IB Union Calendar No. 179 117th CONGRESS 2d Session H. R. 3967 [Report No. 117–249, Part I] IN THE HOUSE OF REPRESENTATIVES June 17, 2021 Mr. Takano (for himself, Mrs. Luria , Mr. Ruiz , Ms. Slotkin , Mr. Trone , Ms. Brownley , Mr. Levin of California , Mr. Pappas , Mr. Lamb , Mr. Brown of Maryland , Mr. Gallego , Ms. Underwood , Mr. Sablan , Mr. Mrvan , Mr. Allred , Ms. Kaptur , Ms. Lois Frankel of Florida , Mr. Ryan , Mr. McGovern , Mr. Harder of California , Mr. Fitzpatrick , Mr. Kilmer , Mr. Soto , Ms. Meng , Ms. Strickland , and Ms. Spanberger ) introduced the following bill; which was referred to the Committee on Veterans' Affairs , and in addition to the Committee on Armed Services , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned February 22, 2022 Additional sponsors: Mrs. Kirkpatrick , Ms. Norton , Mr. Malinowski , Ms. Newman , Ms. Sherrill , Mr. Khanna , Mr. Rush , Mr. Aguilar , Mrs. Hayes , Mrs. Trahan , Ms. Omar , Mr. Levin of Michigan , Mr. O'Halleran , Mr. Kind , Mr. Carson , Mr. San Nicolas , Mr. Perlmutter , Mr. Neguse , Ms. Lofgren , Mrs. Dingell , Ms. Davids of Kansas , Mr. Cohen , Mrs. Axne , Mr. Grijalva , Mr. Grothman , Mr. Cooper , Mr. Moulton , Mr. Pocan , Mr. Swalwell , Mr. Tonko , Ms. Blunt Rochester , Ms. Bonamici , Ms. Porter , Mr. Krishnamoorthi , Mr. Blumenauer , Mrs. Bustos , Ms. DeGette , Mr. Jones , Mr. Courtney , Ms. Pingree , Ms. Bourdeaux , Ms. Manning , Mr. Welch , Ms. Leger Fernandez , Mr. Langevin , Mr. Keating , Mr. Bishop of Georgia , Mr. Lieu , Mr. Cline , Mr. Larsen of Washington , Ms. Kelly of Illinois , Mr. Lynch , Mrs. Torres of California , Ms. Williams of Georgia , Ms. Houlahan , Ms. Sewell , Mr. Casten , Mr. Cicilline , Mr. Schiff , Mr. Cartwright , Mr. Espaillat , Mr. Horsford , Mr. DeFazio , Mr. Schrader , Mr. Carbajal , Ms. Castor of Florida , Ms. Jacobs of California , Mr. Castro of Texas , Mr. Raskin , Mrs. Cherfilus-McCormick , Ms. Scanlon , Mr. Stanton , Mr. Costa , Mr. Gottheimer , and Ms. Bass February 22, 2022 Reported from the Committee on Veterans' Affairs February 22, 2022 Committee on Armed Services discharged; committed to the Committee of the Whole House on the State of the Union and ordered to be printed A BILL To improve health care and benefits for veterans exposed to toxic substances, and for other purposes.

1. Short title; references to title 38, United States Code; table of contents (a) Short title This Act may be cited as the Honoring our Promise to Address Comprehensive Toxics Act of 2021 or the Honoring our PACT Act of 2021 . (b) References to title 38, United States Code Except as otherwise expressly provided, whenever in this title an amendment or repeal is expressed in terms of an amendment to, or repeal of, a section or other provision, the reference shall be considered to be made to a section or other provision of title 38, United States Code. (c) Table of contents The table of contents for this Act is as follows: Sec. 1. Short title; references to title 38, United States Code; table of contents. Title I—Expansion of health care eligibility for toxic exposed veterans Sec. 101. Short title. Sec. 102. Definitions relating to toxic exposed veterans. Sec. 103. Expansion of health care for specific categories of toxic exposed veterans. Title II—Toxic exposure presumption process Sec. 201. Short title. Sec. 202. Improvements to ability of Department of Veterans Affairs to establish presumptions of service connection based on toxic exposure. Sec. 203. Reevaluation of claims for compensation involving presumptions of service connection. Title III—Improving the establishment of service connection process for toxic exposed veterans Sec. 301. Short title. Sec. 302. Presumptions of toxic exposure. Sec. 303. Medical nexus examinations for toxic exposure risk activities. Title IV—Presumptions of service connection Sec. 401. Treatment of veterans who participated in cleanup of Enewetak Atoll as radiation-exposed veterans for purposes of presumption of service connection of certain disabilities by Department of Veterans Affairs. 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 certain locations. 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—Research matters Sec. 501. Coordination by Department of Veterans Affairs of toxic exposure research. Sec. 502. Data collection, analysis, and report on treatment of veterans for illnesses related to toxic exposure. Sec. 503. Studies related to veterans who served in Southwest Asia and certain other locations. Sec. 504. Study on health trends of post 9/11 veterans. Sec. 505. Study on cancer rates among veterans. Sec. 506. Study on feasibility and advisability of furnishing hospital care and medical services to dependents of veterans who participated in toxic exposure risk activities. Title VI—Improvement of resources and training regarding toxic exposed veterans Sec. 601. Short title; definitions. Sec. 602. Publication of list of resources of Department of Veterans Affairs for toxic exposed 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 exposed veterans. Title VII—Registries, records, and other matters Sec. 701. Registry of individuals exposed to per- and polyfluoroalkyl substances on military installations. Sec. 702. Fort McClellan Health Registry. Sec. 703. Independent study on Individual Longitudinal Exposure Record. Sec. 704. Biannual report on Individual Longitudinal Exposure Record. Sec. 705. Correction of exposure records by members of the Armed Forces and veterans. I Expansion of health care eligibility for toxic exposed veterans 101. Short title This title may be cited as the Conceding Our Veterans’ Exposures Now And Necessitating Training Act or the COVENANT Act . 102. Definitions relating to toxic exposed veterans (a) In general Section 1710(a)(2)(F) is amended by striking who was exposed to a toxic substance, radiation, or other conditions, as provided in subsection (e) and inserting in accordance with subsection (e), who is a toxic exposed veteran . (b) Definitions of toxic exposure and toxic exposed veteran Section 101 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, as defined in section 1710(e)(4) of this title. (B) An exposure to a substance, chemical, or airborne hazard specified in section 1119(b)(2). (38) The term toxic exposed veteran means a veteran described in section 1710(e)(1) of this title. . (c) Definition of toxic exposure risk activity Section 1710(e)(4) is amended by adding at the end the following new subparagraph: (C) The term toxic exposure risk activity means any activity— (i) that requires a corresponding entry in the Individual Longitudinal Exposure Record of the Department for the veteran who carried out the activity; or (ii) that the Secretary determines qualifies for purposes of this subsection when taking into account what is reasonably prudent to protect the health of veterans. . 103. Expansion of health care for specific categories of toxic exposed veterans (a) In general Section 1710(e), as amended by section 102(c), is further amended— (1) in paragraph (1), by adding at the end the following new subparagraphs: (G) Subject to paragraph (2), a 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. (H) Subject to paragraph (2), a covered veteran (as defined in section 1119(c) of this title) is eligible for hospital care, medical services, and nursing home care under subsection (a)(2)(F) for any illness. ; and (2) in paragraph (2)(B)— (A) by striking or (F) and inserting (F), (G), or (H) ; and (B) by striking service or testing and inserting service, testing, or activity . (b) Resource assessment and report (1) Initial assessment and report Not later than 180 days after the date of the enactment of this Act, the Secretary of Veterans Affairs shall— (A) complete an assessment to determine— (i) the personnel and material resources necessary to implement the amendments made by subsection (a); and (ii) the total number of covered veterans, as such term is defined in section 1119(c) of title 38, United States Code (as added by section 301), who receive hospital care or medical services furnished by the Secretary under chapter 17 of such title, disaggregated by priority group specified in section 1705(a) of such title; and (B) submit to the Committees on Veterans’ Affairs of the House of Representatives and the Senate an initial report containing the findings of the assessment completed under subparagraph (A), including a specific determination as to whether the Department has the personnel and material resources necessary to implement the amendments made by subsection (a). (2) Subsequent reports If the initial report submitted under paragraph (1)(B) contains a determination that the Department does not have the personnel or material resources necessary to implement the amendments made by subsection (a), beginning not later than 90 days after the submission of such initial report and every 90 days thereafter until the effective date specified in subsection (c), the Secretary shall submit to the Committees on Veterans’ Affairs of the House of Representatives and the Senate a subsequent report containing an update to such determination. (c) Effective date The amendments made by subsection (a) shall take effect on the date that is the earlier of the following: (1) The date on which the Secretary submits a report under subsection (b) containing a determination that the Department has the personnel and material resources necessary to implement such amendments, and notifies the Law Revision Counsel of the House of Representatives of the submission of the report so the Law Revision Counsel may execute the amendments. (2) The date that is 18 months after the date of the enactment of this Act. II Toxic exposure presumption process 201. Short title This title may be cited as the Fairly Assessing Service-related Toxic Exposure Residuals Presumptions Act or the FASTER Presumptions Act . 202. 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 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, or to remove, presumptions of service connection based on toxic exposure pursuant to this subchapter, whereby— (1) the Formal Advisory Committee on Toxic Exposure under section 1172 of this title— (A) provides advice to the Secretary on toxic exposed veterans and cases in which veterans who, during active military, naval, or air service, may have experienced a toxic exposure or their dependents may have experienced a toxic exposure while the veterans were serving in the active military, naval, or air service; (B) provides to the Secretary recommendations on corrections needed in the Individual Longitudinal Exposure Record to better reflect veterans and dependents described in subparagraph (A); and (C) provides to the Secretary recommendations regarding which cases of possible toxic exposure described in subparagraph (A) the Science Review Board should review; (2) the Science Review Board under section 1173 of this title— (A) reviews cases of possible toxic exposure nominated by the Secretary; (B) reviews research nominated by the Secretary; (C) develops recommendations for new research; and (D) determines the strength of evidence supporting positive association between toxic exposure and an illness; (3) the Working Group under section 1174 of this title evaluates the conclusions of the Science Review Board and recommends to the Secretary whether to establish or modify a presumption of service connection; 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 sunset requirements Section 14 of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to an entity established under this subchapter. 1172. Formal Advisory Committee on Toxic Exposure (a) Establishment (1) There is in the Veterans Health Administration of the Department the Formal Advisory Committee on Toxic Exposure (in this section referred to as the Committee ). (2) (A) The Committee shall be composed of nine members appointed as follows: (i) Five members shall be appointed by the Secretary. (ii) One member shall be appointed by the Speaker of the House of Representatives. (iii) One member shall be appointed by the minority leader of the House of Representatives. (iv) One member shall be appointed by the majority leader of the Senate. (v) One member shall be appointed by the minority leader of the Senate. (B) The members appointed under subparagraph (A) shall meet the following criteria: (i) Not more than three members shall be appointed from among individuals who are officials or employees of the Veterans Benefits Administration or the Veterans Health Administration. (ii) At least one member shall be appointed from among individuals who are officials or employees of other departments or agencies of the Federal Government, including the Department of Defense and the Agency of Toxic Substances and Disease Registry of the Centers for Disease Control and Prevention. (iii) At least one member shall be appointed from among individuals who are representatives of disabled veterans. (iv) At least one member shall be appointed from among individuals in the private sector, State or local government, or academia, who are experts in toxicology and epidemiology. (3) The Secretary shall determine the pay and allowances of the members of the Committee, including with respect to any additional pay and allowances for members who are officials or employees of the Federal Government. (4) Each member of the Committee shall be appointed for a two-year term, and may serve not more than three successive terms. (5) A vacancy in the Committee shall be filled in the manner in which the original appointment was made. (b) Consultation The Secretary may consult with, and seek the advice of, the Committee with respect to cases in which veterans who, during active military, naval, or air service, are suspected of having experienced a toxic exposure or dependents of veterans who may have experienced a toxic exposure during such service. (c) Assessments (1) The Committee shall assess cases of the toxic exposure of veterans and their dependents that occurred during active military, naval, or air service. (2) The assessments under paragraph (1) shall cover suspected and known toxic exposures occurring during active military, naval, or air service, including by identifying and evaluating new and emerging toxic exposures that are not recognized under existing presumptions of service connection. (3) The Committee may conduct an assessment under paragraph (1) in response to a person described in subsection (e)(2), by a majority vote of the members of the Committee. (4) The Committee shall on a periodic basis assess the Individual Longitudinal Exposure Record to ensure the accuracy of data collected. (d) Research recommendations (1) Following an assessment of a case of the toxic exposure of veterans or their dependents that occurred during active military, naval, or air service under subsection (c), the Committee may develop a recommendation for the Secretary regarding whether there should be a review of the health effects related to the case of exposure conducted by the Science Review Board established under section 1173 of this title. (2) Upon receipt of evidence suggesting that previous findings regarding the periods and locations of exposure covered by an existing presumption of service connection are no longer supported, the Committee may nominate such evidence for evaluation by the Working Group to modify the periods and locations. (e) Input (1) Not less than quarterly, the Committee shall provide an opportunity for persons described in paragraph (2) to present written or oral comments to the Committee. (2) The persons described in this paragraph are persons who may be affected by the actions of the Committee, including— (A) veterans, the families of veterans, veterans service organizations and representatives, researchers, and other members of the general public; and (B) departments and agencies of the Federal Government. (f) Reports by the Committee Not less frequently than once each year, the Committee shall submit to the Secretary and the Committees on Veterans’ Affairs of the Senate and the House of Representatives, and make publicly available, a report on— (1) recommendations for research under subsection (d), if any; and (2) recommendations for such legislative or administrative action as the Committee considers necessary for the Committee to be more effective in carrying out the requirements of this section. (g) Responses by Secretary In response to each report submitted under subsection (f), the Secretary shall submit to the Secretary and the Committees on Veterans’ Affairs of the Senate and the House of Representatives, and make publicly available, a report on— (1) the findings and opinions of the Secretary with respect to the report most recently submitted under subsection (f); and (2) whether the Secretary intends to nominate to the Science Review Board the review recommended by the Committee in the report, and if not, an explanation of why, including citations and sources. 1173. Science Review Board (a) Establishment (1) There is in the Veterans Health Administration of the Department the Science Review Board (in this section referred to as the Board ). (2) (A) The members of the Board shall be appointed by the Secretary, in consultation with the National Academies of Sciences, Engineering, and Medicine, from the general public from among individuals who are distinguished in the fields of medicine, biological sciences, or health administration. (B) An individual may not concurrently serve on the Board and the Formal Advisory Committee on Toxic Exposure under section 1172 of this title. (C) The Secretary shall determine the number, terms of service, and pay and allowances of members of the Board appointed by the Secretary. (b) Duties (1) Upon receiving a nomination for the evaluation of research on the health effects of toxic exposures of members of the active military, naval, or air service or dependents of such members made by the Secretary, the Board shall— (A) evaluate the likelihood that a positive association exists between an illness and a toxic exposure while serving in the active military, naval, or air service; and (B) assess the toxic exposures and illnesses identified by the Secretary and determine whether the evidence supports a finding of a positive association between the toxic exposure and the illness. (2) In carrying out paragraph (1)(B), the Board shall review all relevant data to determine the strength of evidence for a positive association based on the following four categories: (A) The sufficient category, where the evidence is sufficient to conclude that a positive association exists. (B) The equipoise and above category, where the evidence is sufficient to conclude that a positive association is at least as likely as not, but not sufficient to conclude that a positive association exists. (C) The below equipoise category, where the evidence is not sufficient to conclude that a positive association is at least as likely as not, or is not sufficient to make a scientifically informed judgment. (D) The against category, where the evidence suggests the lack of a positive association. (3) (A) With respect to an evaluation conducted under this subsection, if the Board determines that the evidence for a positive association is categorized as either the sufficient or equipoise and above categories, the Board shall estimate the size of the positive association effect among those exposed by calculating the relative risk and exposure prevalence. (B) (i) The Board shall use the relative risk and exposure prevalence calculated under subparagraph (A) to estimate the service-attributable fraction of illness in a military setting to determine the probability of positive association for an individual. (ii) In calculating the service-attributable fraction of illness, the Board shall consider the dose-response relationships. (4) (A) With respect to an evaluation conducted under this subsection, if the Board determines that the evidence for a positive association is categorized as the below equipoise category, the Board shall develop a recommendation as to whether additional data gathering and research are necessary. (B) If the Board recommends additional data gathering and research pursuant to subparagraph (A), the Secretary shall seek to enter into an agreement with the National Academies of Sciences, Engineering, and Medicine, or another nonprofit, nongovernmental entity that the Secretary determines has similar expertise and objectivity as the National Academies, to conduct such data gathering and research. (c) Reports (1) For each evaluation conducted under subsection (b) where the Board determines that the evidence for positive association is categorized as either the sufficient or equipoise and above categories, the Board shall submit to the Secretary a report identifying the evidence found to reach such positive association determinations. (2) In addition to submitting reports under paragraph (1), the Board shall submit to the Secretary reports, at such times and at such frequencies as the Board considers appropriate, containing such recommendations as the Board may have for additional or new research on matters relating to toxic exposures described in subsection (b)(1). (d) Responses from the Secretary (1) In response to each report received by the Secretary under subsection (c)(1), the Secretary shall submit to the Committees on Veterans’ Affairs of the Senate and the House of Representatives, and make publicly available, a report on the findings and opinions of the Secretary with respect to the report received under such subsection. (2) Each report submitted under paragraph (1) of this subsection shall include, with respect to a report received under subsection (c)(1), the following: (A) The findings and opinions of the Secretary with respect to the report received under subsection (c)(1). (B) Whether the Secretary intends to nominate to the Working Group, established under section 1174(a) of this title, the work of the Science Review Board covered by the report received under subsection (c)(1) for further action, and if not, an explanation of why, including citations and sources. 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 ) to— (1) evaluate— (A) the conclusions of the Science Review Board contained in each report submitted under section 1173(c)(1) of this title; and (B) evidence nominated by the Formal Advisory Committee on Toxic Exposure under section 1172(d)(2) regarding the periods and locations of exposure covered by an existing presumption of service connection; and (2) develop and submit to the Secretary a recommendation with respect to whether— (A) to establish a presumption of service connection for the toxic exposure and illness covered by the report described in subparagraph (A) of paragraph (1); or (B) to modify an existing presumption of service connection described in subparagraph (B) of such paragraph. (b) Recommendations (1) In making a recommendation under subsection (a)(2), the Working Group shall— (A) in cases where the evidence for a positive association is categorized as either the sufficient or equipoise and above categories, as described in subparagraph (A) or (B) of section 1173(b)(2) of this title, weigh such evidence heavily in favor of establishing a presumption of service connection; (B) take into consideration such factors as may be determined appropriate by the Secretary; and (C) 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 appropriate additional research, studies, or reports. (2) At the same time as when the Working Group submits to the Secretary a recommendation under paragraph (2) of subsection (a) with respect to an evaluation under paragraph (1) of such subsection, the Working Group shall submit to the Committees on Veterans’ Affairs of the Senate and the House of Representatives a description of such recommendation. (c) Report The Secretary shall periodically publish on the internet website of the Department a report identifying any factors for the Working Group to consider under subsection (b)(1)(B), as determined appropriate by the Secretary. 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. (b) Final regulation Not later than 180 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 and 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 inserting after the item relating to section 1165 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. Formal Advisory Committee on Toxic Exposure. 1173. Science Review Board. 1174. Working group on presumptions of service connection. 1175. Regulations regarding presumptions of service connection based on toxic exposure. . (b) Conforming amendments Chapter 11 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 Honoring our Promise to Address Comprehensive Toxics 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 Honoring our Promise to Address Comprehensive Toxics 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. . 203. Reevaluation of claims for compensation involving presumptions of service connection (a) In general Subchapter VI of chapter 11 is amended by adding at the end the following new section: 1167. Reevaluation of compensation determinations pursuant to changes in presumptions of service connection (a) Reevaluation Except as provided in subsection (b), whenever a law, including through a regulation or Federal court decision, establishes or modifies a presumption of service connection, the Secretary shall— (1) identify all claims for compensation under this chapter that— (A) were submitted to the Secretary; (B) were evaluated and denied by the Secretary before the date on which such provision of law went into effect; and (C) might have been evaluated differently had the establishment or modification been applicable to the claim; (2) allow for the reevaluation of such claims at the election of the veteran; and (3) with respect to claims approved pursuant to such reevaluation, provide compensation under this chapter effective as if the establishment or modification of the presumption of service connection had been in effect on the date of the submission of the original claim described in paragraph (1). (b) Outreach With respect to each claim identified under subsection (a), the Secretary shall conduct outreach to inform relevant veterans that they may elect to have a claim be reevaluated in light of the establishment or modification of a presumption of service connection described in such subsection. Such outreach shall include the following: (1) The Secretary shall publish on the internet website of the Department a notice that such veterans may elect to have a claim so reevaluated. (2) The Secretary shall notify, in writing or by electronic means, veterans service organizations of the ability of such veterans to elect to have a claim so reevaluated. (c) Relation to other laws The Secretary shall carry out subsection (a) to the degree that doing so does not conflict with any other provision of law. . (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 1165 the following new item: 1167. Reevaluation of compensation determinations pursuant to changes in presumptions of service connection. . (c) Application Section 1167 of title 38, United States Code, as added by subsection (a), shall apply with respect to presumptions of service connection established or modified on or after the date of the enactment of this Act, including pursuant to amendments made by this Act. III Improving the establishment of service connection process for toxic exposed veterans 301. Short title This title may be cited as the Veterans Burn Pits Exposure Recognition Act . 302. Presumptions of toxic exposure (a) In general Subchapter II of chapter 11 is amended by adding at the end the following new section: 1119. Presumptions of toxic exposure (a) Consideration of Individual Longitudinal Exposure Record required If a veteran submits to the Secretary a claim for compensation for a service-connected disability under section 1110 of this title with evidence of a disability and a toxic exposure that occurred during active military, naval, or air service, the Secretary shall, in adjudicating such claim, consider— (1) the Individual Longitudinal Exposure Record of the veteran; and (2) if the Individual Longitudinal Exposure Record of the veteran does not indicate that the veteran was subject to a toxic exposure during active military, naval, or air service, the totality of the circumstances of the service of the veteran. (b) Presumption of specific toxic exposure for members who served in certain locations (1) The Secretary shall, for purposes of section 1110 and chapter 17 of this title, presume that any covered veteran was exposed to the substances, chemicals, and hazards listed in paragraph (2) during the service of the covered veteran specified in subsection (c)(1), unless there is affirmative evidence to establish that the covered veteran was not exposed to any such substances, chemicals, or hazards in connection with such service. (2) (A) Subject to subparagraph (B), the substances, chemicals, and airborne hazards listed in this paragraph are as follows: (i) Particulate matter, including the following: (I) PM-10. (II) PM-2.5. (ii) Polycyclic aromatic hydrocarbons (PAHs), including the following: (I) Acenaphthene. (II) Acenaphthylene. (III) Anthracene. (IV) Benzo(a)anthracene. (V) Benzo(a)pyrene. (VI) Benzo(b)fluoranthene. (VII) Benzo(g,h,i)perylene. (VIII) Benzo(k)fluoranthene. (IX) Chrysene. (X) Dibenz(a,h)anthracene. (XI) Fluoranthene. (XII) Fluorene. (XIII) Indeno(1,2,3-cd)pyrene. (XIV) Naphthalene. (XV) Phenanthrene. (XVI) Pyrene. (iii) Volatile organic compounds (VOCs), including the following: (I) Acetone. (II) Acrolein. (III) Benzene. (IV) Carbon Disulfide. (V) Chlorodifluoromethane. (VI) Chloromethane. (VII) Ethylbenzene. (VIII) Hexachlorobutadiene. (IX) Hexane. (X) m/p-Xylene. (XI) Methylene Chloride. (XII) Pentane. (XIII) Propylene. (XIV) Styrene. (XV) Toluene. (iv) 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) 1,2,3,6,7,8 HXCDD. (VI) 1,2,3,7,8,9 HXCDD. (VII) 1,2,3,4,7,8 HXCDF. (VIII) 1,2,3,6,7,8 HXCDF. (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. (v) Such other substances, chemicals, and airborne hazards as the Secretary, in collaboration with the Secretary of Defense, may determine appropriate. (B) (i) The Secretary may add to or remove from the list under subparagraph (A) as the Secretary, in collaboration with the Secretary of Defense, determines appropriate. (ii) Beginning not later than two years after the date of the enactment of the Honoring our Promise to Address Comprehensive Toxics Act of 2021, and not less frequently than once every two years thereafter, the Secretary shall submit to Congress a report identifying any additions or removals made pursuant to subparagraph (A) during the period covered by the report. (c) Definitions In this section: (1) The term covered veteran means any veteran who— (A) on or after August 2, 1990, performed active military, naval, or air service while assigned to a duty station in— (i) Bahrain; (ii) Iraq; (iii) Kuwait; (iv) Oman; (v) Qatar; (vi) Saudi Arabia; (vii) Somalia; or (viii) United Arab Emirates; or (B) on or after September 11, 2001, performed active military, naval, or air service while assigned to a duty station in— (i) Afghanistan; (ii) Djibouti; (iii) Egypt; (iv) Jordan; (v) Lebanon; (vi) Syria; (vii) Yemen; (viii) Uzbekistan; (ix) the Philippines; or (x) any other country determined relevant by the Secretary. (2) 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. (3) The term toxic exposure risk activity has the meaning given such term in section 1710(e)(4) of this title. . (b) Clerical amendment The table of sections at the beginning of chapter 11 is amended by inserting after the item relating to section 1118 the following new item: 1119. Presumptions of toxic exposure. . 303. Medical nexus examinations for toxic exposure risk activities (a) In general Subchapter VI of chapter 11, as amended by section 203 of this Act, is further amended by adding at the end the following new section: 1168. Medical nexus examinations for toxic exposure risk activities (a) Medical examinations and medical opinions (1) Except as provided in subsection (b), if a veteran submits to the Secretary a claim for compensation for a service-connected disability under section 1110 of this title with evidence of a disability and evidence of participation in a toxic exposure risk activity during active military, naval, or air service, and such evidence is not sufficient to establish a service connection for the disability, the Secretary shall— (A) provide the veteran with a medical examination under section 5103A(d) of this title; and (B) request a medical opinion as to whether it is at least as likely as not that there is a nexus between the disability and the toxic exposure risk activity. (2) When providing the Secretary with a medical opinion requested under paragraph (1), the health care provider shall consider the total potential exposure through all applicable military deployments, and the synergistic, combined effect of all applicable toxic exposure risk activities. (b) Exception Subsection (a) shall not apply if the Secretary determines there is no indication of an association between the disability claimed by the veteran and the toxic exposure risk activity for which the veteran submitted evidence. (c) Toxic exposure risk activity defined In this section, the term toxic exposure risk activity has the meaning given such term in section 1710(e)(4) of this title. . (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 exposure risk activities. . IV Presumptions of service connection 401. Treatment of veterans who participated in cleanup of Enewetak Atoll as radiation-exposed veterans for purposes of presumption of service connection of certain disabilities by Department of Veterans Affairs (a) Short title This section may be cited as the Mark Takai Atomic Veterans Healthcare Parity Act . (b) Enewetak Atoll Section 1112(c)(3)(B) 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 (a) Short title This section may be cited as the Palomares Veterans Act . (b) Palomares Section 1112(c)(3)(B), 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) Short title This section may be cited as the Veterans Agent Orange Exposure Equity Act . (b) In general Section 1116, as amended by section 202, 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, Kampong 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. . (c) Eligibility for hospital care and medical services Section 1710(e)(4), as amended by section 103, is further amended by striking subparagraph (A) and inserting the following new subparagraph: (A) The term Vietnam-era herbicide-exposed veteran means a veteran who— (i) performed covered service, as defined in section 1116(d) 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. . (d) Clerical amendments (1) Section heading The heading for section 1116 is amended by striking the Republic of Vietnam and inserting certain locations . (2) Table of sections The table of sections at the beginning of chapter 11 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 certain locations (a) Short title This section may be cited as the Fair Care for Vietnam Veterans Act . (b) Additional diseases Section 1116(a)(2), 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 is amended by striking became manifest— and all that follows through the period at the end and inserting became manifest to any degree at any time. . (b) Permanent extension of period of eligibility Such section is further amended— (1) by striking subsection (b); (2) by redesignating subsections (c) and (d) as subsections (b) and (c), respectively; and (3) in subsection (a)(2)(C), by striking under subsection (d) and inserting under subsection (c) . (c) Establishing singular disability-Based questionnaire Such section is further amended by inserting after subsection (c) (as redesignated by subsection (b)) the following new subsection (d): (d) If a Persian Gulf veteran at a medical facility of the Department presents with any one symptom associated with Gulf War Illness, the Secretary shall ensure that health care personnel of the Department use a disability benefits questionnaire, or successor questionnaire, to identify Gulf War Illness. . (d) Expansion of definition of Persian Gulf veteran Subsection (f) of such section is amended by inserting , Afghanistan, Israel, Egypt, Turkey, Syria, or Jordan, after operations . (e) Training Such section is further 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) Short title This section may be cited as the Presumptive Benefits for War Fighters Exposed to Burn Pits and Other Toxins Act . (b) In general Subchapter II of chapter 11, as amended by section 303(a), is further amended by inserting after section 1119 the following new section: 1120. 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 (b) 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) Diseases specified The diseases specified in this subsection are the following: (1) Asthma that was diagnosed after service of the covered veteran as specified in subsection (c). (2) The following types of cancer: (A) Head cancer of any type. (B) Neck cancer of any type. (C) Respiratory cancer of any type. (D) Gastrointestinal cancer of any type. (E) Reproductive cancer of any type. (F) Lymphoma cancer of any type. (G) Lymphomatic cancer of any type. (H) Kidney cancer. (I) Brain cancer. (J) Melanoma. (K) Pancreatic cancer. (3) Chronic bronchitis. (4) Chronic obstructive pulmonary disease. (5) Constrictive bronchiolitis or obliterative bronchiolitis. (6) Emphysema. (7) Granulomatous disease. (8) Interstitial lung disease. (9) Pleuritis. (10) Pulmonary fibrosis. (11) Sarcoidosis. (12) Chronic sinusitis. (13) Chronic rhinitis. (14) Glioblastoma. (15) Any other disease for which the Secretary determines, pursuant to regulations prescribed under subchapter VII that a presumption of service connection is warranted based on a positive association with a substance, chemical, or airborne hazard specified in section 1119(b)(2) of this title. (c) Covered veteran defined In this section, the term covered veteran has the meaning given that term in section 1119(c) of this title. . (c) Clerical amendment The table of sections at the beginning of chapter 11, as amended by section 302(b), is further amended by inserting after the item relating to section 1119 the following new item: 1120. Presumption of service connection for certain diseases associated with exposure to burn pits and other toxins. . (d) Conforming amendment Section 1113 is amended by striking or 1118 each place it appears and inserting 1118, or 1120 . V Research matters 501. Coordination by Department of Veterans Affairs of toxic exposure research (a) In general Subchapter II of chapter 73 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 carried out 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 specified in such subsection are collaborative, transparent, and highly coordinated. (c) Report Not later than one year after the date of the enactment of the Honoring our Promise to Address Comprehensive Toxics Act of 2021, and annually thereafter, the Secretary shall submit to the Committee on Veterans’ Affairs of the House of Representatives and the Senate a report on any research activities specified in subsection (a) carried out 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. Data collection, analysis, and report on treatment of veterans for illnesses 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 Secretary in connection with hospital care, medical services, or nursing home care furnished to a veteran for an illness under section 1710(a)(2)(F) of title 38, United States Code, as amended by section 102; and (2) is likely to be scientifically useful, as determined by the Secretary, in determining whether a positive association exists between the illness of the veteran and a toxic exposure. (b) Consent of patients The Secretary shall ensure that the compilation and analysis of the clinical data of a veteran under subsection (a) shall be conducted, and such data shall be used, in a manner that is 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 House of Representatives and the Senate a report containing— (1) any data compiled under subsection (a); (2) an analysis of any such data; (3) a description of the types and incidences of illnesses identified by the Secretary pursuant to such subsection; (4) an explanation by the Secretary for the incidence of such illnesses and such alternate explanations for the incidence of such illnesses as the Secretary may consider reasonable; and (5) a description of the views of the Secretary regarding the scientific validity of drawing conclusions from the incidence of such illnesses, as evidenced by the data compiled under subsection (a), regarding the existence of a positive association between such illness and a toxic exposure. (d) Definitions In this section: (1) The term toxic exposure has the meaning given that term in section 101 of title 38, United States Code. (2) The term illness has the meaning given that term in section 1171 of such title, as added by section 202. 503. Studies related to veterans who served in Southwest Asia and certain other locations (a) Analysis on mortality in covered veterans (1) Analysis Not later than 180 days after the date of the enactment of this Act, the Secretary of Veterans Affairs shall conduct an updated analysis of total and respiratory disease mortality in covered veterans. (2) Elements The analysis under paragraph (1) shall include, to the extent practicable, the following: (A) Metrics of airborne exposures. (B) The location and timing of any deployments of the veteran. (C) The military occupational specialty of the veteran. (D) The Armed Force in which the veteran served. (E) The preexisting health status of the veteran, including with respect to asthma. (F) Such personal information of the veteran as the Secretary may consider relevant, 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 involves— (1) the use of improved spatio-temporal estimates of ambient air pollution exposures that leverage advances in retrospective exposure assessment; and (2) the collection of detailed information on the covered veterans studied through medical records, administrative data, and other existing sources, including, with respect to the covered veterans— (A) personal information, 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) Study 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 toxic exposures of healthy, young members of the Armed Forces, as well as potentially susceptible members, with preexisting health conditions. (2) Elements The study under paragraph (1) shall include— (A) an analysis of results for mechanistic markers and clinically relevant outcomes; and (B) a validation of any serum, tissue, or other biomarkers of toxic exposure, susceptibility, or effect with respect to the subjects of the study. (d) Covered veteran defined In this section, the term covered veteran has the meaning given that term in section 1119(c) of title 38, United States Code, as added by section 302. 504. Study on health trends of post 9/11 veterans (a) Study 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. (b) Report Not later than two years after the date of the enactment of this Act, the Secretary shall submit to the Committees on Veterans’ Affairs of the House of Representatives and the Senate a report on the study under subsection (a). 505. Study on cancer rates among veterans (a) Study 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 under 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) Any military occupational speciality of the veteran. (4) The gender of the veteran. (5) Any type of cancer that the veteran has. (c) Report Not later than two years after the date of the enactment of this Act, the Secretary shall submit to the Committees on Veterans’ Affairs of the House of Representatives and the Senate a report on the study under subsection (a). 506. Study on feasibility and advisability of furnishing hospital care and medical services to dependents of veterans who participated in toxic exposure risk activities (a) Study 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 103(a)(1), for any illness 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 is attributable to such activity. (b) Elements The study under subsection (a) shall include— (1) an assessment of 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) an assessment of the potential cost of furnishing hospital care and medical services to qualifying dependents as described in such subsection; (3) an estimate of the resources required to furnish such care and services; (4) an assessment of any stress or other effect furnishing such care and services would have on the claims and appeals system of the Department; (5) an estimate of the number of qualifying dependents who would be eligible for such care and services; and (6) an assessment of 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 toxic 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 military installations of the Department of Defense located in the United States; (2) analyze the liability of the Department of Defense in each such case; and (3) assess whether the Secretary 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) The terms hospital care and medical services have the meanings given those terms in section 1701 of title 38, United States Code. (2) The term illness has the meaning given that term in section 1171 of such title, as added by section 202. (3) 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 103(a)(1), 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 that is connected to the toxic exposure risk activity of the veteran, as determined by the Secretary. (4) The term toxic exposure has the meaning given that term in section 101 of such title, as added by section 102(b). (5) The term toxic exposure risk activity has the meaning given that term in section 1710(e)(4) of such title, as added by section 103(a)(3). (6) The term TRICARE program has the meaning given that term in section 1072 of such title. VI Improvement of resources and training regarding toxic exposed veterans 601. Short title; definitions (a) Short title This title may be cited as the Toxic Exposure in the American Military Act or the TEAM Act . (b) Definitions In this title, the terms active military, naval, or air service , toxic exposure , and toxic exposed 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 exposed 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 exposed veterans, including with respect to— (i) disability compensation under chapter 11 of title 38, United States Code; and (ii) hospital care, medical services, and nursing home care under section 1710(a)(2)(F) of such title; (B) caregivers of toxic exposed veterans who are participating in the program of comprehensive assistance for family caregivers under section 1720G(a) of such title; and (C) survivors of toxic exposed veterans 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 exposed 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 exposed 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) Standard claims processor training curriculum (A) Curriculum Not later than 180 days after the date of the enactment of this Act, the Secretary shall establish a standard training curriculum 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, including employees who adjudicate such claims. (B) Matters included The Secretary shall ensure that the training under subparagraph (A) includes the following explanations with respect to claims relating to toxic exposure: (i) A lack of a presumption of service connection is not by itself sufficient to determine that service connection does not exist. (ii) The claims adjudicator shall always consider whether direct service connection is applicable and request, as needed, an advisory medical opinion pursuant to section 1168 of title 38, United States Code, as added by section 303. (iii) The claims adjudicator shall always review and consider the Individual Longitudinal Exposure Record program of the Department of Veterans Affairs pursuant to section 1119 of such title, as added by section 302, but a lack of such information is not by itself sufficient to determine that such exposure did not occur or sufficient to deny the claim. (C) Provision of training The Secretary shall— (i) provide training under subparagraph (A) to each employee described in such subparagraph not less frequently than annually; and (ii) using the Systematic Technical Accuracy Review program, or such successor program, conduct a nationwide, quarterly, randomized review of the quality of adjudication of claims relating to toxic exposure. (2) Standard medical examiner training curriculum (A) Curriculum Not later than 180 days after the date of the enactment of this Act, the Secretary shall establish a standard medical training curriculum for medical providers who conduct examinations and provide opinions pursuant to section 1168 of title 38, United States Code, as added by section 303, regardless of whether the provider is an employee of the Department or a contractor. (B) Standardized approach The Secretary shall ensure that the curriculum established under subparagraph (A)— (i) provides a standardized approach to conducting and providing examinations and opinions in accordance with such section 1168; and (ii) instructs medical providers to consider, when conducting an examination or providing an opinion— (I) relevant medical and scientific literature; (II) the proximity, intensity, and frequency of exposure of the individual to the identified toxic exposure; (III) medically unexplained chronic multisymptom illnesses; and (IV) all competent and credible evidence of record. VII Registries, records, and other matters 701. Registry of individuals exposed to per- and polyfluoroalkyl substances on military installations (a) Establishment of registry (1) In general Not later than one year after the date of the enactment of this Act, the Secretary of Veterans Affairs shall— (A) establish and maintain a registry for eligible individuals who may have been exposed to per- and polyfluoroalkyl substances (in this section referred to as PFAS ) due to the environmental release of aqueous film-forming foam (in this section referred to as AFFF ) on military installations to meet the requirements of military specification MIL–F–24385F; (B) include any information in such registry that the Secretary determines necessary to ascertain and monitor the health effects of the exposure of members of the Armed Forces to PFAS associated with AFFF; (C) develop a public information campaign to inform eligible individuals about the registry, including how to register and the benefits of registering; and (D) periodically notify eligible individuals of significant developments in the study and treatment of conditions associated with exposure to PFAS. (2) Coordination The Secretary of Veterans Affairs shall coordinate with the Secretary of Defense in carrying out paragraph (1). (b) Reports (1) Initial report Not later than two years after the date on which the registry under subsection (a) is established, the Secretary of Veterans Affairs shall submit to Congress an initial report containing the following: (A) An assessment of the effectiveness of actions taken by the Secretary of Veterans Affairs and the Secretary of Defense to collect and maintain information on the health effects of exposure to PFAS. (B) Recommendations to improve the collection and maintenance of such information. (C) Using established and previously published epidemiological studies, recommendations regarding the most effective and prudent means of addressing the medical needs of eligible individuals with respect to exposure to PFAS. (2) Followup report Not later than five years after submitting the initial report under paragraph (1), the Secretary of Veterans Affairs shall submit to Congress a followup report containing the following: (A) An update to the initial report submitted under paragraph (1). (B) An assessment of whether and to what degree the content of the registry established under subsection (a) is current and scientifically up to date. (3) Independent scientific organization The Secretary of Veterans Affairs shall enter into an agreement with an independent scientific organization to prepare the reports under paragraphs (1) and (2). (c) Recommendations for additional exposures To be included Not later than five years after the date of the enactment of this Act, and every five years thereafter, the Secretary of Veterans Affairs, in consultation with the Secretary of Defense and the Administrator of the Environmental Protection Agency, shall submit to Congress recommendations for additional chemicals with respect to which individuals exposed to such chemicals should be included in the registry established under subsection (a). (d) Eligible individual defined In this section, the term eligible individual means any individual who, on or after a date specified by the Secretary of Veterans Affairs through regulations, served or is serving in the Armed Forces at a military installation where AFFF was used or at another location of the Department of Defense where AFFF was used. 702. Fort McClellan Health Registry (a) Establishment The Secretary of Veterans Affairs shall establish and maintain a special record to be known as the Fort McClellan Health Registry (in this section referred to as the Registry ). (b) Contents Except as provided in subsection (c), the Registry shall include the following information: (1) A list containing the name of each individual who, while serving as a member of the Armed Forces, was stationed at Fort McClellan, Alabama, at any time during the period beginning January 1, 1935, and ending on May 20, 1999, and who— (A) applies for care or services from the Department of Veterans Affairs under chapter 17 of title 38, United States Code; (B) files a claim for compensation under chapter 11 of such title on the basis of any disability which may be associated with such service; (C) dies and is survived by a spouse, child, or parent who files a claim for dependency and indemnity compensation under chapter 13 of such title on the basis of such service; (D) requests from the Secretary a health examination under subsection (d); or (E) receives from the Secretary a health examination similar to the health examination referred to in subparagraph (D) and requests inclusion in the Registry. (2) Relevant medical data relating to the health status of, and other information that the Secretary considers relevant and appropriate with respect to, each individual described in paragraph (1) who— (A) grants to the Secretary permission to include such information in the Registry; or (B) at the time the individual is listed in the Registry, is deceased. (c) Individuals submitting claims or making requests before date of enactment If in the case of an individual described in subsection (b)(1) the application, claim, or request referred to in such subsection was submitted, filed, or made before the date of the enactment of this Act, the Secretary shall, to the extent feasible, include in the Registry such individual's name and the data and information, if any, described in subsection (b)(2) relating to the individual. (d) Examinations Upon the request of a veteran who was stationed at Fort McClellan, Alabama, at any time during the period beginning January 1, 1935, and ending on May 20, 1999, the Secretary shall provide the veteran with a health examination (including any appropriate diagnostic tests) and consultation and counseling with respect to the results of the examination and the tests. (e) Outreach (1) Ongoing outreach to individuals listed in Registry The Secretary shall, from time to time, notify individuals listed in the Registry of significant developments in research on the health consequences of potential exposure to a toxic substance or environmental hazard related to service at Fort McClellan. (2) Examination outreach The Secretary shall carry out appropriate outreach activities with respect to the provision of any health examinations (including any diagnostic tests) and consultation and counseling services under subsection (d). (f) Consultation The Secretary of Veterans Affairs shall consult with the Secretary of Defense to acquire information maintained by the Secretary of Defense that the Secretary of Veterans Affairs considers necessary to establish and maintain the Registry. 703. 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 determine— (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 they experience during service in the Armed Forces will be accurately reflected in the Individual Longitudinal Exposure Record of the member. (b) Independent research entity The entity described in this subsection is an independent research entity that is a not-for-profit entity or a federally funded research and development center with appropriate expertise and analytical capability to carry out the study required under subsection (a). (c) 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, as added by section 102(b). 704. 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 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 exposure events that may not be fully captured by the current systems of the Department of Defense for environmental, occupational, and 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 if necessary. (c) Definitions In this section: (1) Appropriate committees of Congress The term appropriate committees of Congress means— (A) the Committee on Armed Services and the Committee on Veterans’ Affairs of the Senate; and (B) the Committee on Armed Services and the Committee on Veterans’ Affairs of the House of Representatives. (2) Toxic exposure The term toxic exposure has the meaning given that term in section 101(37) of title 38, United States Code, as added by section 102(b). 705. Correction of exposure records by members of the Armed Forces and veterans (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) Provision of evidence To update a record under subsection (a), a member of the Armed Forces or veteran, as the case may be, shall provide such evidence as the Secretary of Defense and the Secretary of Veterans Affairs jointly consider necessary. (2) Benefit of the doubt In reviewing evidence provided under paragraph (1), the Secretary of Defense and the Secretary of Veterans Affairs shall give the benefit of the doubt to the member of the Armed Forces or veteran who provided the evidence, as the case may be, in a manner that is equivalent to the benefit of the doubt required under section 5107(b) of title 38, United States Code. (3) Regulations The Secretary of Veterans Affairs, in consultation with the Secretary of Defense, shall prescribe by regulation the evidence considered necessary under paragraph (1). (c) 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, as added by section 102(b).

February 22, 2022 Reported from the Committee on Veterans' Affairs February 22, 2022 Committee on Armed Services discharged; committed to the Committee of the Whole House on the State of the Union and ordered to be printed