Veterans submit their disability compensation claims to 1 of VBA’s 57 regional offices. These claims contain, on average, five disabling medical conditions that the veteran believes are service connected. For each claimed condition, VA must determine if credible evidence is available to support the veteran’s contention of service connection. VA grants service connection for an average of three of the five conditions claimed by a veteran. Key sources of evidence for determining service connection are veterans’ military service medical and personnel records. To determine service connection in some cases, VA also may need to obtain information from DOD historical military records for the units in which veterans served. VBA’s regional offices face a complex task in obtaining veterans’ military service records because (1) service records consist of numerous types of records that can originate from numerous sources within or outside DOD, (2) the process for collecting and storing service records has varied substantially for different groups of veterans over time, (3) service records cannot always be found at the expected storage locations, and (4) the service records of many veterans were destroyed by a fire in 1973 at the National Personnel Records Center, a primary repository for service personnel and medical records. For detailed information on military service records, including the types and locations of the records and the process for collecting and storing them, see appendix II. Once a claim has all the necessary evidence, the regional office evaluates the claim and determines whether the claimant is eligible for benefits. If a veteran disagrees with a regional office’s decision on any of the issues in his or her claim, the veteran may file an appeal with the Board of Veterans’ Appeals, requesting a more favorable decision. In many cases, the board finds it cannot make a final decision on a veteran’s appeal until VBA does additional work on the case. In such cases, the board sends (remands) the case back to VBA to perform the necessary additional work. The additional work required for remands can include making initial or follow- up attempts to obtain relevant records in accordance with the requirements of the Veterans Claims Assistance Act. Under the act, if relevant records—such as military service records—are believed to be in the custody of a federal agency, VBA’s regional offices must continue requesting the records until either the agency provides the records or the regional office is reasonably certain the records do not exist or that further efforts would be futile. VA’s regulations state that the regional office cannot discontinue its efforts unless it has obtained a statement from the agency advising VA that the records either do not exist or are not in the agency’s possession. For detailed information on VA’s disability compensation claims and appeals process, see appendix III. VA’s internal assessments indicate that regional offices generally comply with the requirements of the Veterans Claims Assistance Act for obtaining veterans’ military service records. However, VBA does not have a system for assessing the reliability and accuracy of research done on behalf of regional offices by a VBA unit located at the National Personnel Records Center, where the service records of many veterans are stored. The VBA quality review unit that evaluates the accuracy of regional office decisions on compensation claims has found that that less than 4 percent of these decisions contain errors involving regional offices’ failing to obtain military service records as required by law. Similarly, of all the compensation appeals cases decided by the Board of Veterans’ Appeals during November 2004–January 2006, the board remanded less than 3 percent of these cases to VBA for rework due to deficiencies in obtaining military service records. However, because VBA does not systematically evaluate the quality of the research done on behalf of regional offices by the VBA unit at the National Personnel Records Center, VBA does not know the extent to which the information that this unit provides to regional offices is reliable and accurate. VBA maintains a quality review program known as the Systematic Technical Accuracy Review (STAR) program. VBA selects random samples of each regional office’s compensation decisions and assesses the regional office’s accuracy in processing and deciding such cases. For each decision, the STAR quality review unit reviews the documentation contained in the regional office’s claim file to determine, among other things, whether the regional office complied with claims assistance act duty-to-assist requirements for obtaining relevant records, made correct service connection determinations for each claimed condition, and made correct disability rating evaluations for each condition determined to be service connected. An error in any of these decision elements has the potential to result in a different decision outcome. One of VBA’s fiscal year 2007 performance goals is that 88 percent of compensation decisions should contain no errors that could affect decision outcomes, and the long-term strategic goal is 98 percent. STAR data from reviews of regional office decisions made during the first half of fiscal year 2006 showed that less than 4 percent of the cases reviewed contained any type of error related to the law’s requirements for developing evidence. Because military service records are only one component in the overall body of evidence that regional offices must develop, the percentage of cases with errors related to military service records would be even smaller than the 4 percent error rate. While the STAR database does not capture statistical data on specific types of errors in evidence development, it does contain quality reviewers’ narrative comments on the nature of errors found. A VBA analysis of these narrative comments showed that over half of all evidence development errors were due to regional offices not obtaining VA medical examinations or opinions when needed and using inadequate medical examinations. Thus, on the basis of STAR data, one would conclude that errors related to military service records account for less than half—or about 2 percent—of all evidence development errors. Since November 2004, when the Board of Veterans’ Appeals began tracking whether remands are the fault of regional offices, it has remanded relatively few cases—less than 3 percent—because of regional office deficiencies in obtaining military records. For example, as of January 2006, the board had made decisions on 41,517 compensation cases and had remanded at least one issue in 44 percent of these cases (see table 1). However, of the 41,517 cases, 25.6 percent contained issues that had been remanded for reasons considered to be the fault of the regional office, and only 2.8 percent contained issues remanded specifically because of deficiencies in obtaining military service records. For each case decided by the appeals board, it also tracks the outcome of each contested issue in the case—for example, a veteran may have contested the denial of service connection for a specific medical condition and also may have asked for a higher disability rating on another condition for which the regional office granted service connection. The 41,517 compensation cases decided by the board contained a total of 88,156 contested issues, of which 39 percent (34,351) were remanded to VBA. However, of the total contested issues, 23 percent (20,191) were remanded for reasons considered to be the fault of the regional offices. For the 20,191 issues remanded because of regional office deficiencies, the board identified a total of 36,812 reasons for remanding these issues (see table 2). Of these remand reasons, only 7.6 percent were related to inadequacies in obtaining military service records (service medical records, 3.5 percent; service personnel records, 2.4 percent; and military unit historical records, 1.6 percent). The predominant reasons for remands were deficiencies in obtaining medical examinations or opinions and nonmilitary records and in providing proper due process. Focusing only on issues in which veterans asked the appeals board to grant service connection for a medical condition that the regional office had denied, the board identified about 12 percent of the reasons for remanding service connection issues as being related to inadequacies in obtaining military service records. To obtain service records stored at the National Personnel Records Center, regional offices submit requests to a VBA unit located at the center, asking the VBA unit to provide copies of service records and/or provide information contained in the records. This unit responded to such requests from regional offices for about 290,000 cases in calendar year 2005. For certain types of compensations claims, such as herbicide exposure and PTSD claims, VBA’s written procedures instruct regional offices not to request a copy of the veteran’s entire service personnel record, which can be voluminous. Instead, regional offices are supposed to rely on the VBA unit at the National Personnel Records Center to obtain the veteran’s files, perform a physical search of the files for relevant records, provide copies of only certain specified records, analyze certain types of records, and provide regional offices with narrative answers on the results of their research and analyses. Thus, regional offices rely on the VBA unit at the National Personnel Records Center to do thorough and complete searches of records, do reliable analyses of records, and provide accurate and clear narrative reports on the results. VBA, however, does not have a systematic quality review program that evaluates the accuracy of the work that the VBA unit at the National Personnel Records Center performs on behalf of the regional offices. Such a program is needed as part of an adequate system of internal management controls for VBA’s administration of the compensation program. An example of why the records research done by VBA employees at the National Personnel Records Center must be reliable is provided by disability claims based on exposure to herbicides in Vietnam. Under the Agent Orange Act of 1991, VA presumes that any veteran who had set foot on land in the Republic of Vietnam at any time during the Vietnam era (January 9, 1962, to May 7, 1975) was exposed to herbicides such as Agent Orange. If any such veteran files a claim for certain specified diseases that have been determined to be attributable to herbicide exposure, VA must presumptively grant service connection to the veteran for such diseases. If a veteran claims that he or she was officially stationed on land in Vietnam during that period, the VBA unit at the National Personnel Records Center should be able to verify this fact by examining standard personnel forms in his or her service personnel file.