II Calendar No. 145 117th CONGRESS 1st Session S. 3003 IN THE SENATE OF THE UNITED STATES October 19, 2021 Mr. Tester , from the Committee on Veterans' Affairs , reported the following original bill; which was read twice and placed on the calendar A BILL To improve health care and benefits for veterans exposed to toxic substances, and for other purposes.

1. Short title; table of contents (a) Short title This Act may be cited as the Comprehensive and Overdue Support for Troops of War Act of 2021 or the COST of War Act of 2021 . (b) Table of contents The table of contents for this Act is as follows: Sec. 1. Short title; table of contents. TITLE I—Expansion of health care for toxic exposure veterans Sec. 101. Health care for certain toxic exposure veterans. Sec. 102. Expansion of health care eligibility for certain veterans exposed to open burn pits. Sec. 103. Expansion of health care eligibility for veterans awarded certain medals. Sec. 104. Study on feasibility and advisability of furnishing hospital care and medical services to dependents of veterans who participated in toxic exposure risk activities. TITLE II—Reforms to the toxic exposure presumption process Sec. 201. Improvements to ability of Department of Veterans Affairs to establish presumptions of service connection based on toxic exposure. Sec. 202. Technical corrections. TITLE III—Reforms to the service connection process for toxic exposure veterans Sec. 301. Presumptions of toxic exposure. Sec. 302. Presumption of exposure to airborne hazards and substances from burn pits. Sec. 303. Medical nexus examinations for toxic exposures. TITLE IV—Expansion of presumptions of service connection for forgotten veterans Sec. 401. Mark Takai Atomic Veterans Healthcare Parity Act of 2021. Sec. 402. Treatment of veterans who participated in nuclear response near Palomares, Spain, as radiation-exposed veterans for purposes of presumption of service-connection of certain disabilities by Department of Veterans Affairs. Sec. 403. Presumptions of service connection for diseases associated with exposures to certain herbicide agents for veterans who served in certain locations. Sec. 404. Addition of additional diseases associated with exposure to certain herbicide agents for which there is a presumption of service connection for veterans who served in the Republic of Vietnam. Sec. 405. Improving compensation for disabilities occurring in Persian Gulf War veterans. Sec. 406. Presumption of service connection for certain diseases associated with exposure to burn pits and other toxins. TITLE V—Strengthening Federal research on toxic exposures Sec. 501. Coordination by Department of Veterans Affairs of toxic exposure research. Sec. 502. Collection, analysis, and report on treatment of veterans for medical conditions related to toxic exposure. Sec. 503. Studies relating to veterans who served in Southwest Asia. Sec. 504. Study on health trends of post 9/11 veterans. Sec. 505. Study on cancer rates among veterans. TITLE VI—Improving support to toxic exposure veterans Sec. 601. Definitions. Sec. 602. Publication of list of resources of Department of Veterans Affairs for toxic exposure veterans and outreach program for such veterans and caregivers and survivors of such veterans. Sec. 603. Incorporation of toxic exposure questionnaire during primary care appointments. Sec. 604. Training for personnel of the Department of Veterans Affairs with respect to toxic exposure veterans. Sec. 605. SFC Heath Robinson Burn Pit Transparency Act. TITLE VII—Strengthening record-keeping of toxic exposures by Department of Defense Sec. 701. Definitions. Sec. 702. Independent study on Individual Longitudinal Exposure Record. Sec. 703. Biannual report on Individual Longitudinal Exposure Record. Sec. 704. Correction of toxic exposure records. I Expansion of health care for toxic exposure veterans 101. Health care for certain toxic exposure veterans (a) In general Section 1710(e) of title 38, United States Code, is amended— (1) paragraph (1), by adding at the end the following new subparagraph: (G) Subject to paragraph (2), any veteran who participated in a toxic exposure risk activity while serving on active duty, active duty for training, or inactive duty training is eligible for hospital care, medical services, and nursing home care under subsection (a)(2)(F) for any illness, notwithstanding that there is insufficient medical evidence to conclude that such illness is attributable to such toxic exposure risk activity. ; and (2) in paragraph (2)(B)— (A) by striking or (F) and inserting (F), or (G) ; and (B) by striking service or testing and inserting service, testing, or activity . (b) Definitions Section 101 of such title is amended by adding at the end the following new paragraphs: (37) The term toxic exposure includes the following: (A) A toxic exposure risk activity. (B) An exposure to a toxic or hazardous substance that is subject to regulation by the Occupational Safety and Health Administration. (38) The term toxic exposure veteran means any veteran who— (A) carried out a toxic exposure risk activity; or (B) received or receives hospital care, medical services, or nursing home care pursuant to section 1710(e)(1) of this title. (39) The term toxic exposure risk activity means any activity— (A) that requires a corresponding entry in the Individual Longitudinal Exposure Record of the veteran who carried out the activity; or (B) that the Secretary determines qualifies for purposes of section 1710(e)(1) of this title when taking into account what is reasonably prudent to protect the health of veterans. (40) The term Individual Longitudinal Exposure Record includes any pilot program or other program used by the Department of Veterans Affairs or the Department of Defense to track how members of the Armed Forces or veterans have been exposed to various occupational or environmental hazards. . 102. Expansion of health care eligibility for certain veterans exposed to open burn pits (a) In general Section 1710(e) of title 38, United States Code, as amended by section 101(a)(2)(A), is further amended— (1) in paragraph (1), by adding at the end the following new subparagraph: (H) (i) Subject to paragraph (2), a covered veteran is eligible for hospital care, medical services, and nursing home care under subsection (a)(2)(F) for any illness. (ii) For purposes of this subparagraph, a covered veteran is a veteran who— (I) is eligible for inclusion in the Airborne Hazards and Open Burn Pit Registry; or (II) has been identified by the Secretary of Defense to have been possibly exposed, inside or outside the United States, during active duty, active duty for training, or inactive duty training, to an open burn pit. (iii) In this subparagraph: (I) The term Airborne Hazards and Open Burn Pit Registry means the registry established by the Secretary under section 201 of the Dignified Burial and Other Veterans’ Benefits Improvement Act of 2012 ( Public Law 112–260 ; 38 U.S.C. 527 note). (II) The term open burn pit has the meaning given that term in section 201(c) of the Dignified Burial and Other Veterans’ Benefits Improvement Act of 2012 ( Public Law 112–260 ; 38 U.S.C. 527 note). ; and (2) in paragraph (2)(B), as amended by section 101(a)(2)(A), by striking or (G) and inserting (G), or (H) . (b) Effective date The amendments made by subsection (a) shall take effect on the date that is 90 days after the date of the enactment of this Act. 103. Expansion of health care eligibility for veterans awarded certain medals (a) In general Section 1710(e) of title 38, United States Code, as amended by section 102(a)(1), is further amended— (1) in paragraph (1), by adding at the end the following new subparagraph: (I) Subject to paragraph (2), a veteran is eligible for hospital care, medical services, and nursing home care under subsection (a)(2)(F) for any illness if the veteran was awarded any of the following: (i) The Afghanistan Campaign Medal. (ii) The Armed Forces Expeditionary Medal. (iii) The Global War on Terrorism Expeditionary Medal. (iv) The Inherent Resolve Campaign Medal. (v) The Iraqi Campaign Medal. (vi) The Southwest Asia Service Medal. ; and (2) in paragraph (2)(B), as amended by section 102(a)(2), by striking or (H) and inserting (H), or (I) . (b) Effective date The amendments made by subsection (a) shall take effect on the date that is 90 days after the date of the enactment of this Act. 104. Study on feasibility and advisability of furnishing hospital care and medical services to dependents of veterans who participated in toxic exposure risk activities (a) In general The Secretary of Veterans Affairs shall conduct a study on the feasibility and advisability of furnishing hospital care and medical services to qualifying dependents of veterans described in section 1710(e)(1)(G) of title 38, United States Code, as added by section 101(a)(1), for any illness or condition determined by the Secretary to be connected to a toxic exposure risk activity carried out by the veteran, as determined by the Secretary, notwithstanding that there is insufficient medical evidence to conclude that such illness or condition is attributable to such activity. (b) Elements of study The study required under subsection (a) shall— (1) assess the impact of furnishing hospital care and medical services to qualifying dependents as described in such subsection on the ability of the Department of Veterans Affairs to furnish hospital care and medical services to veterans; (2) assess the potential cost of furnishing hospital care and medical services to qualifying dependents as described in such subsection; (3) estimate the resources required to furnish such care and services; (4) assess any stress or other impact furnishing such care and services would have on the claims and appeals system of the Department; (5) estimate the number of qualifying dependents who would be eligible for such care and services; and (6) assess the feasibility of adjudicating claims for such care and services. (c) Phased in application In conducting the study under subsection (a), the Secretary shall assess the feasibility and advisability of phasing in the furnishing of hospital care and medical services to qualifying dependents described in such subsection by the decade in which such toxic exposure risk activity occurred, starting with the most recent decade. (d) Review of exposure cases regarding liability of Department of Defense In conducting the study under subsection (a), the Secretary shall— (1) review known cases of toxic exposure on installations of the Department of Defense in the United States; (2) explore the liability of the Department of Defense in each such case; and (3) assess whether the Department of Defense should provide care and services relating to such toxic exposures under the TRICARE program. (e) Report Not later than two years after the date of the enactment of this Act, the Secretary shall submit to Congress a report on the study conducted under subsection (a). (f) Definitions In this section: (1) Hospital care and medical services The terms hospital care and medical services have the meanings given those terms in section 1701 of title 38, United States Code. (2) Qualifying dependent The term qualifying dependent means— (A) a dependent of a veteran described in section 1710(e)(1)(G) of title 38, United States Code, as added by section 101(a)(2) who resided with the veteran during the period in which, and on the installation at which, the veteran participated in a toxic exposure risk activity; (B) an individual who was in utero of such a veteran or other qualifying dependent when the veteran participated in a toxic exposure risk activity; or (C) a dependent of such a veteran who is not described in subparagraph (A) or (B) but who may have an illness or condition that is connected to the toxic exposure risk activity of the veteran, as determined by the Secretary. (3) TRICARE program The term TRICARE program has the meaning given that term in section 1072(7) of title 10, United States Code. II Reforms to the toxic exposure presumption process 201. Improvements to ability of Department of Veterans Affairs to establish presumptions of service connection based on toxic exposure (a) Advisory committees, panels, and boards (1) Establishment Chapter 11 of title 38, United States Code, is amended by adding at the end the following new subchapter: VII Research and determinations relating to presumptions of service connection based on toxic exposure 1171. Procedures to determine presumptions of service connection based on toxic exposure; definitions (a) Procedures The Secretary shall determine whether to establish, to modify, or to remove presumptions of service connection based on toxic exposure pursuant to this subchapter, whereby— (1) the Toxic Exposure Review Commission advises the Secretary and makes recommendations pursuant to section 1172 of this title; (2) the National Academies of Sciences, Engineering, and Medicine, reviews and evaluates the available scientific evidence pursuant to an agreement under section 1173 of this title; (3) the working group established under section 1174 of this title evaluates the conclusions of the National Academies of Sciences, Engineering, and Medicine pursuant to the agreement described in paragraph (2) and makes recommendations to the Secretary under such section; and (4) the Secretary prescribes regulations under section 1175 of this title. (b) Illness defined In this subchapter, the term illness includes a disease or other condition affecting the health of an individual. (c) Nonapplication of FACA The Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to an entity established under this subchapter. 1172. Toxic Exposure Review Commission (a) Establishment The Secretary shall establish an independent commission to be known as the Toxic Exposure Review Commission (in this section referred to as the Commission ). (b) Purpose The Commission shall— (1) advise the Secretary on questions relating to toxic exposures that require scientific research; and (2) assist in the consideration of possible presumptions of service connection relating to toxic exposure. (c) Duties (1) The Commission shall carry out the following duties: (A) Collect any relevant information from the Department of Defense and other sources to identify possible toxic exposures relating to service during active duty, active duty for training, or inactive duty training in order to determine the need for a comprehensive review under an agreement with the National Academies of Sciences, Engineering, and Medicine under section 1173 of this title. (B) Recommend to the Secretary, by majority vote, whether a review should be conducted under an agreement with the National Academies of Sciences, Engineering, and Medicine under section 1173 of this title. (C) Recommend to the Secretary, by majority vote, whether new, independent studies regarding the health outcomes of toxic exposures, or any other new, independent studies that the Commission deems necessary and appropriate, should be conducted. (D) Annually report to Congress on progress regarding the duties set forth in subparagraphs (A) through (C), any recommendations made to the Secretary, and any responses of the Secretary to such recommendations. (2) (A) Relevant information may be collected under paragraph (1)(A) from the following: (i) Any Federal agency as the Commission considers necessary to carry out this section. (ii) Public meetings or hearings, which may be held to take such testimony and receive such evidence as the Commission considers advisable to carry out the duties of the Commission. (B) Upon request of the chairperson of the Commission, the head of a Federal agency shall furnish information collected under subparagraph (A)(i) to the Commission unless such information is classified. (d) Membership (1) (A) The Commission shall be composed of nine members, appointed as follows: (i) Two members appointed by the majority leader of the Senate. (ii) Two members appointed by the minority leader of the Senate. (iii) Two members appointed by the Speaker of the House of Representatives. (iv) Two members appointed by the minority leader of the House of Representatives. (v) One member appointed by the Secretary. (B) The initial members of the Commission shall be appointed under subparagraph (A) not later than 180 days after the date of the enactment of the Comprehensive and Overdue Support for Troops of War Act of 2021 . (2) In appointing individuals under paragraph (1)(A), the majority leader of the Senate, the minority leader of the Senate, the Speaker of the House of Representatives, the minority leader of the House of Representatives, and the Secretary shall jointly ensure that at least five members of the Commission are scientists or health care professionals— (A) of whom— (i) one has a background in the field of respiratory medicine; (ii) one has a background in the field of endocrinology and metabolic medicine; (iii) one has a background in hematology; (iv) one has a background in oncology; and (v) one has a background in occupational and environmental health; and (B) who are not officials or employees of the Federal Government. (3) In appointing individuals under paragraph (1)(A), the majority leader of the Senate, the minority leader of the Senate, the Speaker of the House of Representatives, the minority leader of the House of Representatives, and the Secretary shall jointly ensure that at least two members of the Commission represent an organization recognized by the Secretary for the representation of veterans under section 5902 of this title. (4) In appointing individuals under paragraph (1)(A), the majority leader of the Senate, the minority leader of the Senate, the Speaker of the House of Representatives, the minority leader of the House of Representatives, and the Secretary shall jointly give consideration to including in the Commission at least one member who works with survivors of illnesses relating to toxic exposures and has a background in the field of study of toxic exposures. (e) Meetings (1) The Commission shall meet not less frequently than twice each year. (2) (A) Each meeting of the Commission shall be open to the public. (B) All the proceedings, information, and deliberations of the Commission shall be available for review by the public. (C) Meetings of the Commission may be carried out through the use of telephonic or other appropriate telecommunication technology if the Commission determines that such technology will allow the members to communicate simultaneously. (f) Chairperson and vice chair At the initial meeting of the Commission under subsection (e), the Commission shall select a chairperson and vice chairperson from among the members of the Commission by a majority vote of the members of the Commission. (g) Period of appointment; vacancies (1) A member of the Commission shall be appointed for a term that may not exceed four years. (2) The Secretary shall ensure that terms of members of the Commission are staggered so that no such terms end on the same date. (3) A vacancy in the Commission shall be filled in the same manner as the original appointment, but the individual appointed to fill the vacancy shall serve only for the unexpired portion of the term for which the individual’s predecessor was appointed. (4) In appointing the initial members of the Commission, each official who is authorized to appoint two members of the Commission shall appoint— (A) one member whose term expires after two years; and (B) one member whose term expires after four years. (h) Pay (1) Members of the Commission shall serve without pay. (2) Each member of the Commission who is an officer or employee of the United States shall serve without compensation in addition to that received for service as an officer or employee of the United States. (3) Members shall receive travel expenses, including per diem in lieu of subsistence, in accordance with sections 5702 and 5703 of title 5. (i) Director of staff (1) The Commission shall appoint a Director who— (A) has not served as an employee of the Department during the one-year period preceding the date of such appointment; and (B) is not otherwise barred or prohibited from serving as Director under Federal ethics laws and regulations, by reason of post-employment conflict of interest. (2) The Director shall be paid at the rate of basic pay payable for level IV of the Executive Schedule under section 5315 of title 5. (j) Staff (1) Subject to paragraphs (2) and (3), the Director, with the approval of the Commission, may appoint and fix the pay of additional personnel. (2) The Director may make such appointments without regard to the provisions of title 5 governing appointments in the competitive service, and any personnel so appointed may be paid without regard to the provisions of chapter 51 and subchapter III of chapter 53 of that title relating to classification and General Schedule pay rates, except that an individual so appointed may not receive pay in excess of the annual rate of basic pay payable for GS–15 of the General Schedule. (3) (A) Not more than two-thirds of the personnel employed by or detailed to the Commission may be on detail from the Department. (B) Not more than half of the professional analysts of the Commission staff may be persons detailed from the Department to the Commission. (4) Subject to paragraph (3), the head of any Federal agency, upon the request of the Director, may detail any of the personnel of that agency to the Commission to assist the Commission in carrying out its duties under this section. (5) The Commission may secure directly from any Federal agency such information as the Commission considers necessary to carry out this section. Upon request of the chairperson of the Commission, the head of such agency shall furnish such information to the Commission, unless such information is classified. (k) Other authority (1) The Commission may procure by contract, to the extent funds are available, the temporary or intermittent services of experts or consultants pursuant to section 3109 of title 5. (2) To the extent funds are available, the Commission may lease real property and acquire personal property either of its own accord or in consultation with the General Services Administration. (l) Communications (1) (A) Except as provided in subparagraph (B), no person may restrict an employee of the Department in communicating with the Commission. (B) Subparagraph (A) does not apply to a communication that is unlawful. (2) All ex parte communications with the Commission shall be made part of the public record. (m) Responses by Secretary In response to each report submitted to the Secretary by the Commission under subsection (c)(1), the Secretary shall submit to the Committee on Veterans’ Affairs of the Senate and the Committee on Veterans’ Affairs of the House of Representatives and make available to the public a report on— (1) the findings and opinions of the Secretary with respect to the report most recently submitted under subsection (c)(1); (2) whether the Secretary intends to nominate for review under an agreement with the National Academies of Sciences, Engineering, and Medicine under section 1173 of this title the review recommended by the Committee in the report, and if not, an explanation of why, including citations and sources; and (3) whether the Secretary intends to follow any other recommendation made by the Commission. 1173. Science review agreement (a) Purpose The purpose of this section is to provide for the National Academies of Sciences, Engineering, and Medicine (in this section referred to as the Academies ), an independent nonprofit scientific organization with appropriate expertise that is not part of the Federal Government, to review and evaluate the available scientific evidence regarding associations between illnesses and toxic exposures. (b) Agreement (1) The Secretary shall seek to enter into a 10-year agreement with the Academies to perform the services covered by this section. (2) The Secretary shall seek to enter into an agreement described in paragraph (1) not later than 60 days after the date of the enactment of the Comprehensive and Overdue Support for Troops of War Act of 2021 . (3) An agreement under this section may be extended in five-year or 10-year increments. (c) Review of scientific evidence Under an agreement between the Secretary and the Academies under this section, the Academies shall review and summarize the scientific evidence, and assess the strength thereof, concerning the association between toxic exposures during active military, naval, or air service and each illness suspected to be associated with such exposure in the human population. (d) Scientific determinations concerning illnesses For each illness reviewed under subsection (c), the Academies shall determine, to the extent that available scientific data permit meaningful determinations— (1) whether an association exists between a toxic exposure and the occurrence of the illness, taking into account the strength of the scientific evidence and the appropriateness of the statistical and epidemiological methods used to detect the association; (2) the increased risk of the illness among those subject to toxic exposures during active military, naval, or air service; and (3) whether there exists a plausible biological mechanism or other evidence of a causal relationship between the toxic exposure and the occurrence of the illness. (e) Cooperation of Federal agencies The head of each relevant Federal agency, including the Secretary of Defense, shall cooperate fully with the Academies in performing the services covered by this section. (f) Recommendations for additional scientific studies (1) Under an agreement between the Secretary and the Academies under this section, the Academies shall make any recommendations for additional scientific studies to resolve areas of continuing scientific uncertainty relating to toxic exposures. (2) In making recommendations under paragraph (1), the Academies shall consider— (A) the scientific information that is available at the time of the recommendation; (B) the value and relevance of the information that could result from additional studies; and (C) the cost and feasibility of carrying out such additional studies. (g) Reports (1) Under an agreement between the Secretary and the Academies under this section, for each review conducted under subsection (c), the Academies shall submit to the Secretary, the Committee on Veterans’ Affairs of the Senate, and the Committee on Veterans’ Affairs of the House of Representatives an initial report on the activities of the Academies under the agreement. (2) The report submitted under paragraph (1) shall include the following: (A) The determinations described in subsection (d). (B) A full explanation of the scientific evidence and reasoning that led to such determinations. (C) Any recommendations of the Academies under subsection (f). (h) Alternative contract scientific organization (1) If the Secretary is unable to enter into an agreement with the Academies for the purposes of this section on terms acceptable to the Secretary, the Secretary shall seek to enter into an agreement for the purposes of this section with another appropriate scientific organization that— (A) is not part of the Federal Government; (B) operates as a not-for-profit entity; and (C) has expertise and objectivity comparable to that of the Academies. (2) If the Secretary enters into an agreement with another organization as described in paragraph (1), any reference in this subchapter to the National Academies of Sciences, Engineering, and Medicine shall be treated as a reference to the other organization. 1174. Working group on presumptions of service connection (a) Establishment The Secretary shall establish a working group (in this section referred to as the Working Group )— (1) to evaluate the conclusions of the National Academies of Sciences, Engineering, and Medicine contained in each report submitted under section 1173(g) of this title; and (2) to develop and submit to the Secretary a recommendation within 60 days of the Secretary’s receipt of a report under section 1173(g) of this title with respect to whether— (A) to establish a presumption of service connection between each toxic exposure and illness covered by a report described in paragraph (1); or (B) to modify an existing presumption of service connection covered by a report described in paragraph (1). (b) Recommendations (1) In making a recommendation under subsection (a)(2), the Working Group shall, if the Working Group determines that additional research, studies, or reports are appropriate before making a final recommendation with respect to establishing or modifying a presumption of service connection, submit to the Secretary a description of such additional research, studies, or reports. (2) In making a recommendation under subsection (a)(2), the Working Group shall consider only the positive association between a toxic exposure and an illness. (3) Concurrent with the submittal of a recommendation to the Secretary under subsection (a)(2), the Working Group shall submit to the Committee on Veterans’ Affairs of the Senate and the Committee on Veterans’ Affairs of the House of Representatives a description of such recommendation. 1175. Regulations regarding presumptions of service connection based on toxic exposure (a) Action upon Working Group recommendation Not later than 60 days after the date on which the Secretary receives a recommendation to establish or modify a presumption of service connection under section 1174(a)(2) of this title— (1) if the Secretary determines that the presumption, or modification, is warranted, the Secretary shall issue proposed regulations setting forth the presumption or revise regulations to carry out such modification; or (2) if the Secretary determines that the presumption, or modification, is not warranted, the Secretary shall publish in the Federal Register a notice of the determination, including the reasons supporting the determination, and all materials the Secretary relied upon for the determination. (b) Final regulation Not later than 90 days after the date on which the Secretary issues any proposed regulations under subsection (a)(1), the Secretary shall issue final regulations. Such regulations shall be effective on the date of issuance. (c) Removal of presumption (1) The Secretary may issue regulations to remove an illness from a presumption of service connection previously established pursuant to a regulation issued under subsection (b). (2) Whenever an illness is removed from regulations pursuant to paragraph (1), or the periods or locations of exposure covered by a presumption of service connection are modified under subsection (a)— (A) a veteran who was awarded compensation for such illness on the basis of the presumption provided under such regulations before the effective date of the removal or modification shall continue to be entitled to receive compensation on that basis; and (B) a survivor of a veteran who was awarded dependency and indemnity compensation for the death of a veteran resulting from such illness on the basis of such presumption shall continue to be entitled to receive dependency and indemnity compensation on such basis. . (2) Clerical amendment The table of sections at the beginning of such chapter is amended by adding at the end the following new items: SUBCHAPTER VII—Research and determinations relating to presumptions of service connection based on toxic exposure 1171. Procedures to determine presumptions of service connection based on toxic exposure; definitions. 1172. Toxic Exposure Review Commission. 1173. Science review agreement. 1174. Working group on presumptions of service connection. 1175. Regulations regarding presumptions of service connection based on toxic exposure. . (b) Establishment of working group Not later than 120 days after the date of the enactment of this Act, the Secretary of Veterans Affairs shall establish the working group required by section 1174(a) of title 38, United States Code, as added by subsection (a). (c) Conforming amendments Chapter 11 of title 38, United States Code, is amended— (1) in section 1116— (A) by striking subsections (b), (c), (d), and (e); (B) by inserting after subsection (a) the following new subsection (b): (b) The Secretary shall ensure that any determination made on or after the date of the enactment of the Comprehensive and Overdue Support for Troops of War Act of 2021 regarding a presumption of service connection based on exposure to an herbicide agent under this section is made pursuant to subchapter VII of this chapter, including with respect to assessing reports received by the Secretary from the National Academy of Sciences under section 3 of the Agent Orange Act of 1991 ( Public Law 102–4 ). ; and (C) by redesignating subsection (f) as subsection (c). (2) in section 1116B(b)(2)(A), by inserting pursuant to subchapter VII of this chapter, before the Secretary determines ; and (3) in section 1118— (A) by striking subsections (b) through (e); and (B) by inserting after subsection (a) the following new subsection (b): (b) The Secretary shall ensure that any determination made on or after the date of the enactment of the Comprehensive and Overdue Support for Troops of War Act of 2021 regarding a presumption of service connection based on a toxic exposure under this section is made pursuant to subchapter VII of this chapter. . 202. Technical corrections (a) In general Subchapter VI of chapter 11 of title 38, United States Code, is amended— (1) by redesignating section 1165 as section 1166; and (2) by redesignating the section 1164 that was added by section 5501(a)(1) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 ( Public Law 116–315 ) as section 1165. (b) Conforming clerical amendments The table of sections at the beginning of such chapter is amended by striking the items relating to the section 1164 that was added by section 5501(a)(1) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 ( Public Law 116–315 ) and section 1165 and inserting the following new items: 1165. Specialized teams to evaluate claims involving military sexual trauma. 1166. Choice of sex of medical examiner for certain disabilities. . III Reforms to the service connection process for toxic exposure veterans 301. Presumptions of toxic exposure (a) In general Subchapter II of chapter 11 of title 38, United States Code, is amended by adding at the end the following new section: 1119. Presumptions of toxic exposure (a) Presumption of toxic exposure Except as provided in section 1120 of this title, if a veteran submits to the Secretary a claim for compensation for a service-connected disability under section 1110 of this title with indication of a toxic exposure that occurred during active military, naval, or air service, the Secretary shall presume that the veteran was subject to such toxic exposure— (1) if the Individual Longitudinal Exposure Record of the veteran includes evidence of the toxic exposure; or (2) in a case in which the Individual Longitudinal Exposure Record of the veteran does not indicate that the veteran was subject to the claimed toxic exposure during active military, naval, or air service, if credible evidence of the facts, places, and circumstances of the service of the veteran in the active military, naval, or air service, including evidence of the veteran’s unit assignments, military specialty, or date and location of service, shows the veteran was subject to the claimed toxic exposure during such service. (b) Role of lay statements In a case described in subsection (a)(2), the Secretary shall accept as credible evidence under such subsection a lay statement by the veteran or another that is consistent with the other credible evidence of the facts, places, and circumstances of the veteran’s service in the active military, naval, or air service. . (b) Clerical amendment The table of sections at the beginning of chapter 11 of such title is amended by inserting after the item relating to section 1118 the following new item: 1119. Presumptions of toxic exposure. . (c) Conforming amendment Section 1113 of such title is amended by striking or 1118 each place it appears and inserting 1118, or 1119 . 302. Presumption of exposure to airborne hazards and substances from burn pits (a) In general Subchapter II of chapter 11 of title 38, United States Code, as amended by section 301(a), is further amended by adding at the end the following new section: 1120. Presumption of exposure to certain airborne hazards and substances from participation in contingency operations (a) In general For purposes of section 1110 and chapter 17 of this title, any veteran described in subsection (b) shall be presumed to have been exposed to the substances, chemicals, and hazards listed in subsection (c), unless there is affirmative evidence to establish that the veteran was not exposed to any such substances, chemicals, or hazards during that service. (b) Veterans described (1) A veteran described in this paragraph is any veteran who— (A) during active military, naval, or air service, was deployed in support of a contingency operation while so serving and as part of such deployment served in a covered location during a corresponding period set forth under paragraph (2); or (B) on or after August 2, 1990, was awarded any of the following: (i) The Afghanistan Campaign Medal. (ii) The Armed Forces Expeditionary Medal. (iii) The Global War On Terrorism Expeditionary Medal. (iv) The Inherent Resolve Campaign Medal. (v) The Iraqi Campaign Medal. (vi) The Southwest Asia Service Medal. (2) (A) The covered locations and corresponding periods set forth under this subsection are as follows: (i) Iraq and the following periods: (I) The period beginning on August 2, 1990, and ending on February 28, 1991. (II) The period beginning on March 19, 2003, and ending on such date as the Secretary determines burn pits are no longer used in Iraq. (ii) The Southwest Asia Theater of operations, other than Iraq, and the period beginning on August 2, 1990, and ending on such date as the Secretary determines burn pits are no longer used in such location, including the following: (I) Kuwait. (II) Saudi Arabia. (III) Oman. (IV) Qatar. (iii) Afghanistan and the period beginning on September 11, 2001, and ending on such date as the Secretary determines burn pits are no longer used in Afghanistan. (iv) Djibouti and the period beginning on September 11, 2001, and ending on such date as the Secretary determines burn pits are no longer used in Djibouti. (v) Syria and the period beginning on September 11, 2001, and ending on such date as the Secretary determines burn pits are no longer used in Syria. (vi) Jordan and the period beginning on September 11, 2001, and ending on such date as the Secretary determines burn pits are no longer used in Jordan. (vii) Egypt and the period beginning on September 11, 2001, and ending on such date as the Secretary determines burn pits are no longer used in Egypt. (viii) Lebanon and the period beginning on September 11, 2001, and ending on such date as the Secretary determines burn pits are no longer used in Lebanon. (ix) Yemen and the period beginning on September 11, 2001, and ending on such date as the Secretary determines burn pits are no longer used in Yemen. (x) Such other locations as are set forth by the Airborne Hazards and Open Burn Pit Registry established under section 201 of the Dignified Burial and Other Veterans' Benefits Improvement Act of 2012 ( Public Law 112–260 ; 38 U.S.C. 527 note) and corresponding periods set forth in such registry. (xi) Such other locations and corresponding periods as the Secretary, in collaboration with the Secretary of Defense, may determine appropriate in a report the Secretary of Veterans Affairs shall submit to Congress not later than two years after the date of the enactment of the Veterans Burn Pits Exposure Recognition Act of 2021 and not less frequently than once every two years thereafter. (B) A location set forth under this paragraph shall not include any body of water around or any airspace above such location. (c) Substances, chemicals, and airborne hazards (1) Subject to paragraph (2), the substances, chemicals, and airborne hazards listed in this subsection are as follows: (A) Particulate matter, including the following: (i) PM-10. (ii) PM-2.5. (B) Polycyclic aromatic hydrocarbons (PAHs), including the following: (i) Acenaphthene. (ii) Acenaphthylene. (iii) Anthracene. (iv) Benzo(a)anthracene. (v) Benzo(a)pyrene. (vi) Benzo(b)fluoroanthene. (vii) Benzo(g,h,i)perylene. (viii) Benzo(k)fluoroanthene. (ix) Chrysene. (x) Dibenz(a,h)anthracene. (xi) Fluoranthene. (xii) Fluorene. (xiii) Indeno(1,2,3-cd)pyrene. (xiv) Naphthalene. (xv) Phenanthrene. (xvi) Pyrene. (C) Volatile organic compounds (VOCs), including the following: (i) Acetone. (ii) Acrolein. (iii) Benzene. (iv) Carbon Disulfide. (v) Chlorodifluoromethane. (vi) Chloromethane. (vii) Ethylbenzene. (viii) Hexane. (ix) Hexachlorobutadiene. (x) m/p-Xylene. (xi) Methylene Chloride. (xii) Pentane. (xiii) Propylene. (xiv) Styrene. (xv) Toluene. (D) Toxic organic halogenated dioxins and furans (dioxins), including the following: (i) 1,2,3,4,6,7,8 HPCDD. (ii) 1,2,3,4,6,7,8 HPCDF. (iii) 1,2,3,4,7,8,9 HPCDF. (iv) 1,2,3,4,7,8 HXCDD. (v) 1,2,3,4,7,8 HXCDF. (vi) 1,2,3,6,7,8 HXCDD. (vii) 1,2,3,6,7,8 HXCDF. (viii) 1,2,3,7,8,9 HXCDD. (ix) 1,2,3,7,8,9 HXCDF. (x) 1,2,3,7,8 PECDD. (xi) 1,2,3,7,8 PECDF. (xii) 2,3,4,6,7,8 HXCDF. (xiii) 2,3,4,7,8 PECDF. (xiv) 2,3,7,8 TCDD. (xv) 2,3,7,8 TCDF. (xvi) octachlorodibenzodioxin. (xvii) octachlorodibenzofuran. (E) Such other substances, chemicals, and airborne hazards as the Secretary, in collaboration with the Secretary of Defense, may add under paragraph (2). (2) The Secretary may add to or remove from the list under paragraph (1) as the Secretary determines appropriate in a report the Secretary shall submit to Congress not later than two years after the date of the enactment of the Comprehensive and Overdue Support for Troops of War Act of 2021 , and not less frequently than once every two years thereafter. . (b) Clerical amendment The table of sections at the beginning of chapter 11 of such title, as amended by section 301(b), is further amended by inserting after the item relating to section 1119 the following new item: 1120. Presumption of exposure to certain airborne hazards and substances from participation in contingency operations. . (c) Conforming amendment Section 1113 of such title, as amended by section 301, is amended by striking or 1119 each place it appears and inserting 1119, or 1120 . 303. Medical nexus examinations for toxic exposures (a) In general Subchapter VI of chapter 11 of title 38, United States Code, as amended by title II of this Act, is further amended by adding at the end the following new section: 1168. Medical nexus examinations for toxic exposures (a) In general Except as provided in subsection (c), if a covered veteran submits to the Secretary a claim for compensation for a service-connected disability under section 1110 of this title relating to a toxic exposure or exposure to a substance, chemical, or hazard listed in section 1120(c) of this title during active military, naval, or air service, and such evidence is not sufficient to establish a service connection for the disability, the Secretary shall— (1) provide the veteran with a medical examination of the claimed disability relating to such exposure; (2) provide the veteran the option to have the examination provided under paragraph (1) conducted by a specialist in the field of medicine which covers the specifically claimed disability; and (3) request a medical opinion, as part of the medical examination provided under paragraph (1), as to whether it is at least as likely as not that there is a nexus between the claimed disability and the exposure. (b) Covered veterans For purposes of this section, a covered veteran is— (1) a veteran presumed under section 1119(a) of this title to have been subject to a toxic exposure; or (2) a veteran presumed under subsection (a) of section 1120 of this title to have been exposed to a substance, chemical, or hazard listed in subsection (c) of such section. (c) Exception Subsection (a) shall not apply in a case in which a covered veteran claims a disability that is clearly unrelated to the claimed exposure. (d) Considerations in provision of medical opinions When providing the Secretary with a medical opinion requested under subsection (a)(3), the examiner shall consider the total potential exposure through all applicable military deployments, and the synergistic, combined effect of all applicable toxic exposure risk activities. . (b) Clerical amendment The table of sections at the beginning of chapter 11 of such title, as amended by title II of this Act, is further amended by inserting after the item relating to section 1167, as added by such title, the following new item: 1168. Medical nexus examinations for toxic exposures. . IV Expansion of presumptions of service connection for forgotten veterans 401. Mark Takai Atomic Veterans Healthcare Parity Act of 2021 Section 1112(c)(3)(B) of title 38, United States Code, is amended by adding at the end the following new clause: (v) Cleanup of Enewetak Atoll during the period beginning on January 1, 1977, and ending on December 31, 1980. . 402. Treatment of veterans who participated in nuclear response near Palomares, Spain, as radiation-exposed veterans for purposes of presumption of service-connection of certain disabilities by Department of Veterans Affairs Section 1112(c)(3)(B) of title 38, United States Code, as amended by section 401, is further amended by adding at the end the following new clause: (vi) Onsite participation in the response effort following the collision of a United States Air Force B–52 bomber and refueling plane that caused the release of four thermonuclear weapons in the vicinity of Palomares, Spain, during the period beginning January 17, 1966, and ending March 31, 1967. . 403. Presumptions of service connection for diseases associated with exposures to certain herbicide agents for veterans who served in certain locations (a) In general Section 1116 of title 38, United States Code, as amended by section 201, is further amended— (1) by striking , during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 each place it appears and inserting performed covered service ; (2) by striking performed active military, naval, or air service in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 each place it appears and inserting performed covered service ; and (3) by adding at the end the following new subsection: (d) In this section, the term covered service means active military, naval, or air service— (1) performed in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975; (2) performed in Thailand at any United States or Royal Thai base during the period beginning on January 9, 1962, and ending on June 30, 1976, without regard to where on the base the veteran was located or what military job specialty the veteran performed; (3) performed in Laos during the period beginning on December 1, 1965, and ending on September 30, 1969; (4) performed in Cambodia at Mimot or Krek, Kompon Cham Province during the period beginning on April 16, 1969, and ending on April 30, 1969; or (5) performed on Guam or American Samoa, or in the territorial waters thereof, during the period beginning on January 9, 1962, and ending on July 31, 1980, or served on Johnston Atoll or on a ship that called at Johnston Atoll during the period beginning on January 1, 1972, and ending on September 30, 1977. . (b) Eligibility for hospital care and medical services Section 1710(e)(4) is amended by amending subparagraph (A) to read as follows: (A) The term Vietnam-era herbicide-exposed veteran means a veteran who— (i) performed covered service, as defined in section 1116(c) of this title; or (ii) the Secretary finds may have been exposed during such service to dioxin or was exposed during such service to a toxic substance found in a herbicide or defoliant used for military purposes during such period. . (c) Clerical amendments (1) Section heading The heading for section 1116 is amended by striking and the Republic of Vietnam and inserting certain locations . (2) Table of sections The table of sections at the beginning of chapter 11 of such title is amended by striking the item relating to section 1116 and inserting the following new item: 1116. Presumptions of service connection for diseases associated with exposure to certain herbicide agents; presumption of exposure for veterans who served in certain locations. . 404. Addition of additional diseases associated with exposure to certain herbicide agents for which there is a presumption of service connection for veterans who served in the Republic of Vietnam Section 1116(a)(2) of title 38, United States Code, as amended by section 9109 of the William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021 ( Public Law 116–283 ), is further amended by adding at the end the following new subparagraphs: (L) Hypertension. (M) Monoclonal gammopathy of undetermined significance. . 405. Improving compensation for disabilities occurring in Persian Gulf War veterans (a) Reduction in threshold of eligibility Subsection (a)(1) of section 1117 of title 38, United States Code, is amended by striking became manifest— and all that follows through the period at the end and inserting became manifest to a degree of 10 percent or more at any time. . (b) Permanent extension of period of eligibility (1) In general Such section is amended by striking subsection (b). (2) Conforming amendments Such section, as amended by paragraph (1), is further amended— (A) by redesignating subsections (c) and (d) as subsections (b) and (c), respectively; and (B) in subsection (a)(2)(C), by striking under subsection (d) and inserting under subsection (c) . (c) Establishing singular disability based questionnaire Such section, as amended by subsection (b), is further amended by inserting after subsection (c) the following new subsection (d): (d) The Secretary shall develop a Disability Benefits Questionnaire (DBQ), or successor questionnaire, such that if a Persian Gulf veteran presents with any one symptom associated with Gulf War Illness, use of such questionnaire is mandatory for health care personnel of the Department for the identification of Gulf War Illness. . (d) Training Such section is amended by adding at the end the following new subsection: (i) (1) The Secretary shall take such actions as may be necessary to ensure that health care personnel of the Department are appropriately trained to effectively carry out this section. (2) Not less frequently than once each year, the Secretary shall submit to Congress a report on the actions taken by the Secretary to carry out paragraph (1). . 406. Presumption of service connection for certain diseases associated with exposure to burn pits and other toxins (a) In general Subchapter II of chapter 11 of title 38, United States Code, as amended by section 302(a), is further amended by inserting after section 1120 the following new section: 1120A. Presumption of service connection for certain diseases associated with exposure to burn pits and other toxins (a) Presumption of service connection For the purposes of section 1110 of this title, and subject to section 1113 of this title, a disease specified in subsection (c) becoming manifest in a covered veteran shall be considered to have been incurred in or aggravated during active military, naval, or air service, notwithstanding that there is no record of evidence of such disease during the period of such service. (b) Covered veterans For purposes of this section, a covered veteran is a veteran presumed under subsection (a) of section 1120 of this title to have been exposed to a substance, chemical, or hazard listed in subsection (c) of such section. (c) Diseases specified The diseases specified in this subsection are the following: (1) Asthma that was diagnosed after— (A) a deployment described in subparagraph (A) of section 1120(b)(1) of this title; or (B) a period of service for which a medal set forth under subparagraph (B) of such section was awarded. (2) Chronic obstructive pulmonary disease. (3) Chronic bronchitis. (4) Constrictive bronchiolitis or obliterative bronchiolitis. (5) Emphysema. (6) Pleuritis. (7) Pulmonary fibrosis. (8) Interstitial lung disease. (9) Sarcoidosis. (10) Respiratory cancer of any type. (11) Glioblastoma. (12) Rhinitis. (13) Sinusitis. . (b) Clerical amendment The table of sections at the beginning of chapter 11 of title 38, United States Code, as amended by section 302(b), is further amended by inserting after the item relating to section 1120 the following new item: 1120A. Presumption of service connection for certain diseases associated with exposure to burn pits and other toxins. . (c) Conforming amendment Section 1113 of such title, as amended by section 302, is further amended by striking or 1120 each place it appears and inserting 1120, or 1120A . V Strengthening Federal research on toxic exposures 501. Coordination by Department of Veterans Affairs of toxic exposure research (a) In general Subchapter II of chapter 73 of title 38, United States Code, is amended by adding at the end the following new section: 7330D. Coordination of toxic exposure research (a) In general The Secretary shall coordinate all research activities undertaken or funded by the Executive Branch of the Federal Government on the health consequences of toxic exposures experienced during service in the Armed Forces. (b) Strategic plan In carrying out subsection (a), the Secretary shall establish a strategic plan, to be known as the Toxic Exposure Research Strategic Plan , to ensure that the research activities described in such subsection are collaborative, transparent, and highly coordinated. (c) Report Not later than one year after the date of the enactment of the Comprehensive and Overdue Support for Troops of War Act of 2021 , and annually thereafter, the Secretary shall submit to the Committee on Veterans’ Affairs of the Senate and the Committee on Veterans' Affairs of the House of Representatives a report on all research activities described in subsection (a) undertaken during the year covered by the report. . (b) Clerical amendment The table of sections at the beginning of such subchapter is amended by inserting after the item relating to section 7330C the following new item: 7330D. Coordination of toxic exposure research. . 502. Collection, analysis, and report on treatment of veterans for medical conditions related to toxic exposure (a) In general The Secretary of Veterans Affairs shall compile and analyze, on a continuous basis, all clinical data that— (1) is obtained by the Department of Veterans Affairs in connection with hospital care, medical services, and nursing home care furnished under section 1710(a)(2)(F) of title 38, United States Code; and (2) is likely to be scientifically useful in determining the association, if any, between the medical condition of a veteran and a toxic exposure. (b) Consent of patients Compilation and analysis by the Secretary of clinical data of a veteran under subsection (a) shall be conducted, and such data shall be used, consistent with the informed consent of the veteran and in compliance with all applicable Federal law. (c) Annual report Not later than one year after the date of the enactment of this Act, and annually thereafter, the Secretary shall submit to the Committee on Veterans’ Affairs of the Senate and the Committee on Veterans’ Affairs of the House of Representatives a report containing— (1) the data compiled under subsection (a); (2) an analysis of such data; (3) a description of the types and incidences of medical conditions identified by the Department under such subsection; (4) the explanation of the Secretary for the incidence of such medical conditions and other explanations for the incidence of such conditions as the Secretary considers reasonable; and (5) the views of the Secretary on the scientific validity of drawing conclusions from the incidence of such medical conditions, as evidenced by the data compiled under subsection (a), regarding any association between such conditions and a toxic exposure. (d) Toxic exposure defined In this section, the term toxic exposure has the meaning given that term in section 101(37) of title 38, United States Code. 503. Studies relating to veterans who served in Southwest Asia (a) Analysis (1) In general Not later than 180 days after the date of the enactment of this Act, the Secretary of Veterans Affairs, in coordination with the Secretary of Defense, shall conduct an updated analysis of total and respiratory disease mortality in covered veterans. (2) Elements The analysis required by paragraph (1) shall include, to the extent practicable, the following: (A) Metrics of airborne exposures. (B) The location and timing of deployments. (C) The military occupational specialty. (D) The Armed Force in which the veteran served. (E) Pre-existing health status, including with respect to asthma. (F) Relevant personal information, including cigarette and e-cigarette smoking history, diet, sex, gender, age, race, and ethnicity. (b) Epidemiological study Not later than 180 days after the date of the enactment of this Act, the Secretary shall conduct an epidemiological study of covered veterans that uses the following: (1) Improved spatio-temporal estimates of ambient air pollution exposures using advances in retrospective exposure assessment. (2) Detailed information on the study subjects obtained through medical records, administrative data, and other existing sources, that include— (A) personal characteristics, including cigarette and e-cigarette smoking history, diet, sex, gender, age, race, and ethnicity; (B) deployment history, including locations, periods, and number of deployments; (C) biospecimen data; and (D) supplementary health status and outcomes data, including imaging and physiological parameters. (c) Toxicology study (1) In general Not later than 180 days after the date of the enactment of this Act, the Secretary shall conduct a toxicology study to include variability to replicate exposures of healthy, young members of the Armed Forces, as well as potentially susceptible members, with preexisting health conditions. (2) Elements The study required under paragraph (1) shall— (A) analyze the study results for mechanistic markers and clinically relevant outcomes; and (B) validate serum, tissue, and other biomarkers of exposure, susceptibility, or effect. (d) Covered veteran defined In this section, the term covered veteran means any veteran who— (1) on or after August 2, 1990, served on active duty in— (A) Bahrain; (B) Iraq; (C) Kuwait; (D) Oman; (E) Qatar; (F) Saudi Arabia; (G) Somalia; or (H) the United Arab Emirates; or (2) on or after September 11, 2001, served on active duty in— (A) Afghanistan; (B) Djibouti; (C) Egypt; (D) Jordan; (E) Lebanon; (F) Syria; or (G) Yemen. 504. Study on health trends of post 9/11 veterans The Secretary of Veterans Affairs shall conduct an epidemiological study on the health trends of veterans who served in the Armed Forces after September 11, 2001. 505. Study on cancer rates among veterans (a) In general The Secretary of Veterans Affairs shall conduct a study on the incidence of cancer in veterans to determine trends in the rates of the incidence of cancer in veterans. (b) Elements The study required by subsection (a) shall assess, with respect to each veteran included in the study, the following: (1) The age of the veteran. (2) The period of service and length of service of the veteran in the Armed Forces. (3) The military occupational speciality or specialties of the veteran. (4) The gender of the veteran. (5) The type or types of cancer that the veteran has. VI Improving support to toxic exposure veterans 601. Definitions In this title, the terms active military, naval, or air service , toxic exposure , and toxic exposure veteran have the meanings given those terms in section 101 of title 38, United States Code. 602. Publication of list of resources of Department of Veterans Affairs for toxic exposure veterans and outreach program for such veterans and caregivers and survivors of such veterans (a) Publication of list of resources (1) In general Not later than one year after the date of the enactment of this Act, and annually thereafter, the Secretary of Veterans Affairs shall publish a list of resources of the Department of Veterans Affairs for— (A) toxic exposure veterans; (B) families and caregivers of toxic exposure veterans; and (C) survivors of toxic exposure veterans (or who would be toxic exposure veterans were the veterans alive) who are receiving death benefits under the laws administered by the Secretary. (2) Update The Secretary shall periodically update the list published under paragraph (1). (b) Outreach The Secretary shall develop, with input from the community, an informative outreach program for veterans on illnesses that may be related to toxic exposure, including outreach with respect to benefits and support programs. 603. Incorporation of toxic exposure questionnaire during primary care appointments (a) In general The Secretary of Veterans Affairs shall incorporate a clinical questionnaire to help determine potential toxic exposures during active military, naval, or air service as part of the initial screening conducted for an appointment of a veteran with a primary care provider of the Department of Veterans Affairs to improve understanding by the Department of toxic exposures of veterans while serving in the Armed Forces. (b) Determination of questions The questions included in the questionnaire required under subsection (a) shall be determined by the Secretary with input from medical professionals. 604. Training for personnel of the Department of Veterans Affairs with respect to toxic exposure veterans (a) Health care personnel The Secretary of Veterans Affairs shall provide to health care personnel of the Department of Veterans Affairs education and training to identify, treat, and assess the impact on toxic exposure veterans of illnesses related to toxic exposure and inform such personnel of how to ask for additional information from veterans regarding different toxic exposures. (b) Benefits personnel (1) In general The Secretary shall establish a training program for processors of claims under the laws administered by the Secretary who review claims for disability benefits relating to service-connected disabilities based on toxic exposure. (2) Annual training Training provided to processors under paragraph (1) shall be provided not less frequently than annually. 605. SFC Heath Robinson Burn Pit Transparency Act (a) Short title This section may be cited as the SFC Heath Robinson Burn Pit Transparency Act . (b) Quarterly notifications (1) In general On a quarterly basis, the Secretary of Veterans Affairs shall submit to the appropriate congressional committees a report on each reported case of burn pit exposure by a covered veteran reported during the previous quarter. (2) Elements Each report submitted under paragraph (1) shall include, with respect to each reported case of burn pit exposure of a covered veteran included in the report, the following: (A) Notice of the case, including the medical facility at which the case was reported. (B) Notice of, as available— (i) the enrollment status of the covered veteran with respect to the patient enrollment system of the Department of Veterans Affairs under section 1705(a) of title 38, United States Code; (ii) a summary of all health care visits by the covered veteran at the medical facility at which the case was reported that are related to the case; (iii) the demographics of the covered veteran, including age, sex, and race; (iv) any non-Department of Veterans Affairs health care benefits that the covered veteran receives; (v) the Armed Force in which the covered veteran served and the rank of the covered veteran; (vi) the period in which the covered veteran served; (vii) each location that the covered veteran reported as being a location at which the veteran was exposed to toxic airborne chemicals and fumes from an open burn pit; (viii) the medical diagnoses of the covered veteran and the treatment provided to the veteran; and (ix) whether the covered veteran is registered in the Airborne Hazards and Open Burn Pit Registry. (3) Protection of information The Secretary shall ensure that the reports submitted under paragraph (1) do not include the identity of covered veterans or contain other personally identifiable data. (c) Annual report on cases (1) In general Not later than 180 days after the date of the enactment of this Act, and annually thereafter, the Secretary of Veterans Affairs, in collaboration with the Secretary of Defense, shall submit to the appropriate congressional committees a report detailing the following: (A) The total number of covered veterans. (B) The total number of claims for disability compensation under chapter 11 of title 38, United States Code, approved and the total number denied by the Secretary of Veterans Affairs with respect to a covered veteran, and for each such denial, the rationale of the denial. (C) A comprehensive list of— (i) the conditions for which covered veterans seek treatment; and (ii) the locations that the covered veterans reported as being locations at which the veterans were exposed to toxic airborne chemicals and fumes from open burn pits. (D) Identification of any illnesses relating to exposure to open burn pits that formed the basis for the Secretary to award benefits, including entitlement to service connection or an increase in disability rating. (E) The total number of covered veterans who died after seeking care for an illness relating to exposure to an open burn pit. (F) Any updates or trends with respect to the information described in subparagraphs (A), (B), (C), (D), and (E) that the Secretary determines appropriate. (2) Matters included in first report The Secretary shall include in the first report under paragraph (1) information specified in subsection (b)(2) with respect to reported cases of burn pit exposure made during the period beginning January 1, 1990, and ending on the day before the date of the enactment of this Act. (d) Comptroller General report Not later than 180 days after the date of the enactment of this Act, the Comptroller General of the United States shall submit to the appropriate congressional committees a report containing an assessment of the effectiveness of any memorandum of understanding or memorandum of agreement entered into by the Secretary of Veterans Affairs with respect to— (1) the processing of reported cases of burn pit exposure; and (2) the coordination of care and provision of health care relating to such cases at medical facilities of the Department of Veterans Affairs and at non-Department facilities. (e) Definitions In this section: (1) The term Airborne Hazards and Open Burn Pit Registry means the registry established by the Secretary of Veterans Affairs under section 201 of the Dignified Burial and Other Veterans' Benefits Improvement Act of 2012 ( Public Law 112–260 ; 38 U.S.C. 527 note). (2) The term appropriate congressional committees means— (A) the Committee on Veterans’ Affairs and the Committee on Armed Services of the Senate; and (B) The Committee on Veterans’ Affairs and the Committee on Armed Services of the House of Representatives. (3) The term covered veteran means a veteran who presents at a medical facility of the Department of Veterans Affairs (or in a non-Department facility pursuant to section 1703 or 1703A of title 38, United States Code) for treatment that the veteran describes as being related to, or ancillary to, the exposure of the veteran to toxic airborne chemicals and fumes caused by open burn pits at any time while serving in the Armed Forces. (4) The term open burn pit has the meaning given that term in section 201(c) of the Dignified Burial and Other Veterans' Benefits Improvement Act of 2012 ( Public Law 112–260 ; 38 U.S.C. 527 note). (5) The term reported case of burn pit exposure means each instance in which a veteran presents at a medical facility of the Department of Veterans Affairs (or in a non-Department facility pursuant to section 1703 or 1703A of title 38, United States Code) for treatment that the veteran describes as being related to, or ancillary to, the exposure of the veteran to toxic airborne chemicals and fumes caused by open burn pits at any time while serving in the Armed Forces. VII Strengthening record-keeping of toxic exposures by Department of Defense 701. Definitions In this title: (1) Individual longitudinal exposure record The term Individual Longitudinal Exposure Record has the meaning given that term in section 101(40) of title 38, United States Code, as added by section 101(b). (2) Toxic exposure The term toxic exposure has the meaning given that term in section 101(37) of such title, as so added. 702. Independent study on Individual Longitudinal Exposure Record (a) In general Not later than 60 days after the date of the enactment of this Act, the Secretary of Defense shall enter into a contract with an independent research entity described in subsection (b) to carry out a comprehensive study of the development of the Individual Longitudinal Exposure Record to evaluate— (1) the quality of the location data, occupational and environmental exposure data, and health surveillance data; and (2) whether a member of the Armed Forces can be reasonably assured that any toxic exposure experienced by the member during service in the Armed Forces will be accurately reflected in the Individual Longitudinal Exposure Record of the member. (b) Independent research entity described An independent research entity described in this subsection is a federally funded research and development center with appropriate expertise and analytical capability to carry out the study required under subsection (a). 703. Biannual report on Individual Longitudinal Exposure Record (a) In general Not later than one year after the date on which the Individual Longitudinal Exposure Record achieves full operation capability, as determined by the Secretary of Defense, and every 180 days thereafter, the Secretary of Defense shall, in consultation with the Secretary of Veterans Affairs, submit to the appropriate committees of Congress a report on the data quality of the databases of the Department of Defense that provide the information presented in the Individual Longitudinal Exposure Record and the usefulness of the Individual Longitudinal Exposure Record in supporting members of the Armed Forces and veterans in receiving health care and benefits from the Department of Defense and the Department of Veterans Affairs. (b) Elements Each report required by subsection (a) shall include, for the period covered by the report, the following: (1) An identification of toxic exposures that may not be fully captured by the current systems of the Department of Defense for environmental and occupational health monitoring, and recommendations for how to improve those systems. (2) An analysis of the quality of the location data used by the Department of Defense in determining toxic exposures of members of the Armed Forces and veterans, and recommendations for how to improve the quality of that location data. (c) Appropriate committees of Congress defined In this section, the term appropriate committees of Congress means— (1) the Committee on Armed Services and the Committee on Veterans’ Affairs of the Senate; and (2) the Committee on Armed Services and the Committee on Veterans’ Affairs of the House of Representatives. 704. Correction of toxic exposure records (a) In general The Secretary of Defense and the Secretary of Veterans Affairs shall provide a means for members of the Armed Forces and veterans to update their records as necessary to reflect a toxic exposure by such member or veteran in the Individual Longitudinal Exposure Record. (b) Evidence (1) In general To update a record under subsection (a), a member of the Armed Forces or veteran, as the case may be, must provide such evidence as the Secretary of Defense and the Secretary of Veterans Affairs jointly consider sufficient. (2) Regulations The Secretary of Veterans Affairs shall prescribe by regulation the evidence considered sufficient under paragraph (1).

October 19, 2021 Read twice and placed on the calendar