blocks 8-33. Last Name of Veteran.** Beginning in Block 8,
enter veteran's current last name. If veteran had an earlier last name
used during the veteran's Persian Gulf service, e.g., an unmarried
woman, leave one space blank after the current name and enter "E." If
veteran has had any other later name, leave another blank space (i.e.,
after "E"), and enter the later name followed by another blank space and
then enter "L." Do not use apostrophe and/or hyphen in the name or skip
blocks between the letters of the last name. Skip a block if the last
name is followed with Jr., Sr., I, II, III, etc.

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

d\. **Item 4. Blocks 49-58. Middle Name of Veteran**. Beginning in Block
49, enter veteran's middle name or initial.

e\. **Item 5. Block 59. Type of Examination**. The following transaction
type must be entered in Block 59 as appropriate:

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

B - To delete an entire initial examination with a noted error, after it
has been accepted into the registry, resubmit the original code sheet
with a "B" and submit another code sheet with the correct information
with an "A." All fields must be completed on a resubmission. The code
sheets can be submitted in the same batch. Examples of this usage are
incorrect diagnosis, military statistics, Social Security Number (SSN),
etc.

C - Follow-up examination. Veteran's second Persian Gulf examination.
Additional follow-up examinations, as required, will continue to be
documented in the CHR, but a code sheet will not be prepared or
submitted to the AAC with the following exception: if a diagnostic code
differs from previously submitted code sheets, then a code sheet should
be prepared and submitted for entry into the PGR.

D - To delete an entire follow-up PGR examination with a noted error,
after it has been accepted into the registry, resubmit the original code
sheet with a "D" and submit another code sheet with the correct
information with a "C."

E - To submit change in demographics, i.e., change of address or date of
birth enter "E" and complete items with name, SSN, date of birth, and
address. No other items need to be completed.

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

X - When a registry participant has been identified and verified as
being deceased, enter "X." Complete items with name, SSN, and date of
birth. No other items need to be completed.

f\. **Item 6. Blocks 60-69. SSN**. Shaded Block 60 is to be used ONLY if
a pseudo SSN is being submitted. In this event, the letter "P" will be
entered in Block 60. Leave Block 60 blank when the actual SSN is used.
Beginning in Block 61 enter the veteran's actual SSN, or pseudo SSN.
(See M-1, Part I, Ch. 5, Par. 5.29, for instructions on pseudo SSN
assignment.) **NOTE:** *All efforts should be made to obtain veteran\'s
actual SSN***.**

g\. **Item 7. Blocks 70-75.** **Date of Birth**. Beginning in Block 70
enter numerical equivalent for the month, day and year in that order
(e.g., ∅1/19/5∅). All blocks must be completed.

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

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

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

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

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

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

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

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

1 = American Indian or Alaskan Native

2 = Asian or Pacific Islander

3 = Black, not of Hispanic Origin

4 = White, not of Hispanic Origin

5= Hispanic

6= Unknown

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

1 = Married

2 = Divorced

3 = Separated

4 = Widowed

5 = Single, Never Married

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

M = Male

F= Female

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

1 = Inpatient

2 = Outpatient

3 = Incarcerated

4 = Active Duty (Outpatient)

5 = Active Duty (Inpatient)

m\. **Item 13. Block 146. Branch of Service.** If veteran was in more
than one branch of service, code the latest Persian Gulf service. Enter
one of the following codes in Block 146:

1 = Army (including Reserves & National Guard)

2 = Air Force (including Reserves & National Guard)

3 = Navy (including Reserves)

4 = Marine Corps

5 = Coast Guard

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

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

\(1\) [Block 147]{.underline}. Enter one of the following codes:

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

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

\(2\) Item 14A. Enter the numerical equivalent of the month and also two
digits of the year of last period of service in Persian Gulf (e.g., from
∅2/91 to ∅5/91) in Blocks 148 through 155.

\(3\) Item 14B. If veteran had two or more periods of service in Persian
Gulf, the longest period of service should be entered in Blocks 156
through 163. If only one period of service in Persian Gulf, enter in 14A
and leave 14B blank.

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

\(1\) Item 15A. [Block 164.]{.underline} Enter one of the following
codes:

1 = Combat Zone

2 = Other Land Area

3 = Sea Duty

\(2\) Item 15B. [Block 165.]{.underline} If other service is indicated
or, if the response is "Don't Know" enter appropriate code in Block 165.

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

5 = Don't Know

p\. **Item 16, 16A-16E. Military Units, MOS and [Block 166]{.underline}.
MOS-Different Duties** .

\(1\) Item 16A. Military Units. Enter the military unit in which the
veteran served. Specify complete unabbreviated title, that is, company,
battalion, corps, ship, division, etc., (e.g., Company C, 1st Battalion,
4th Army).

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

\(3\) Item 16C. [Block 166.]{.underline} Were actual duties different
from MOS? Enter one of the following codes in Block 166: If no, go to
Item 16E

Y = Yes

N = No

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

\(5\) Item 16E. Enter the name of unit with which the veteran had the
longest and next to longest period of service while in the Persian Gulf.

**NOTE:** *Items 16A & 16E: These units could be different from the one
to which the veteran was assigned if the veteran was on detached duty.*

q\. **Items 17, 17A and 17B. Blocks 167-182. Last two periods of
service** (If different from 14A and 14B). Enter the numerical
equivalent of the month and the last two digits of the year for the last
two periods of service regardless of whether or not they were in the
Persian Gulf (e.g., from 12/9∅ to ∅4/91 and 9/9∅ to 11/9∅). 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., 12/9∅) and
enter nines (e.g., 99/99) to indicate the veteran is still actively
serving in the military.

r**. Items 18, 18A-18Z1. Blocks 183-216. Veteran's Exposure to
Environmental Factors**. Enter the following codes in appropriate
blocks.

Y = Yes

N = No

\(1\) Item 18A. [Block 183.]{.underline} Are you currently smoking
cigarettes? If no, go to Item 18D.

\(2\) Item 18B. [Blocks 184-185]{.underline}. If yes, how many years
have you been smoking cigarettes? Enter number of years.

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

\(4\) Item 18D. [Blocks 188.]{.underline} Have you smoked cigarettes in
the past? If no, go to Item 18G.

\(5\) Item 18E. [Blocks 189-190]{.underline}. If yes, how many years did
you smoke?

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

\(7\) Item 18G-Z1. [Blocks 193-212]{.underline}. While in the Persian
Gulf do you believe you were exposed to any of the following? Enter the
following codes:

Y = Yes

N = No

U = Unknown

\(8\) Item 18G. [Block 193.]{.underline} Smoke from oil fires?

\(9\) Item 18H. [Block 194]{.underline}. Smoke or fumes from tent
heaters?

\(10\) Item 18I. [Block 195.]{.underline} Cigarette Smoke (passive) from
others?

\(11\) Item 18J. [Block 196.]{.underline} Diesel and/or other
petrochemical fumes?

\(12\) Item 18K. [Block 197]{.underline}. Exposure to burning
trash/feces?

\(13\) Item 18L. [Block 198]{.underline}. Skin exposure to diesel or
other petrochemical fumes?

(l4) Item 18M. [Block 199.]{.underline} Chemical Agent Resistant
Compound (CARC) paint?

\(15\) Item 18N. [Block 200.]{.underline} Other paints and/or solvents
and/or petrochemical substances?

\(16\) Item 18O. [Block 201.]{.underline} Depleted uranium?

\(17\) Item 18P. [Block 202]{.underline}. Microwaves?

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

\(19\) Item 18R. [Block 204]{.underline}. Nerve gas or other nerve
agents?

\(20\) Item 18S. [Block 205.]{.underline} Drug (pyridostigmine) used to
protect against nerve agents?

\(21\) Item 18T. [Block 206]{.underline}. Mustard gas or other nerve
agents?

\(22\) Item 18U. [Block 207]{.underline}. Ate or drank food contaminated
with smoke, oil or other chemical?

\(23\) Item 18V. [Block 208]{.underline}. Ate food other than provided
by Armed Forces?

\(24\) Item 18W. [Block 209]{.underline}. Bathed in or drank water
contaminated with smoke, oil or other chemical?

\(25\) Item 18X. [Block 210]{.underline}. Bathed in water other than
provided by Armed Forces?

\(26\) Item 18Y. [Block 211]{.underline}. Immunization against anthrax?

\(27\) Item 18Z. [Block 212]{.underline}. Immunization against botulism?

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

s\. **Items 19A-F. Blocks 213-218 Persian Gulf Experience.** Did you
have any of the following experiences while in the Persian Gulf?

\(1\) Item 19A. [Block 213]{.underline}. Did you ever go on combat
patrols or have other very dangerous duty? Enter the following codes:

1 = No

2 = 1-3X

3 = 4-12X

4 = 13-50X

5 = 51+times

\(2\) Item 19B. [Block 214.]{.underline} Were you ever under enemy fire,
including, Soviet designed surface to surface missiles (SCUDS)? Enter
the following codes:

1 = Never

2 = less than 1 day

3 = less than 1 week

4 = 1-4 weeks

5 = 4 weeks or more

\(3\) Item 19C. [Block 215.]{.underline} What percentage of people in
your unit (your immediate group) were Killed in Action (KIA), wounded or
Missing In Action (MIA)? Enter the following codes:

1 = None

2 = 1-25%

3 = 26-50%

4 = 51-75%

5 = 76% or more

\(4\) Item 19D. [Block 216]{.underline}. How often did you see someone
hit by incoming or outgoing rounds? Enter the following codes:

1 = Never

2 = 1-2X

3 = 3-12X

4 = 13-50X

5 = 51 or more

\(5\) Item 19E. [Block 217.]{.underline} How often were you in danger of
being injured or killed (i.e., pinned down, overrun, ambushed, near
miss, etc.)? Enter the following codes:

1 = Never

2 = 1-2X

3 = 3-12X

4 = 13-50X

5 = 51 or more

\(6\) Item 19F. [Block 218.]{.underline} Witnessed chemical alarms?
Enter the following codes:

Y = Yes

N = No

U = Unknown

t\. **Item 20. Block 219. Veteran's Health** (Veteran's evaluation).

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

1 = Very good

2 = Good

3 = Fair

4 = Poor

5 = Very poor

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

\(1\) Item 21A. Enter code which describes veteran's assessment of the
veteran's functional impairment, after Persian Gulf Service, using the
following scale:

1 = No impairment

2 = Slight impairment

3 = Moderate impairment

4 = Severe impairment

\(2\) Item 21B. Blocks 221-222. How many workdays were lost by veteran
due to illness in the past 90 days? Enter number of days lost in Blocks
221-222 (e.g., 8/∅).

v\. **Item 22. Blocks 223-262. Evidence of Birth Defects and Infant
Death(s) among veteran's children and problems with pregnancy and
infertility.**

\(1\) Item 22A. [Blocks 223-224]{.underline}. How many children does
veteran have? If none, leave blank and go to 22C.

\(2\) Item 22B. [Blocks 225-226.]{.underline} Birth Defects. **NOTE:**
*Birth defects are any structural, functional, or biochemical
abnormality at birth whether genetically determined or induced during
gestation that is not due to injuries suffered during birth*. How many
of these children were born with birth defects? Enter number of children
in Blocks 225-226. If none, go to Item 22C.

\(a\) Item 22B1. Blocks [227-228]{.underline}. How many of these
children were conceived before Gulf service? If none, leave blank and go
to Item 22B2.

\(b\) Item 22B1(a). Blocks [229-230.]{.underline} State maternal age at
conception of first child conceived before Gulf service. Enter age in
Blocks 229-230.

\(c\) Item 22B2. Blocks [231-232.]{.underline} How many children were
conceived during or after Gulf service? Enter number in Blocks 231-232.
If none, leave blank and go to Item 22C.

(d). Item 22B2(a) [Blocks 233-234.]{.underline} State maternal age at
conception of first child conceived during or after Persian Gulf
service? Enter age in Blocks 233-234. If none, leave blank.

\(3\) Item 22C. [Blocks 235-241.]{.underline} Infertility (Problems of
veteran or spouse becoming pregnant). **NOTE:** *Infertility=relative
sterility defined as inability to conceive after 12 or more months of
intercourse without use of contraception when neither spouse is
surgically sterilized.* Has veteran or spouse had infertility problems?
Enter one of the following codes in Block 235. If none, go to Item 22D.

Y = Yes

N = No

\(a\) Item 22C1. [Block 236.]{.underline} Has veteran or spouse had
infertility before Gulf service? Enter one of the following codes:

Y = Yes

N = No

If no, go to Item 22C2.

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

\(c\) Item 22C2. [Block 239.]{.underline} Has veteran or spouse had
infertility after return from Gulf service? Enter one of the following
codes.

Y = Yes

N = No

If no, go to Item 22D.

\(d\) Item 22C2(a). [Blocks 240-241]{.underline}. State maternal age
during first attempts to conceive.

Enter age in Blocks 240-241.

\(4\) Item 22D. [Blocks 242-248]{.underline}. Miscarriage(s). **NOTE:**
*Miscarriages are spontaneous expulsion of the products of conception
before 20 weeks of gestation (spontaneous abortion*). Has veteran or
spouse had miscarriage(s)? Enter one of the following codes in Block
242.

Y = Yes

N = No

If no, go to Item 22E.

\(a\) Item 22D1. [Block 243]{.underline}. If yes, has veteran or spouse
had miscarriage(s) before Gulf service? Enter one of the following
codes:

Y = Yes

N = No

If no, go to Item 22D2.

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

\(c\) Item 22D2. Block 246. Has veteran or spouse had miscarriage(s)
after return from Gulf service? Enter one of the following codes:

Y = Yes

N = No

If no, go to Item 22E.

\(d\) Item 22D2(a). [Blocks 247-248.]{.underline} State maternal age at
conception. Enter age in Blocks 247-248.

\(5\) Item 22E. [Blocks 249-255]{.underline}. Still Birth(s).
**NOTE*:*** *Still births are births after 20 weeks of gestation of an
infant who showed no evidence of life after birth.* Has veteran or
spouse had still birth(s)? Enter one of the following codes in Block
249:

Y = Yes

N = No

If no, go to Item 22F.

\(a\) Item 22E1. [Block 250.]{.underline} Has veteran or spouse had
still birth(s) before Persian Gulf service? Enter one of the following
codes in Block 250.

Y = Yes

N = No

If no, go to Item 22E2.

\(b\) Item 22E1(a). [Blocks 251-252.]{.underline} State maternal age at
conception. Enter age in Blocks 251-252.

\(c\) Item 22E2. [Block 253]{.underline}. Has veteran or spouse had
still birth(s) after return from Persian Gulf service? Enter one of the
following codes in Block 253:

Y = Yes

N = No

If no, go to Item 22F.

\(d\) Item 22E2(a). [Blocks 254-255.]{.underline} State maternal age at
conception. Enter age in Blocks 253-254.

\(6\) Item 22F. [Blocks 256-262.]{.underline} Infant Death(s). **NOTE:**
*Death that occurred within 1 year of birth among babies born alive.*
Has veteran or spouse had babies with infant death(s)? Enter one of the
following codes in Block 256:

Y = Yes

N = No

If no, go to Item 22G.

\(a\) Item 22F1. [Block 257]{.underline}. Has veteran or spouse had
babies with infant death(s) before Gulf service? Enter one of the
following codes in Block 257:

Y = Yes

N = No

If no, go to Item 22F2.

\(b\) Item 22F1(a). [Blocks 258-259]{.underline}. State maternal age at
conception. Enter age in Blocks 258-259.

\(c\) Item 22F2. Block 260. Has veteran or spouse had babies with infant
death(s) after return from Gulf service? Enter one of the following code
in Block 260: If no, go to Item 22G.

Y = Yes

N = No

\(d\) Item 22F2(a) [Blocks 261-262.]{.underline} State maternal age at
conception. Enter age in Blocks 261-262.

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

3\. **Instructions for Completing PGR code sheet, Part II (Initial
Examination** )- *To be completed by the examining physician)*

a\. **Item 23. Blocks 263-270. Date of Examination**. Enter the
numerical equivalent for the month, day, and year in that order (e.g.,
∅9/22/1992).

b\. **Item 24. Blocks 271-272. Total Number of Veteran's Complaints**.

c\. **Item 25, 25A-M. Blocks 273-417. Veteran's Complaints, Month and
Year of Onset, Duration in Months, Whether Symptom is Currently Present,
and Most Severe Complaint**.

\(1\) Item 25A-J. [Blocks 273-417.]{.underline} Columns: (1) Veteran's
Complaints/Symptoms; (2) ICD-9-CM codes; (3) Month and Year of Onset;
(4) Duration in months; and (5) State whether symptom is still present.
List up to ten major and current symptoms/complaints. If veteran has
more than 10, enter most severe. Any additional symptoms should be
listed in CHR. **NOTE**: *MAS coders, use ICD-9-CM "Symptom" codes in
first five numbered blocks of each line. For uncodable symptoms use
"78999." For no known complaints, use "78000." (All zeros are to be
slashed.) However, ICD-9 code 78999 should ONLY be used if all possible
codes have been reviewed, and if necessary, seek physician consultation
to make a correct choice.*

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

\(3\) Item 25A-J(2). [Blocks 273-322.]{.underline} MAS coders are to
complete the ICD-9-CM codes as they relate to each symptom.

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

\(5\) Item 25A-J(4). [Blocks 383-402.]{.underline} For each symptom
listed in 25A-J, state duration in months that veteran has been
experiencing this symptom.

(6). Item 25A-J(5). [Blocks 403-412.]{.underline} For each symptom
listed in 25A-J, indicate if symptom is currently present, using one of
the following codes:

Y = Yes

N = No

\(7\) Item 25K. [Block 413-417.]{.underline} Most Severe
Symptom/Complaint. List ICD-9-CM code for most severe symptom (A symptom
from Item A-J, which VETERAN considers the most severe, i.e., Chief
Complaint).

d\. **Item 26, A-S. Blocks 418-435. Diagnostic workup/consultation.**
Enter one of the following codes in Blocks 418-435. All blocks must be
completed.

1 = No workup. No consultation done.

2 = Workup/consultation done. Unexplained illness.

3 = Workup/consultation done. Diagnosis established.

4 = Workup/consultation done. No diagnosis.

\(1\) Item 26A. [Block 418.]{.underline} Allergy/Immunology.

\(2\) Item 26B. [Block 419.]{.underline} Audiology.

\(3\) Item 26C. [Block 420]{.underline}. Cardiology.

\(4\) Item 26D. [Block 421]{.underline}. Dentistry.

\(5\) Item 26E. [Block 422]{.underline}. Dermatology.

\(6\) Item 26F. [Block 423]{.underline}. Ear, Nose and Throat.

\(7\) Item 26G. [Block 424]{.underline}. Endocrinology.

\(8\) Item 26H. [Block 425]{.underline}. Gastroenterology.

\(9\) Item 26I. [Block 426.]{.underline} Hematology/Oncology.

\(10\) Item 26J. [Block 427]{.underline}. Infectious
Diseases/Parasitology.

\(11\) Item 26K. [Block 428]{.underline}. Nephrology.

\(12\) Item 26L. [Block 429.]{.underline} Neurology.

\(13\) Item 26M. [Block 430]{.underline}. Occupational Medicine.

\(14\) Item 26N. [Block 431.]{.underline} Pulmonary.

\(15\) Item 26O. [Block 432.]{.underline} Psychiatry.

\(16\) Item 26P. [Block 433]{.underline}. Psychology/Psychometric
Testing.

\(17\) Item 26Q. [Block 434]{.underline}. Rheumatology.

\(18\) Item 26R. [Block 435.]{.underline} Other. Were any additional
workups/consultations performed as part of Persian Gulf examination
which were not listed in Items 26A-Q. Enter one of the following codes:

Y = Yes

N = No

\(19\) Item 26S. Specify on code sheet and CHR any additional
workups/consultations performed as part of Persian Gulf examination,
which were not listed in Item 26A-Q.

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

\(1\) Item 27A. List up to ten major definite medical diagnoses on lines
27A-J. The examining physician will select the 10 most
significant/serious in the examining physician's opinion, **listing the
primary diagnosis in Item A**. The additional diagnosis(es) should be
included in patient's CHR. Blocks 436-485 are to be used for ICD-9-CM
coding of each diagnosis listed. Leave blank if no diagnosis is made.
**NOTE:** *Diagnostic coding assignment will be completed by MAS.* **DO
NOT REPEAT OR LIST SYMPTOM CODE ALREADY LISTED UNDER ITEM 25A-J.**

f\. **Item 28. Block 486. No Diagnosis Made.** If no diagnosis is made,
enter a "1" in Block 486; otherwise, leave this block blank. This item
must be considered in conjunction with Item 27, "Diagnoses." A "1"
should be entered for Item 28 only when no diagnosis is given in Item 27
indicating that no significant defect, disease, injury or history of a
relevant diagnosis in the past is detected.

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

Y = Yes

N = No

\(1\) Item 29A. [Block 487]{.underline}. Examination completed?

\(2\) Item 29B. [Block 488.]{.underline} Hospitalized at the VAMC for
further tests?

\(3\) Item 29C. [Block 489.]{.underline} Hospitalized at the VAMC for
treatment?

\(4\) Item 29D. [Block 490]{.underline}. Referred for outpatient care?

\(5\) Item 29E. [Block 491.]{.underline} Referred to private physician,
non-VA clinic or non-VA hospital?

\(6\) Item 29F. [Block 492.]{.underline} Biopsy?

h\. **Item 30. Block 493. Phase I examination, refer to paragraph 5, has
been completed and the physician has determined that veteran has
unexplained illness.** Enter one of the following codes:

Y = Yes

N = No

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

Y = Yes

N = No

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

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

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

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

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

4\. **Follow-up Examinations**. Instructions for completing Parts I and
II. In addition to initial registry submissions, VA Form 10-9009A (July
1995), Parts I, II and III (if applicable) will be completed in
reporting the first follow-up examination, and subsequent follow-up
examinations if diagnostic code is different from previous examinations
as follows:

a\. Items 1-12 [must be completed]{.underline} - Control Data.

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

c\. Items 23 [must be completed.]{.underline}

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

e\. Item 27-35 [must be completed.]{.underline}

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

**REPORTING REQUIREMENTS**

1\. **Submission**. **NOTE**: *The use of Persian Gulf Code Sheet, VA
Form 10-9009A, December 1991, will be discontinued on September 24,
1995. **Existing stock must be destroyed**. All completed Persian Gulf
Code Sheets dated December 1991, and submitted to Austin Automation
Center (AAC) on and after September 24, 1995, will be rejected and
returned to the submitting VA facility. The use of revised VA Form
10-9009A, dated July 1995, must be implemented on September 25, 1995*.
Requirements or the submission of Department of Veterans Affairs (VA)
Form 10-9009A (July 1995), Persian Gulf Registry Code Sheet are as
follows:

a\. Legible copies of completed code sheets are submitted to the Office
of Financial Management Austin Automation Center (AAC), Austin, TX, for
data entry into the Persian Gulf Registry (PGR).

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

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

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

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

f\. AAC will send copies of code sheets, once entered into the PGR, to
the Senior Registry Coordinator, Environmental Agents Service (103A),
Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC
20420**,** for disposition.

2\. **Batching of Code Sheets**

a\. Preparation

\(1\) VA Form 10-9009A (July 1995) code sheets, Parts I through III, are
provided in booklet form. If any of the pages are removed, they should
be stapled in the upper-left hand corner.

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

\(3\) Facilities and/or a division of a consolidated facility must keep
submissions separate, i.e., each batch will include code sheets from one
facility. These code sheets should be arranged in numerical order
according to the Social Security Number (SSN), i.e., lowest SSN first
and highest SSN last).

**NOTE:** *Corrected code sheets do not have to be batched separately.
They can be mailed with the regular code sheets as long as they are from
the same facility.*

b\. If a veteran has had two examinations within the same mailing
period, that is, an initial and a follow-up examination, only the
initial examination code sheet should be submitted in the batch. Hold
the follow-up examination code sheet until you are certain the AAC has
processed and accepted the initial examination code sheet. If submitted
simultaneously, an error message may occur.

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

a\. Three copies of VA Form 7252 (formerly VA Form 30-7252), Transmittal
Form for the Use in Shipment of Tabulating Data, must accompany each
batch of code sheets. One copy must be retained at the AAC and the other
copy will be returned by the AAC to the transmitting facility
acknowledging receipt of code sheets and the third will include any
rejected code sheets and the edit analysis printout, entitled
"Transaction Change and Error (Reject) Listing."

b\. If there were no examinations or code sheets processed for each
month, a transmittal form must be completed indicating "0" for the "Code
Sheet Count" and sent to the AAC. This will assist the AAC in
maintaining a control on the code sheets transmitted by each facility.

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

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

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

\(b\) **Example**: If there are 50 code sheets to be submitted to the
AAC during the month of January, prepare two batches of 25 per batch,
with the control log number 001 and 002.

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

\(1\) Facility code number,

\(2\) Batch number assigned sequentially by facility beginning with 001
in January of each year (also to be recorded on transmittal sheet);

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

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

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

4\. **Mailing**

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

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

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

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

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

b\. The mailing address for the AAC is:

Department of Veterans Affairs

Automation Center (200/397A)

ATTN: PERSIAN GULF CLERK

1615 Woodward Street

Austin, TX 78772-0001

c\. It is not appropriate to call the AAC in regard to questions on code
sheet completion or correction. These questions should be referred to
the Veterans Registry Coordinator(s), the Environmental Agents Service,
VA Central Office.

d\. The AAC will process the data from the code sheets twice each month
(10th and 25th). The AAC will return all batches with the printout
"Transaction Change and Error (Reject) Listing" to the transmitting
facility.

5\. **Transaction Change and Error (Reject) Listing**

a\. A computerized printout "Transaction Change and Error (Reject)
Listing" will be returned to the transmitting facility with the
processed code sheets.

\(1\) This printout will reflect:

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

\(b\) Other messages not necessarily rejecting records; and

\(c\) The number of records inputted, i.e., accepted as well as
rejected.

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

b\. Corrections are to be made on the returned code sheet with RED pen
or RED felt-tipped pen or a new code sheet can be made with the
correction in the appropriate field(s). If a new code sheet is prepared
for the return of a correction, do not complete just the corrected
fields. **NOTE:** *All of the fields must be completed as if it were an
initial input.*

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

\(1\) Message. "This record rejected for edit errors."

[Action:]{.underline} Correct error(s) (\*) and resubmit code sheet.

\(2\) Message. "Transaction accepted, initial examination already
established at (facility number); transaction will be processed as a
follow-up examination for your facility."

[Action:]{.underline} AAC will not return a code sheet to the facility
since it has been accepted as a follow-up examination. Original code
sheet on file at facility should be corrected and card file or
computerized record should reflect the facility number where initial
examination was performed.

\(3\) Message. "Transaction accepted but an initial examination is
needed. Action Required."

[Action:]{.underline} The registry does not contain an initial
examination record for this veteran, but the registry has accepted the
follow-up examination record that was submitted. Reconstruct, if
possible, the initial examination record and submit to the AAC. A code
sheet will not be returned to the facility on this transaction since it
has been accepted in the PGR as a follow-up examination.

\(4\) Message. "Duplicate Follow-up Segment."

[Action:]{.underline} This message will appear if the examination date
on the code sheet submitted on the veteran is identical to an
examination date already existing in the registry. There is the
possibility of a coding or entry error. Examination date should be
verified using the veteran's medical record. If there is a duplicate
record, it should be deleted by submitting a code sheet in accordance
with instructions for deleting a record.

\(5\) Message. "No matching initial examination."

[Action:]{.underline} When deletion of an initial record in the registry
is attempted, the code sheet submitted with a type "B" must have the
identical information as on the original record previously accepted into
the registry, otherwise deletion process cannot be carried out.

6\. **Miscellaneous**

a\. [Forms Acquisition.]{.underline} Forms can be obtained from the VA
Forms and Publication Depot through local channels. VA Form 30-7252 has
been changed to VA Form 7252. The form itself has not been revised.

\(1\) Facilities can use either form when submitting reports. An initial
supply of VA Form 10-9009A (July 1995), has been provided to each
facility.

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

b\. [Reports Control Symbol.]{.underline} Reports Control Symbol (RCS)
10-0860 applies to this reporting requirement.

\(1\) The original code sheet will be filed in the veteran's CHR with
the documentation, i.e., laboratory test results, etc., from the PGR
examination and one legible copy sent to the AAC to be entered in the
PGR.

\(2\) If a CHR does not already exist for a veteran, one will be
established. A locator card will be created with the establishment of
the CHR. **NOTE:** *It is highly recommended that all registry records
are maintained in a separate section of CHR where they are easily
identifiable for quality monitoring and research availability.*

c\. [Record Disposition.]{.underline} Refer to Records Control Schedule
10-1, Section XXII, Item No. 136-5 for record disposition (see Medical
Administration Service).

d\. [Records Retention]{.underline}. Refer to Records Control Schedule
10-1 for records retention. Persian Gulf examination information will be
made part of the perpetual medical record at medical facilities
following the same retention requirements specified for VA CHR's Agent
Orange and Ionizing Radiation examinations. This includes:

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

\(2\) Progress notes,

\(3\) Laboratory reports,

\(4\) Patient locator cards, and

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

**INSTRUCTIONS AND SAMPLE OF COMPLETED VA FORM 7252,**

**TRANSMITTAL FORM FOR USE IN SHIPMENT OF TABULATING DATA**

1\. **Item 1. Addressee.** Department of Veterans Affairs Automation
Center (200/397), 1615 Woodward Street, Austin, TX 78722-0001, ATTN:
Persian Gulf Clerk.

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

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

4\. **Item 4.** Leave blank.

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

6\. **Item 6. Dispatch Date.** - Enter date submitting to the Office of
Financial Management Austin Automation Center (AAC).

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

8\. **Item 7. Official Responsible for Shipment.** - Enter name, title
and FTS telephone number of individual responsible for transmitting code
sheets to the AAC.

9\. **Item 8. Tabulating Data.**

a\. [Column A]{.underline}. Enter Records Control Symbol number 10-0860.

b\. [Column B.]{.underline} Job Number. Enter "1∅" in first segment and
"2∅A1" in second segment.

c\. [Column C.]{.underline} Description.

\(1\) First line enter "PERSIAN GULF;"

\(2\) Second line enter "Facility Number;\"

\(3\) Third line enter "Batch Number;"

\(4\) Fourth line enter "Code Sheet Count;" and

\(5\) Fifth line enter "Cumulative Count." **NOTE:** *This figure should
be the total number of veterans who have had registry examinations since
the onset of the Persian Gulf Registry Program in 1992**.***

\(d\) [Columns D and E.]{.underline} Leave blank.

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

**SAMPLE OF COMPLETED VA FORM 7252**

**INSTRUCTIONS AND SAMPLE FORMAT FOR COMPLETION OF BI-MONTHLY REPORT**

**ON PERSIAN GULF WAR VETERANS REGISTRY EXAMINATIONS (RCS 10-0875)**

A bi-monthly report is required from all Department of Veterans Affairs
(VA) facilities providing up-to-date statistical information on Persian
Gulf Registry (PGR) examinations. Instructions are provided below for
the completion and submission of this report.

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

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

Department of Veterans Affairs

Environmental Agents Service (103A)

ATTN: Persian Gulf Coordinator

810 Vermont Avenue, N.W.

Washington, DC 20420

3\. **Mailing Date.** This report should be sent to the above address NO
LATER THAN 5 WORKING DAYS FOLLOWING THE END OF EACH BI-MONTHLY REPORTING
PERIOD.

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

a\. **Initial Examination**. (The first physical examination of the
Persian Gulf veteran.) List the total number of completed initial
examinations performed during the current 2-month reporting period.
**NOTE:** *A completed code sheet has already been sent to Austin
Automation Center (AAC). which was completed for the purpose of entering
a Persian Gulf veteran into the PGR. This count should be verified with
the computerized or card file records maintained at each facility (see
par. 2.04) describing the computerized or card file requirement. A
printout of this computerized record should be enclosed with each
bi-monthly report sent to VA Central Office.*

b\. **Cumulative Initial Examinations**. The total number of cumulative
initial examinations listed in the previous bi-monthly report.

c\. **Cumulative Initial Examination**. The total number of "first-time"
examinations performed by the medical facility since the beginning of
the PGR in 1992. This number should include the current month's initial
examinations (par. 4.a) plus the sum of the previous month's cumulative
initial examinations (par. 4.b) . **NOTE:** *Examinations performed by
satellite outpatient clinics should be included in the total cumulative
figure for VA medical center of jurisdiction. Justification for
exceptions to this requirement should be directed to EAS (103) VACO.
Independent outpatient clinics should report in a manner similar to VA
medical centers.*

d\. **Initial Incomplete Examinations (In process**). The total number
of incomplete (code sheet(s) that has/have not been sent to AAC) initial
examinations in process during the period of the current report.

e\. **Follow-up Examinations.** (A first-time examination subsequent to
the initial examination-a completed initial examination code sheet has
been sent to AAC.) The total number of follow-up examinations during the
period of the current report.

f\. **Cumulative Follow- Examinations.** The total number of follow-up
examinations performed by the medical facility since the beginning of
the registry in 1992. This total should be the sum of the previous
months' cumulative follow-up examination total and the current
bi-monthly follow-up examinations.

g\. **Follow-up Examinations in Process**. The total number of follow-up
examinations being processed (completed code sheet(s) has/have not been
sent to AAC).

h\. **Pending Examination Appointments**. The total number of initial
Persian Gulf examinations for which appointments have been scheduled
beyond the end of the bi-monthly report period. **NOTE*:*** *This is not
cumulative and applies to the current bi-monthly report*.

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

j\. **Number of Veterans Failing to Keep an Initial Examination
Appointment**. The total number of veterans who failed to keep a
scheduled appointment during the bi-monthly reporting report. **NOTE:**
*This is not cumulative and applies to reporting period only.*

k\. **Comments or Problems Regarding Pending Examination Appointments**.
Problems or challenges should be documented with comments regarding
examination workload. An explanation and action plan to alleviate delays
should be provided in situations where a facility has 50 or more
examinations pending, and/or the next available appointment is more than
30 days beyond the date of request. If statistics have been adjusted due
to AAC acceptance of code sheets, the message "Cumulative statistics
adjusted per transaction acceptance at AAC" need to be included in this
paragraph.

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

**SAMPLE FORMAT FOR BI-MONTHLY REPORT ON PERSIAN GULF VETERANS**

**(RCS-10-0875)**

![](media/image1.emf){width="0.9895833333333334in"
height="0.9243055555555556in"}

**DEPARTMENT OF VETERANS AFFAIRS**

**Medical Center**

**Phoenix, AZ 85012**

In Reply Refer To:

August 7, 1995

Department of Veterans Affairs

Environmental Agents Service (103A)

ATTN: Persian Gulf Coordinator

810 Vermont Avenue, N.W.

Washington, DC 20420

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

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

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

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

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

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

code sheets submitted to Austin Automation Center (AAC):
[100]{.underline}

b\. **Cumulative Initial Examinations from Previous Bi-Monthly
Report:** + [450]{.underline}

c\. **Cumulative Number of Completed Initial Examinations Performed**

**Since Onset of Program (August, 1992):**

Total of numbers listed in Paragraphs 1-a and 1-b.
***[550]{.underline}***

**No*te: This should be the total number of all initial examination code
sheets***

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

***to AAC, [do not]{.underline} include in this total.***

d\. **Initial Incomplete Examinations (In process)**:

Total number of initial (incomplete) examinations in process:

(code sheets have not been sent to AAC): [75]{.underline}

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

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

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

where a completed code sheet for an initial examination has been sent to
AAC): [15]{.underline}

f\. **Cumulative Follow-Examinations:**

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

listed in above (par. 1-e) and all follow-up examinations previously
reported

since August, 1992): [75]{.underline}

g\. **Follow-up Examinations in Process:**

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

have not been sent to AAC during this reporting period):
[12]{.underline}

h\. **Pending Examination Appointments**:

Total number of initial examinations for which appointments have been

scheduled beyond the end of the bi-monthly report period:
[20]{.underline}

i\. The next Available Appointment Date: [8/10/95]{.underline}

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

Total number of veterans who failed to keep a scheduled appointment

during the current bi-monthly reporting period. This is not cumulative.
[10]{.underline}

. k**. Comments/problems regarding pending examinations**:

None

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

Ms. Joan Smith

VA Medical Center

650 E. Indian School Road

Phoenix, AZ 85012

[(Signature)]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

John Doe

Medical Center Director

**2**

**EXAMPLES OF PERSIAN GULF REGISTRY FOLLOW-UP LETTERS**

**SAMPLE PERSIAN GULF REGISTRY FOLLOW-UP LETTER**

**(MEDICAL PROBLEMS INDICATED)**

> ![](media/image1.emf){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) Persian Gulf Registry. This effort should prove
> to be helpful in assisting us to serve you and other veterans who are
> concerned about the possible health problems which may have resulted
> from service in Southwest Asia during the Persian Gulf War.
>
> As discussed at the conclusion of your visit, results of your
> examination and laboratory tests showed certain problems
> (optional\--these findings may be described in lay terms). In view of
> these findings, we have scheduled you for treatment of these health
> problems on ([date]{.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 Persian Gulf Registry examination, please contact
> the Veterans' Registry Coordinator at ([telephone number]{.underline})
> for assistance.
>
> Whether you are entitled to cost-free treatment or will be responsible
> for partial co-payment will be determined by your income and other
> factors unless the VA determines that your health problems are service
> connected. You may wish to file a claim for compensation to establish
> possible service connection. The injury or illness need not have been
> incurred in combat; the law requires only that a disease or disability
> was incurred or aggravated during military service.
>
> Please remember that this examination does not automatically initiate
> a claim for VA benefits. If you wish to file a claim, please contact
> your nearest VA Regional Office. In your area, the Regional Office is
> located at ([address]{.underline}). Their telephone number is
> ([telephone number]{.underline}). If you need any further assistance,
> you may contact a Veterans' Benefits Counselor by calling the VA
> toll-free telephone number 1-800-827-1000.
>
> An outreach program has been implemented by which VA notifies all
> individuals listed in the Registry of significant VA activities,
> including the health consequences of military service in the Persian
> Gulf theater of operations during the Persian Gulf War. You will be
> receiving a "Persian Gulf Review" which is published periodically by
> VA's Environmental Agents Service. A copy of this "Review" is enclosed
> for your reference.
>
> We trust this information is helpful to you. Once again, your
> participation in the registry is appreciated.
>
> Sincerely,
>
> [(Signature)]{.underline}
>
> Name of Veterans' Registry Physician
>
> Enclosure

**SAMPLE PERSIAN GULF REGISTRY FOLLOW-UP LETTER**

**(NO MEDICAL PROBLEMS INDICATED)**

> ![](media/image1.emf){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) Persian Gulf Registry. This effort should prove
> to be helpful in assisting us to serve you and other veterans who are
> concerned about the possible health problems which may have resulted
> from service in Southwest Asia during the Persian Gulf War.
>
> As discussed at the conclusion of your visit, results of your
> examination and laboratory tests indicate that there are no detectable
> medical problems. At this time you have no reason to be concerned
> about any adverse health effects resulting from your service in the
> Persian Gulf. However, in the future if you have a medical problem, I
> would encourage you to seek the help and advice of your nearest VA
> medical center or outpatient clinic. You may reach us at ([telephone
> number)]{.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, please contact
> your 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 a Veterans' Benefits Counselor by calling the VA
> toll-free telephone number 1-800-827-1000.
>
> An outreach program has been implemented by which VA notifies all
> individuals listed in the Registry of significant VA activities,
> including the health consequences of military service in the Persian
> Gulf theater of operations during the Persian Gulf War. You will be
> receiving a "Persian Gulf Review" which is published periodically by
> VA's Environmental Agents Service. A copy of this "Review" is enclosed
> for your reference.
>
> We trust this information is helpful to you. Once again, your
> participation in the registry is appreciated.
>
> Sincerely,
>
> \_\_\_\_\_\_\_\_\_\_[(Signature)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}
>
> Name of Veterans' Registry Physician
>
> Enclosure
>
> **CONTENTS**
>
> **CHAPTER 3. PHASE II, PERSIAN GULF UNIFORM CASE ASSESSMENT PROTOCOL
> (UCAP)**
>
> **PARAGRAPH PAGE**
>
> 3.01 Purpose 3-1
>
> 3.02 Background 3-1
>
> 3.03 Authority 3-1
>
> 3.04 Policy 3-1
>
> 3.05 Responsibilities 3-2
>
> **APPENDICES**
>
> 3A Uniform Case Assessment Protocol (UCAP) 3A-1
>
> 3B Instructions and Sample Format for Completion of VA Form 10-9009A
> (July 1995),
>
> Persian Gulf Registry Code Sheet, Part III, Uniform Case Assessment,
> Phase II 3B-1
>
> 3C Instructions and Sample Format for Completion of Bi-monthly Report
> on
>
> Persian Gulf Uniform Case Assessment, Phase II (RCS 10-0860) 3C-1

**CHAPTER 3. PHASE II, PERSIAN GULF UNIFORM CASE ASSESSMENT PROTOCOL
(UCAP)**

**3.01 PURPOSE**

This chapter provides a Uniform Case Assessment Protocol (UCAP) for the
evaluation of Persian Gulf veterans with unexplained illnesses.

**3.02 BACKGROUND**

a\. Many of the almost 690,000 personnel who served in the Persian Gulf
have reported health problems since their return to the United States.
While most of the health problems of these veterans have been diagnosed
as conditions that are readily definable, some veterans have unexplained
illnesses which developed after their Persian Gulf service. Many of the
Gulf War veterans seen by Department of Veterans Affairs (VA) Veteran\'s
Registry Physicians (VRPs) have complex, multifaceted health problems
that provide difficult diagnostic challenges. Veterans are
understandably frustrated that definitive answers regarding the cause(s)
of their problems are not immediately forthcoming.

b\. VA and the Department of Defense (DOD) working cooperatively
developed a UCAP for the evaluation of these Persian Gulf veterans who
after a thorough routine medical evaluation are determined to have
unexplained illnesses. **NOTE:** *This UCAP, grew out of the medical
experience in diagnostic evaluation of Gulf War veterans seen at VA
Referral Centers. The protocol was then further refined and adapted for
use by both VA and DOD facilities.*

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

d\. The concept behind the protocol was to identify previously
unrecognized major diagnostic entities which could provide an
explanation for the symptoms commonly reported in Persian Gulf veterans
with unexplained illnesses. It should be emphasized that the protocol is
not designed to be all-encompassing; therefore, it needs to be carried
out with a high degree of clinical judgment. All significant symptoms
and abnormalities not specifically outlined in the protocol, must be
fully evaluated according to the medical judgment of the VRP who is
directing the work-up. The information gathered by this process is to be
entered into a computerized database through the use of VA Form 10-9009A
(July 1995), Persian Gulf Registry Code Sheet, Part III (see App. 3B),
and will be analyzed for patterns of disease.

**3.03 AUTHORITY**

The UCAP for Persian Gulf veterans with unexplained illnesses was
administratively established by the Under Secretary for Health to assist
in addressing the unique health concerns of the Persian Gulf veterans.
On November 2, 1994, Public Law (Pub. L.) 103-446 amended Title 38
United States Code (U.S.C.) 1117 implementing the uniform and
comprehensive medical evaluation protocol for the veterans of the
Persian Gulf War.

**3.04 POLICY**

It is VA policy that all VA health care facilities must examine the
available services for Persian Gulf veterans to ensure that quality
outreach, diagnostic, and treatment services are furnished as intended;
and if these services cannot be provided by the local VA facility, a
mechanism must be developed to provide these services by contract,
sharing agreements or referral to other VA facilities.

**3.05 RESPONSIBILITIES**

a\. **VRPs.** The responsibility of the VRP is to:

\(1\) Conduct the Registry examination (Phase I), which is the first
step toward diagnosis of the health problems of a Persian Gulf veteran;
and

\(2\) If a diagnosis is not readily apparent after conducting routine
medical evaluations, to initiate the UCAP, (Phase II) using the protocol
provided in Appendix 3A.

b\. **Veterans\' Registry Coordinators (VRCs)** The VRC is responsible
for:

\(1\) Reporting instructions as included in Appendix 2D and Appendix 3B.

\(2\) Providing accurate coding of both symptoms and diagnoses and ,when
questions arise about these items, consult with VRP, or designee.

\(3\) Completing and submitting the UCAP and VA Form 10-9009A (July
1995) through appropriate channels to VA Central Office of Environmental
Agents Service (EAS). **NOTE:** *Related questions may be referred to
EAS, telephone (202) 565-4183.*

**UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)**

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

a\. Complete Blood Count (CBC),

b\. Urinalysis, and

c\. Blood Chemistry - SMA-6.

2\. **Phase II-Level Evaluation Protocol.** Phase II Level Evaluations
are recommended for those veterans after complete clinically indicated
evaluations are conducted and the physician determines that the patient
has an unexplained illness. Individuals who after completing Phase I or
Registry evaluations, have a disability and do not have a clearly
defined diagnosis which explains their symptoms, must receive the
following supplemental baseline laboratory tests and consultations.

a\. **Supplemental Baseline Laboratory Tests**

\(1\) CBC,

\(2\) Sedimentation Rate Erythrocyte Sedimentation Rate (ESR),

\(3\) C-Reactive Protein,

\(4\) Rheumatoid Factor,

\(5\) Anti-Nuclear Antibody (ANA),

\(6\) Liver Function,

\(7\) Creatine Phosphokinase (CPK),

\(8\) Hepatitis Serology,

\(9\) Human Immuno-deficiency (HIV),

\(10\) Venereal Disease Research Laboratory (VDRL),

\(11\) B-12 and Folate,

\(12\) Thyroid function Test,

\(13\) Urinalysis, and

\(14\) Tuberculosis (TB) skin test Purified Protein Derivative (PPD).

b\. **Consultations,** to include:

\(1\) Dental, but only if participant's annual screening is not done.

\(2\) Infectious Disease.

\(3\) Psychiatry, but only with physician-administered instruments.

\(a\) Structured Clinical Interview for the Diagnostic and Statistical
Manual of Mental Disorders, Third Edition, Revised (DSM III-R).
**NOTE:** *Delete nodules for mania and psychosis.*

\(b\) Clinician Administered Post Traumatic Stress Disorder (PTSD) Scale
(CAPS).

\(4\) Neuropsychological Testing, but only as indicated by a psychiatry
consult.

c\. **Symptom-specific Examination**. Individuals who have the following
symptoms should have the listed minimum work-up.

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

\(a\) Gastrointestinal (GI) consult,

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

\(c\) 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 Persian Gulf
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/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 Persian Gulf 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 Persian Gulf veterans with
complaints related to birth defects or genetic disorders in offspring
conceived during or after Persian Gulf 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.

\* *For copies of these questionnaires (Items d-1 and e-1 and 2) contact
VA Environmental Agents Service (103A) at 202-565-4183.*

**INSTRUCTIONS AND SAMPLE FORMAT FOR COMPLETION OF**

**VA FORM 10-9009A (JULY 1995), PERSIAN GULF REGISTRY CODE SHEET, PART
III,**

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

1\. **General Instructions for Completing Department of Veterans Affairs
(VA) Form 10-9009A, Part III, Phase II Persian Gulf Registry
Examination.**

a\. The mandated Phase II examination (VA Form 10-9009A (July 1995),
Part III) must be offered to all eligible Persian Gulf War veterans with
unexplained illnesses. The Phase II examination should be performed
after the completion of the Phase I registry examination and a thorough
clinically-based evaluation of the veteran's symptoms as deemed
necessary by the examining physician.

b\. Phase II should be performed at the local VA medical facility or if
the medical expertise is unavailable, local referral must be made to the
nearest regional tertiary care center or Persian Gulf Referral Center.

c\. Reporting requirements described in Appendix 2D will apply to, VA
Form 10-9009A (July 1995), Part III.

\(1\) Part III of the code sheet must be completed at the time of the
examination by the veteran\'s registry physician (VRP). A completed Part
III will be returned to Medical Administration Service (MAS) for
completion of ICD-9-CM codes where appropriate.

\(2\) A bi-monthly report of Phase II examinations is to be sent to
Department of Veterans Affairs, Environmental Agents Service (103A), 810
Vermont Avenue, N.W., Washington, DC 20420, 5 work days following the
end of each reporting period (refer to instructions and sample report in
App. 3B).

2\. **Instructions for Completing VA Form 10-9009A (July 1995), Part
III, Phase II**

a\. **Tests and Consultations**

\(1\) **Item 1. Blocks 1-24.** Were the following tests performed? Enter
one of the following codes in designated blocks:

Y = Yes

N = No

\(2\) **Item 2. Blocks 1-18.** **Blood Tests**

\(a\) [Block 1.]{.underline} Complete Blood Count (CBC)?

\(b\) [Block 2]{.underline}. Skin Erethyma Dose (SED) Rate?

\(c\) [Block 3]{.underline}. C-Reactive Protein?

\(d\) [Block 4.]{.underline} Rheumatoid Factor?

\(e\) [Block 5.]{.underline} Fluorescent Anti-Nuclear Antibody (ANA)?

\(f\) [Block 6]{.underline}. SGOT (AST) (Glutamic Oxaloacetic
Transaminase)?

\(g\) *Block 7*. SGPT (ALT) (Transaminase Glutamic Pyruvate)?

\(h\) [Block 8.]{.underline} Lactic Acid Hydrogenase (LDH)?

\(I\) [Block 9.]{.underline} Alkaline Phosphatase

\(j\) [Block 10.]{.underline} Creatine Phosphokinase (CPK)?

\(k\) [Block 11]{.underline}. Hepatitis B Surface Antibody?

\(l\) [Block 12.]{.underline} Hepatitis B Core Antigen?

\(m\) [Block 13.]{.underline} Venereal Disease Research Laboratory
(VDRL)?

\(n\) [Block 14.]{.underline} Vitamin B-12?

\(o\) [Block 15.]{.underline} Folate?

\(p\) [Block 16.]{.underline} Human Immuno-deficiency (HIV)?

\(q\) [Block 17.]{.underline} Thyroxine Total Serum (T4)?

\(r\) [Block 18.]{.underline} Thyroid Stimulating Hormone (TSH)?

\(3\) **Item 3. Block 19.** **Urinalysis?**

\(4\) **Item 4. Block 20.** **Tuberculosis (TB) Skin Test Purified
Protein Derivative (PPD)?**

\(5\) **Item 5. Block 21. Chest X-ray?**

\(6\) **Item 6. Block 22**. **Psychiatric Consultation?**

\(a\) [Item 6A. Block 23.]{.underline} Structured Clinical Interview for
Diagnoses (SCID) for Diagnostic and Statistical Manual of Mental
Disorders, Third Edition, Revised (DSM-III-R). Was the SCID interview
given?

\(b\) [Item 6B. Block 24.]{.underline} Clinical Administered
Post-Traumatic Stress Disorder (PTSD) Scale (CAPS). Was the CAPS
performed?

\(7\) **Item 7. Blocks 25-39.** List of Diagnoses. Designated physician
staff or physician assistants are to provide narrative description of
diagnoses. If none, leave blank. **NOTE:** *MAS coders: Enter ICD-9-CM
codes in Blocks 25-39.*

\(8\) **Item 8. Block 40.** Psychology-Neuropsychological Test. Was this
test performed? Enter on of the following codes in Block 40.

Y = Yes

N = No

\(9\) **Item 8A. Blocks 41-55. List of Diagnoses.** Designated physician
staff or physician assistants are to provide narrative description of
diagnoses. If none, leave blank. **NOTE:** *MAS coders: Enter ICD-9-CM
codes in Blocks 41-55.*

\(10\) **Item 9. Block 56**. Infectious Disease-Screening Examination.
Was this examination performed? Enter one of the following codes in
Block 56.

Y = Yes

N = No.

\(11\) **Item 9A. Blocks 57-66. List of Diagnoses.** Designated
physician staff or physician assistants are to provide narrative
description of diagnoses. If none, leave blank. **NOTE:** *MAS coders:
Enter ICD-9-CM codes in Blocks 57-66.*

\(12\) **Item 10. Block 67**. **Dental Examination**. Was this
examination performed? Enter one of the following codes in Block 67.

Y = Yes

N = No

\(13\) **Item 10A. Blocks 68-77. List of Diagnoses.** Designated dental
staff are to provide narrative description of diagnoses. If none, leave
blank. **NOTE:** *MAS coders: Enter ICD-9-CM codes in Blocks 68-77.*

**SYMPTOM-SPECIFIC EXAMINATIONS , PHASE II**

\(14\) **Item 11. Blocks 78-98. Diarrhea and/or Abdominal Pain**

\(a\) [Item 11A. Block 78.]{.underline} Did patient receive a GI
(Gastrointestinal) consult? Enter one of the following codes in Block
78.

Y = Yes

N = No

\(b\) [Item 11B. Blocks 79-98. List Diagnoses.]{.underline} Designated
physician staff are to provide narrative description of diagnoses. If
none, leave blank. **NOTE:** *MAS coders: Enter ICD-9-CM codes in Blocks
79-98.*

\(15\) **Item 12. Blocks 99-109.** **Headache and/or Memory Loss**

\(a\) [Block 12A. Block 99.]{.underline} Did patient receive neurology
consult? Enter one of the following codes in Block 99:

Y = Yes

N = No

(b). [Item 12B. Blocks 100-109. List Diagnoses]{.underline}. Designated
physician staff are to provide narrative description of diagnoses. If
none, leave blank. **NOTE:** *MAS coders: Enter ICD-9-CM codes in Blocks
100-109.*

\(16\) **Item 13. Blocks 110-120**. **Muscle Aches or Numbness**

\(a\) Item 13A. Block 110. Did patient receive a neurology consult?
Enter one of the following codes:

in Block 110.

Y = Yes

N = No

\(b\) Item 13B. Blocks 111-120. List Diagnoses. Designated physician
staff are to provide narrative description of diagnoses. If none, leave
blank. **NOTE:** *MAS coders: Enter ICD-9-CM codes in Blocks 111-120.*

\(17\) **Item 14. Blocks 121-131**. **Chronic Fatigue**

\(a\) [Item 14A. Block 121.]{.underline} Did patient receive consult(s)
relating to chronic fatigue? Enter one of the following codes in Block
121.

\(b\) [Item 14B. Blocks 122-131.]{.underline} List Diagnoses. Designated
physician staff are to provide narrative description of diagnoses. If
none, leave blank. **NOTE:** *MAS coders: Enter ICD-9-CM codes in Blocks
122-131.*

\(18\) **Item 15. Blocks 132-142.** **Joint Pain**

\(a\) [Item 15A. Block 132.]{.underline} Rheumatology Consult. Did
patient receive rheumatology consult? Enter one of the following codes
in Block 132:

Y = Yes

N = No

(b). [Item 15B. Blocks 133-142.]{.underline} List Diagnoses. Designated
physician staff are to provide narrative description of diagnoses. If
none, leave blank. **NOTE:** *MAS coders: Enter ICD-9-CM codes in Blocks
133-142.*

\(19\) **Item 16. Blocks 143-153.** **Chronic Cough and/or Shortness of
Breath**

\(a\) [Item 16A. Block 143.]{.underline} Pulmonary Consult. Did patient
receive pulmonary consult? Enter one of the following codes in Block
143:

Y = Yes

N = No

(b). [Item 16B. Blocks 144-153]{.underline}. List Diagnoses. Designated
physician staff are to provide narrative description of diagnoses. If
none, leave blank. **NOTE:** *MAS coders: Enter ICD-9-CM codes in Blocks
144-153.*

\(20\) **Item 17. Blocks 154-164.** **Skin Rash**

\(a\) [Item 17A. Block 154.]{.underline} Dermatology Consult. Did
patient receive a dermatology consult? Enter one of the following codes
in Block 154.

Y = Yes

N = No

\(b\) [Item 17B. Blocks 155-164.]{.underline} List Diagnoses. Designated
physician staff are to provide narrative description of diagnoses. If
none, leave blank. **NOTE:** *MAS coders: Enter ICD-9-CM codes in Blocks
155-164.*

\(21\) **Item 18. Blocks 165-175. Vertigo and/or Tinnitus**

\(a\) [Item 18A. Block 165.]{.underline} Audiology consult? Did patient
receive an audiology consult? Enter one of the following codes in Block
165:

Y = Yes

N = No

\(b\) [Item 18B. Blocks 166-175]{.underline}. List Diagnoses. Designated
physician staff are to provide narrative description of diagnoses. If
none, leave blank. **NOTE:** *MAS coders: Enter ICD-9-CM codes in Blocks
166-175.*

\(22\) **Item 19. Blocks 176-186.** **Chest Pain and/or Palpitations**

\(a\) [Item 19A. Block 176.]{.underline} Cardiology Consult? Did patient
receive a cardiology consult? Enter one of the following codes in Block
176:

Y = Yes

N = No

\(b\) [Item 19B. Blocks 177-186.]{.underline} List Diagnoses. Designated
physician staff are to provide narrative description of diagnoses. If
none, leave blank. **NOTE:** *MAS coders: Enter ICD-9-CM codes in Blocks
177-186.*

\(23\) **Item 20. Blocks 187-198. Reproductive Concerns**

\(a\) [Item 20A. Block 187]{.underline}. Did male patient receive a
urology consult? Enter of the following codes in Block 187.

Y = Yes

N = No

\(b\) [Item 20B. Block 188.]{.underline} Did female patient receive a
gynecology consult? Enter one of the following codes in Block 188.

Y = Yes

N = No

\(c\) [Item 20C. Blocks 189-198]{.underline}. List Diagnoses. Designated
physician staff are to provide narrative description of diagnoses. If
none, leave blank. **NOTE:** *MAS coders: Enter ICD-9-CM codes in Blocks
189-198.*

\(24\) **Item 21. Blocks 199-248. Final Diagnoses.** List up to 10 major
definite medical diagnoses on lines 21A-J, with the primary diagnosis
listed on line 21A. If no diagnosis is made, leave these lines blank as
well as blocks for ICD-9 codes. **NOTE:** *MAS coders: Use ICD-9-CM
codes in first five numbered blocks of each diagnosis.*

\(25\) **Item 22. Block 249.** After completing UCAP, Phase II, the
physician feels that the veteran has an unexplained illness? Enter one
of the following codes in Block 249.

Y = Yes

N = No.

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

**UCAP (UNIFORM CASE ASSESSMENT PROTOCOL) PHASE III**

**INSTRUCTIONS AND SAMPLE FORMAT FOR COMPLETION OF BI-MONTHLY REPORT**

**ON PERSIAN GULF UNIFORM CASE ASSESSMENT PROTOCOL (UCAP), PHASE II**

**(RCS-10-0860)**

A bi-monthly report is required from all Department of Veterans Affairs
(VA) facilities for all Persian Gulf veterans receiving a Uniform Case
Assessment Protocol (UCAP). Instructions are provided below for the
completion and submission of this report: **NOTE:** *A sample report is
provided in Appendix 3C.*

1\. **Title of Report:** Bi-monthly Persian Gulf Registry Phase II
Examination Report

2\. **Reporting Months:** The 2-month reporting period including month
and year.

3\. **Reporting Facility, Address, and Station Code:** Identify name,
address and station code of each reporting facility. If Uniform Case
Assessments (UCAs) are performed by satellite outpatient clinics, these
clinics should be identified and UCEs reported by VA medical center of
jurisdiction.

4\. **Column A:** Include the Persian Gulf veteran's name, Social
Security Number, (SSN), race, sex and branch of service.

5\. **Column B:** If Persian Gulf veteran was an outpatient, indicate
this by providing the date of the initial Persian Gulf Registry
examination, in Column B.

6\. **Column C:** If Persian Gulf veteran was an inpatient, indicate
this by providing the date of admission, date of discharge, and the date
of the initial Persian Gulf Registry examination in Column C.

7\. **Column D:** List up to ten exposures as indicated by veteran.

8\. **Column E:** List up to ten symptoms/complaints (with ICD-9 codes)
as indicated by veteran.

9\. **Column F:** List up to ten diagnoses (with ICD-9 codes). If there
are no diagnoses, indicate "None."

10\. **Column G:** List all pending tests, consultations, and
procedures, if incomplete prior to discharge.

11\. **Evaluation:** Summarize the total number of Persian Gulf veterans
(inpatients, outpatients receiving UCA's during the current reporting
months, and cumulative statistics since the onset of this program (June,
1994). The total number of pending UCA's (those Persian Gulf veterans
for whom a UCAE has been scheduled but not performed) should be listed
for the current month and not cumulative.

12\. **Reporting Information:** Provide the date of this report and the
name of the staff member preparing this report and the staff member's
telephone contact.

13\. **Mailing Address:** This report should be transmitted to the
following address:

Department of Veterans Affairs

Environmental Agents Service (103A)

ATTN: Persian Gulf Coordinator

810 Vermont Avenue, N.W.

Washington, DC 20420

**SAMPLE FORMAT OF BI-MONTHLY PERSIAN GULF REGISTRY PHASE II**

**UCAP (UNIFORM CASE ASSESSMENT PROTOCOL) REPORT (RCS-10-0860)**

**SAMPLE FORMAT OF**

**BI-MONTHLY PERSIAN GULF REGISTRY PHASE II UCAP (UNIFORM CASE
ASSESSMENT PROTOCOL)**

**REPORT (RCS-10-0860)**

**REPORTING PERIOD-JUNE-JULY, 1994**

**VAMC: PHOENIX, AZ (644)**

+----------+--------+--------+---------+--------+---------+-----------+
| **(A)**  | *      | *      | **(D)** | *      | **(F)** | **(G)**   |
|          | *(B)** | *(C)** |         | *(E)** |         |           |
+----------+--------+--------+---------+--------+---------+-----------+
| **NAM    | **     | *      | **LIST  | **LIST | **LIST  | **PENDING |
| E/SSN/** | OUTPAT | *INPAT | OF**    | OF**   | OF**    | TES       |
|          | IENT** | IENT** |         |        |         | TS/CON-** |
| **AGE/RA |        |        | **EXPO  | **SYMP | **DIAG  |           |
| CE/SEX** | **DATE | **     | SURES** | TOMS** | NOSIS** | **SULT    |
|          | OF**   | ADMISS |         |        |         | ATIONS/** |
| **BRANCH |        | ION/** | **(UP   | **(UP  | **(UP   |           |
| OF**     | **E    |        | TO      | TO     | TO TEN) | **PROC    |
|          | XAMINA | **     | TEN)**  | TEN)   | &**     | E-DURES** |
| **S      | TION** | DISCHA |         | &**    |         |           |
| ERVICE** |        | RGE/** |         |        | **ICD-9 |           |
|          |        |        |         | *      | CODES** |           |
|          |        | **PRGR |         | *ICD-9 |         |           |
|          |        | EXAM   |         | C      |         |           |
|          |        | D      |         | ODES** |         |           |
|          |        | ATES** |         |        |         |           |
+----------+--------+--------+---------+--------+---------+-----------+
| **PRIOR, | **6/1  |        | *       | **FATI | **N     | **MRI;**  |
| R        | 7/94** |        | *DIESEL | GUE/** | EURA-ST |           |
| ICHARD** |        |        | FUEL**  |        | HENIA** | **THYROID |
|          |        |        |         | **MAL  |         | F         |
| **222-22 |        |        | **MICRO | AISE** | **(     | UNCTION** |
| 2-2222** |        |        | WAVES** |        | 3005)** |           |
|          |        |        |         | **(    |         | **TEST**  |
| **30     |        |        | **NERVE | 7807)\ |         |           |
| Y.       |        |        | GAS**   | **     |         |           |
| O.W.M.** |        |        |         |        |         |           |
|          |        |        | **AN    |        |         |           |
| **ARMY** |        |        | THRAX** |        |         |           |
+----------+--------+--------+---------+--------+---------+-----------+
| **M      |        | **7/1  | **SA    | *      | **MUL   | *         |
| AITLAND, |        | 7/94** | NDFLY** | *JOINT | TIPLE** | *NEURO-** |
| JANE**   |        |        |         | PA     |         |           |
|          |        | **7/2  | **OIL   | IN(789 | **SYM   | **PSYCHO  |
| **777-7  |        | 0/94** | WELL    | 99);** | PTOMS** | LOGICAL** |
| 7-7777** |        |        | S       |        |         |           |
|          |        | **6/1  | MOKE.** | **RASH | **OF**  |           |
| **25     |        | 8/94** |         | (78    |         |           |
| Y.       |        |        |         | 21);** | **UN    |           |
| O.B.F.** |        |        |         |        | KNOWN** |           |
|          |        |        |         | **     |         |           |
| **ARMY** |        |        |         | WEIGHT | **ETI   |           |
|          |        |        |         | LOSS   | OLOGY** |           |
|          |        |        |         | (78    |         |           |
|          |        |        |         | 32);** | **(     |           |
|          |        |        |         |        | 7999)** |           |
|          |        |        |         | *      |         |           |
|          |        |        |         | *HEADA |         |           |
|          |        |        |         | CHES** |         |           |
|          |        |        |         |        |         |           |
|          |        |        |         | **(78  |         |           |
|          |        |        |         | 40);** |         |           |
|          |        |        |         |        |         |           |
|          |        |        |         | **INSO |         |           |
|          |        |        |         | MNIA** |         |           |
|          |        |        |         |        |         |           |
|          |        |        |         | **(780 |         |           |
|          |        |        |         | 50);** |         |           |
|          |        |        |         |        |         |           |
|          |        |        |         | **     |         |           |
|          |        |        |         | DEPRES |         |           |
|          |        |        |         | SION** |         |           |
|          |        |        |         |        |         |           |
|          |        |        |         | **(7   |         |           |
|          |        |        |         | 809)** |         |           |
+----------+--------+--------+---------+--------+---------+-----------+

***SUMMARIES***

**INPATIENT INPATIENT PENDING**

**ADMISSIONS DISCHARGES OUTPATIENTS: UCE'S**

**CURRENT MONTH: 1 1 1 2**

**CUMULATIVE: 0 0 0 0**

**TOTALS: 1 1 1 2**

**DATE: 8/7/94; PREPARED BY: JANE DOE; PHONE #602-222-2222**

**\* Y.O.W.M. = Year old white male; \*\* Y.O.B.F.= Year old black
female**

**CONTENTS**

**CHAPTER 4. PERSIAN GULF REFERRAL CENTERS (PGRCs)**

**PARAGRAPH PAGE**

4.01 Purpose 4-1

4.02 Background 4-1

4.03 Authority 4- 1

4.04 Policy 4- 1

4.05 Program Guidance 4-1

4.06 Responsibilities 4-2

4.07 Reporting Requirements 4-4

4.08 Media and Other External Contacts 4-5

**APPENDIX**

4A Instructions and Sample Format for Completion of the Persian Gulf

Referral Center (PGRC) Monthly Report (RCS 10-0860) 4A-1

**CHAPTER 4. PERSIAN GULF REFERRAL CENTERS (PGRCs)**

**4.01 PURPOSE**

This chapter sets forth clinical and administrative policies concerned
with program management of Veterans Health Administration (VHA) Persian
Gulf Referral Center (PGRC) examination programs established at
Department of Veterans Affairs (VA) Medical Centers in Birmingham, AL,
Houston,TX, Washington, DC, and West Los Angeles, CA.

**4.02 BACKGROUND**

a\. In August 1992, VA established three PGRCs to medically assist
Persian Gulf veterans whose symptoms defy explanation through the usual
diagnostic and therapeutic endeavors of local VA medical centers. An
additional center was established in June, 1995. The centers were
established when it became clear that increasing number of Desert Storm
veterans appeared to be incapacitated and had symptoms which eluded
routine medical diagnosis despite thorough medical work-ups at VA
medical centers. VA determined that for these veterans it was desirable
to provide for inpatient stays to allow for observation,
multidisciplinary consultation, documentation of lengthy occupational
and exposure histories, and an opportunity for frequent re-examination.
For such veterans, local VA medical centers make special arrangements
for the transfer, following consultation with the referral center
clinicians, to the appropriate center.

b\. The referral centers, located at VA Medical Center in Birmingham,
AL, Houston, TX, Washington, DC, and West Los Angeles, CA, were selected
based on availability of clinical and academic expertise in such areas
as pulmonary and infectious diseases, neurology, immunology,
neuropsychology and access to toxicologic expertise. The centers place
an emphasis on specific symptom complexes, such as fevers of unknown
origin, chronic fatigue, memory loss, unexplained weight loss and other
adverse health conditions possibly associated with chemical/toxic
environmental exposures in the Persian Gulf.

**4.03 AUTHORITY**

Authority for the VHA PGRCs is provided by Persian Gulf-related
legislation including:

a\. Public Law (Pub. L.) 102-25 which established a Persian Gulf War
period of service affecting persons serving on active duty as of August
2, 1990. At this time, there is no ending date established by law.

b\. Pub. L. 102-585, Title VII, "Persian Gulf War Veterans' Health
Status Act," enacted November 4, 1992, mandates the Secretary of
Veterans Affairs to establish and maintain a Persian Gulf Registry and
provide health examinations and counseling for eligible veterans;.

c\. Pub. L. 103-210, enacted December 20, 1993, provides the Secretary
of Veterans Affairs, with authority to provide priority health care for
eligible Persian Gulf veterans presenting adverse health conditions
possibly associated with service in the Persian Gulf.

**4.04 POLICY**

Persian Gulf veterans already determined to be eligible for a Persian
Gulf Registry examination and/or health care under the authorities cited
in paragraphs 2.02 and 3.02, and who have been admitted for outpatient
and/or inpatient care at a VA medical center, may be considered for
referral to a PGRC **NOTE:** *Final eligibility determinations for
admission to a PGRC is be left to the discretion of the PGRC Director.*

**4.05 PROGRAM GUIDANCE**

a\. Special directives and other program guidance prepared by VA Central
Office's Environmental Agents Service (EAS) (103A), provides the basis
for PGRC program activities.

b\. Appropriate means, i.e., medical center memoranda, need to be taken
to circulate this information throughout each Referral Center.

c\. PGRC staff must be aware of educational information and other
materials and publications prepared by EAS (e.g., Persian Gulf posters,
Persian Gulf Reviews, Persian Gulf Staff Updates, Persian Gulf Fact
Sheets, etc.).

d\. It is expected that PGRC staff will participate in national
education meetings and attend periodic nationwide conference calls
conducted by the EAS. **NOTE**: *They should be joined by VA medical
center staff concerned with the delivery of health care to Persian Gulf
veterans and the maintenance of the Persian Gulf Registry Examination
Program.*

**4.06 RESPONSIBILITIES**

a\. PGRC program management requires close coordination and interaction
between PGRC staff and VA medical center staff making medical referrals
of Persian Gulf veterans with difficult to diagnose health conditions.

b\. VA Central Office's EAS (103A) provides program guidance and
administratively oversee activities of the PGRCs and referring medical
centers.

c\. [PGRC Responsibilities]{.underline}. A specially dedicated clinical
and administrative support staff headed by a "Referral Center Clinical
Director" is established at each PGRC. The Director is responsible for
the clinical management of all medical and administrative activities
associated with the special diagnostic program. Major responsibilities
include:

\(1\) Consulting with VA medical center staff to determine
appropriateness of referral of Persian Gulf veteran to the PGRC.

\(2\) Providing medical consultation to VA medical centers of origin for
those cases in which it is determined that a PGRC admission is not
required. Such consultative support is to assist the local medical
center in arriving at a diagnosis and treatment regimen for Persian gulf
veteran(s) in question.

\(3\) Providing for all administrative aspects of admission, with the
close support and assistance of the medical center's Medical
Administration Service (MAS), of patient referrals to the PGRC.

\(4\) Developing a medical plan of action on each referral, i.e.:

\(a\) Reviewing and confirming the complete medical history in veteran's
Consolidated Health Record (CHR),

\(b\) Providing a comprehensive physical examination,

\(c\) Providing routine baseline laboratory tests,

\(d\) Providing other diagnostic testing as required, and

\(e\) Arranging specialty consultations as determined medically
appropriate.

\(5\) Advising the veteran(s) if they have not already done so, of the
opportunity to participate in, and be included in VA's computerized
Persian Gulf Veterans Health Registry Examination Program. If veteran
wishes to participate in the registry, the PGRC is to ensure compliance
with all registry procedures as outlined in M-10, Part III, Chapter 2.
**NOTE**: *Before referral to one of VA's PGRCs, it is requested that
all VA medical centers perform a Persian Gulf Registry Examination
(Phase I) and if at all possible a Uniform Case Assessment Protocol
(UCAP) (Phase II).*

\(6\) Providing for the documentation in the veteran's CHR of all
medical information pertinent to each referral (PGR code sheets,
laboratory reports, etc.).

\(7\) Upon conclusion of the PGRC's diagnostic work-up of each veteran,
providing for administrative referral of that individual back to the
referring medical center. The PGRC contacts the medical center of
referral prior to the veteran's departure from the facility.

\(8\) Providing each veteran with a final "consultation" by the PGRC
Director, and/or other PGRC staff as designated, of results of
diagnostic procedures/treatment.

\(9\) Providing each referral with a follow-up letter discussing the
results of the diagnostic work-up at the PGRC including results of
examination and laboratory tests with recommendations, as appropriate,
personalized to each referral.

\(10\) Providing copies of pending test or consultation results for each
referred veteran to EAS (103A) and VA facility of origin.

\(11\) Completing a VA Form 10-9009A (July 1995), Persian Gulf Registry
Code Sheet, and sending to Austin Automation Center (AAC) as a follow-up
examination when there is a new diagnosis or a change in diagnosis since
the initial registry examination code sheet should have been completed
by the referral facility and sent to AAC as an initial examination.

\(12\) Maintaining a special file on each referral at PGRC, for easy
accessibility.

\(13\) Providing cumulative monthly reports to EAS (103A) no later than
5 working days following the end of each month, see paragraph 3.05 and
Appendix 3B.

\(14\) Providing copies of discharge summaries, laboratory test results
and code sheets (both initial examination and follow-up, if there is a
new diagnosis or a change in diagnosis, for each referred Persian Gulf
veteran, to EAS (103A) within 5 working days following the end of each
monthly reporting period (see par. 3.05 and App. 3B).

d\. [Originating Medical Center Responsibilities]{.underline}. VA
medical centers are responsible for the medical referral to the PGRCs of
those Persian Gulf veterans for whom a medical diagnosis cannot
reasonably be determined in spite of extensive diagnostic, including
comprehensive clinical examination work-ups. Routine responsibilities of
the medical centers making the referral are:

\(1\) Contacting the Director, PGRC, or other appropriate PGRC clinical
staff member to discuss patients who meet the necessary criteria for
referral. Referral criteria include:

\(a\) Performing a Persian Gulf Registry examination, Phase I and Phase
II (if facility has these medical capabilities), prior to referral
consideration; and

\(b\) Reviewing medical records of those Persian Gulf veterans with
multiple symptoms for which a diagnosis has not been determined or those
veterans requiring a "second opinion."

\(2\) Providing, when necessary, the appropriate PGRC with any
documentation which will assist the PGRC in making its determination
whether a referral is appropriate, i.e., any examination data described
in the patient's CHR including, among others, medical history, progress
notes, test results, Persian Gulf Registry diagnostic code sheets, and
any other relevant medical/demographic information.

\(3\) Coordinating with the PGRC clinical and medical administrative
service staff, all necessary travel and per diem arrangements for the
veteran(s), including dates of planned transfer to the referral center
and projected return date.

\(4\) Obtaining the veteran's permission for transfer and providing
counseling concerning the reason(s) for referral, projected period of
inpatient admission at the PGRC, travel arrangements and responding to
any questions the veteran might have concerning the referral. **NOTE:**
*In some instances veterans may not wish to be referred. Ensure that
documentation of the veteran's decision in this regard is fully
documented in the CHR progress notes.*

\(5\) Upon notification of a referral's return from the PGRC, initiating
follow-up contact by telephone and/or letter with the veteran within 2
weeks of discharge from the referral center to determine the veteran's
health status and to provide any assistance for which the veteran may be
eligible.

\(6\) Discussing with Referral Center Directors outstanding consultation
results, either performed at referral centers or to be completed at the
local medical centers, and maintained in patient's files at both
facilities (local and referral).

\(7\) Documenting within the veteran's CHR all results, findings and
recommendations of the special diagnostic work-up provided by the PGRC.

**4.07 REPORTING REQUIREMENTS**

a\. Originating VA medical centers

\(1\) Prepare an original VA Form 10-9009A (July 1995) for each referred
Persian Gulf Registry veteran.

\(2\) Submit a legible copy to the ACC in accordance with the general
instructions found in Appendix 2C.

\(3\) Submit a legible copy of the VA Form 10-9009A (July 1995) to the
PGRC with the patients CHR.

\(4\) Submit all follow-up results of specialty consultations obtained
after the veteran's discharge from a PGRC, including further
consultation with the veteran, if appropriate, to:

Department of Veterans Affairs

EAS (103)

ATTN: Senior Registry Coordinator

810 Vermont Avenue, N.W.

Washington, DC 20420

b\. **PGRC**

\(1\) Submit follow-up Persian Gulf Code Sheets (VA Form 10-9009A (July
1995)) to AAC when new diagnostic code differs from previously submitted
code sheets, (see App.2B).

(2). Submit a PGRC report of admissions and/or discharges to EAS (103A)
, Attn.: Senior Registry Coordinator, within 5 working days following
the end of each reporting month (refer to App. 2B for instructions and
sample format).

\(3\) Submit a negative PGRC report if there were no admissions or
discharges during the reporting month.

\(4\) Submit copies of discharge summaries, laboratory reports, i.e.,
chest x-ray, blood count, blood chemistries or enzyme studies,
urinalysis and code sheets to EAS (103A), Attn.: Senior Registry
Coordinator, no later than 10 working days following the end of each
month.

\(5\) Submit all original medical records to local VA medical center to
be maintained in veteran's CHR.

\(6\) Maintain copies at PGRC in a special file for each referred
patient.

\(7\) Submit copies of results of follow-up specialty consultation after
discharge of veteran from PGRC to EAS and local VA medical center for
patient's CHR and/or further consultation with veteran, if appropriate.

**4.08 MEDIA AND OTHER EXTERNAL CONTACTS**

a\. **Media Contacts.** Reports of Contact from various media sources
(e.g., radio, television, newspapers, etc.) concerning PGRC activities
will be referred by phone to the facility public affairs officer.
Interviews should not be given unless approved by the medical center
Public Affairs Officer who may appropriately coordinate response with
the regional VA public affairs representative.

b\. **Contacts to Advise Centers of "Special Cures" for Persian
Gulf-related Illnesses.** Referral centers can expect, on occasion, to
be contacted by private sector physicians, researchers, and the general
public with information regarding "quick cures" for Persian Gulf-related
illnesses. Such individuals need to be politely advised that:

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

\(2\) All new treatments suggested must be reviewed by a formally
designated and staffed human subjects review committee.

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

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

\(5\) The individual might want to consider presenting the "new
approach" at a VA or medical school grand rounds or staff review
committee meetings.

\(6\) VA and the National Institutes of Health fund quality research
proposals.

**INSTRUCTIONS AND SAMPLE FORMAT FOR COMPLETION OF**

**PERSIAN GULF REFERRAL CENTER MONTHLY REPORT**

**(RCS 10-0860)**

A monthly report is required from all Department of Veterans Affairs
(VA) Persian Gulf Referral Centers (PGRC) receiving an extensive,
additional diagnostic and therapeutic work-up to evaluate those Persian
Gulf War veterans who are incapacitated and experiencing symptoms that
have eluded medical diagnosis despite thorough examinations at local VA
facilities. The following instructions are provided for the completion
and submission of this reported **NOTE:** *A sample report is provide on
page 4A-2.*

1\. **Title of Report.** Monthly Persian Gulf Referral Center Report

2\. **Reporting Period.** Month and Year of the reporting period.

3\. **Reporting Facility, Address and Station Code.** Identify name,
address and station code of each reporting PGRC.

4\. **Column A.** Include the Persian Gulf veteran's name, Social
Security Number, Race, Sex and Branch of Service.

5\. **Column B.** Provide the name, city and state of the VA facility
from which the Persian Gulf veteran was referred.

6\. **Column C.** Indicate date of admission, date of discharge, and the
date of initial Persian Gulf Registry examination.

7\. **Column D.** List up to ten exposures as indicated by the veteran.

8\. **Column E.** List up to ten symptoms/complaints (with ICD-9 codes)
as indicated by the veteran.

9\. **Column F.** List up to ten diagnoses (with ICD-9 codes). If there
are no diagnoses, -indicate "None."

10\. **Column G.** List all pending tests/consultations/procedures,
either those that have been performed at the PGRC or those to be
performed at the local VA medical center.

11\. **Number of Veterans.** List the total number of Persian Gulf
veterans admitted, discharged and any pending referrals for current
reporting month and cumulative numbers from the onset of this program:

a\. Total Admissions;

b\. Total Discharges; and

c\. Total Referrals Pending: (current month).

12\. **Date of Report.** Submit the date of this report.

13\. **Contact.** Name of staff member preparing this report and the
telephone contact.

14\. **Mailing Address**. This report must be transmitted to the
following address:

Department of Veterans Affairs

Environmental Agents Service (103A)

ATTN: Persian Gulf Coordinator

810 Vermont Avenue, N.W.

Washington, DC 20420

**PERSIAN GULF REFERRAL CENTER MONTHLY REPORT (RCS 10-0860)**

**REPORTING MONTH JULY, 1994**

**PGRC: HOUSTON, TX (580)**

+---------+--------+-------+---------+-----------+---------+---------+
| **(A)** | *      | **    | **(D)** | **(E)**   | **(F)** | **(G)** |
|         | *(B)** | (C)** |         |           |         |         |
+---------+--------+-------+---------+-----------+---------+---------+
| **NAME  | **REFE | **AD  | **LIST  | **LIST    | **LIST  | **      |
| /SSN/** | RRED** | MISSI | OF**    | OF**      | OF**    | PENDING |
|         |        | ON/** |         |           |         | TESTS   |
| **      | *      |       | **EXPO  | **S       | **DIAG  | /CON-** |
| AGE/RAC | *BY:** | **D   | SURES** | YMPTOMS** | NOSIS** |         |
| E/SEX** |        | ISCHA |         |           |         | *       |
|         | **VAMC | RGE** | **(UP   | **(UP TO  | **(UP   | *SULTAT |
| *       | /OPC** |       | TO      | TEN)&**   | TO TEN) | IONS/** |
| *BRANCH |        | **PGR | TEN)**  |           | &**     |         |
| OF**    |        | E     |         | **ICD-9   |         | **PROCE |
|         |        | XAM** |         | CODES**   | **ICD-9 | DURES** |
| **SE    |        |       |         |           | CODES** |         |
| RVICE** |        | **DA  |         |           |         |         |
|         |        | TES** |         |           |         |         |
+---------+--------+-------+---------+-----------+---------+---------+
| *       | **A    | **5/1 | **DU;** | **F       | *       | *       |
| *JONES, | LBANY, | /94** |         | ATIGUE/** | *NEURA- | *MRI;** |
| HARRY** | NY**   |       | **      |           | STHENIA |         |
|         |        | *     | CARC;** | **MALAISE | (       | **TH    |
| *       | **     | *5/10 |         | (7807)**  | 3005)** | YROID** |
| *555-55 | VAMC** | /94** | **PESTI |           |         |         |
| -5555** |        |       | CIDES** |           |         | **FUN   |
|         |        | *     |         |           |         | CTION** |
| **40    |        | *4/11 |         |           |         |         |
| Y.O     |        | /93** |         |           |         | *       |
| .W.M.** |        |       |         |           |         | *TEST** |
|         |        |       |         |           |         |         |
| *       |        |       |         |           |         |         |
| *ARMY** |        |       |         |           |         |         |
+---------+--------+-------+---------+-----------+---------+---------+
| **SMITH | **MON  | **5/2 | **OIL   | **JOINT   | **M     | **N     |
| ,JOHN** | TROSE, | /94** | FIRE    | PAIN**    | ULTIPLE | EURO-** |
|         | NY     |       | SMOKE;  |           | S       |         |
| *       | VAMC** | **    | ANTHRAX | **(       | YMPTOMS | **PS    |
| *333-33 |        | 5/19/ | VAC     | 78999);** | OF      | YCHO-** |
| -3333** |        | 94;** | CINE.** |           | UNKNOWN |         |
|         |        |       |         | **MEMORY  | ETI     | **LO    |
| **25    |        | **    |         | LOSS      | OLOGY** | GICAL** |
| Y.O.B   |        | 3/10/ |         | (7809);** |         |         |
| .M.\*** |        | 94.** |         |           | **(     |         |
|         |        |       |         | **LOOSE   | 7999)** |         |
| *       |        |       |         | BOWEL     |         |         |
| *NAVY** |        |       |         | STOOLS    |         |         |
|         |        |       |         | (7879);** |         |         |
|         |        |       |         |           |         |         |
|         |        |       |         | **FATIGUE |         |         |
|         |        |       |         | (7807);   |         |         |
|         |        |       |         | HEARING   |         |         |
|         |        |       |         | LOSS**    |         |         |
|         |        |       |         |           |         |         |
|         |        |       |         | *         |         |         |
|         |        |       |         | *(78999); |         |         |
|         |        |       |         | HE        |         |         |
|         |        |       |         | ADACHES** |         |         |
|         |        |       |         |           |         |         |
|         |        |       |         | **        |         |         |
|         |        |       |         | (7840);** |         |         |
+---------+--------+-------+---------+-----------+---------+---------+
| **      | **DU   | **    | **TENT  | **FATIGUE | **ARTHR | *       |
| WRIGHT, | RHAM** | 5/20/ | HEATER  | (7807);** | ALGIA** | *NONE** |
| ANN**   |        | 94;** | S       |           |         |         |
|         | **     |       | MOKE;** | **JOINT   | **(7    |         |
| *       | VAMC** | **    |         | PAINS     | 194);** |         |
| *666-66 |        | 5/30/ | **ATE   | (78999);  |         |         |
| -6666** |        | 94;** | LOCAL   | HE        | **D     |         |
|         |        |       | FOOD;   | ADACHES** | IARRHEA |         |
| **30    |        | *     | MICROW  |           | (       |         |
| Y.O.W.F |        | *3/4/ | AVES.** | **        | 3064)** |         |
| .\*\*** |        | 94.** |         | (7840);** |         |         |
|         |        |       |         |           |         |         |
| *       |        |       |         | **SLEE    |         |         |
| *ARMY** |        |       |         | PLESSNESS |         |         |
|         |        |       |         | (         |         |         |
|         |        |       |         | 78050);** |         |         |
|         |        |       |         |           |         |         |
|         |        |       |         | **LOOSE   |         |         |
|         |        |       |         | BOWEL**   |         |         |
|         |        |       |         |           |         |         |
|         |        |       |         | **STOOLS  |         |         |
|         |        |       |         | (7879)**  |         |         |
+---------+--------+-------+---------+-----------+---------+---------+

**SUMMARIES**

**ADMISSIONS DISCHARGES: PENDING EXAMS:**

**CURRENT MO. 3 3 10**

**CUMULATIVE: 10 10 N/A**

**DATE: 8/7/94;**

**PREPARED BY: JOHN DOE; PHONE #713-222-222**

**\*-Y.O.B.M. (Year Old Black Male)**

**\*\*-Y.O.W.F. (Year Old White Female)**

**Department of Veterans Affairs M-10, Part III**

**Veterans Health Administration Change 1**

**Washington, DC 20420**

**September 14, 1995**

1\. Transmitted is a change to the Department of Veterans Affairs (VA),
Veterans Health Administration M-10, "Environmental Agents Service,\"
Part III, "Persian Gulf Program."

2\. Principal changes are:

a\. **Appendix 2A:** This change adds to "Definitions and Acronyms",
"RHP, Reproductive Health Problems."

b\. **Appendix 2C**: Changes the VHA manual references for pseudo Social
Security Numbers, Facility, County and State Codes.

c\. **Appendix 2D:** Changes to the "Reporting Requirements," specifies
date of the discontinuation of VA Form 10-9009A, Persian Gulf Code
Sheet, dated December 1991, and the date of implementation of VA Form
10-9009A, Persian Gulf Code Sheet, dated July 1995.

d\. **Appendix 3A:** Changes the "Uniform Case Assessment Protocol
(UCAP)" which provides additional elements for the evaluation of Persian
Gulf veterans with complaints of Reproductive Health Problems (RHP).

3\. **Filing Instructions**

**Remove pages Insert pages**

2A-3 through 2A-4 2A-3 through 2A-4

2C-1 through 2C-2 2C-1 through 2C-2a

2D-1 through 2D-4 2D-1 through 2D-4

3A-3 through 3A-4 3A-3 through 3A-5

4\. **RESCISSIONS**: None.

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

Under Secretary for Health

Distribution: **RPC: 1323**

FD

Printing Date: 9/95