AGENT ORANGE      3

*********************************************************


January 17, 2002

Director (00/21)        In Reply Refer To: 211
All VBA Regional Offices and Centers    Fast Letter 02-04


SUBJ:  Public Law 107-103, Veterans Education and Benefits Expansion Act of 2001
There are a number of changes in this new law that impact veterans' benefits programs.  This letter identifies these changes and gives initial processing guidance.

Section 201-Presumptions Based on Herbicide Exposure in Vietnam (Amends 38 U.S.C. § 1116)

Section 202-Gulf War Veterans' Chronic Disabilities (Amends 38 U.S.C. § 1117)

 

Section 203-Protection of Service-Connected Status for Gulf War Veterans Participating in Medical Research (Amends 38 U.S.C. § 1117)

Section 204-Repeal of Limitation of Benefits for Incompetent Institutionalized Veterans (Amends 38 U.S.C. § 5503)

Section 206-Presumption of Permanent and Total Disability for Veterans Applying for Nonservice-Connected Pension-Nursing Home Patients and SSA Disabled (Amends 38 U.S.C. § 1502)

Section 207-Elimination of Permanent and Total Disability Requirement for Nonservice-Connected Pension Applicants Who Are Age 65 or Over (Adds a New 38 U.S.C. § 1513)

Section 304¾Improvement of Veterans Outreach Programs (amends 38 U.S. Code
§ 7722)

Section 501-Increase in Burial Benefits (Amends 38 U.S.C. §§ 2307 and 2303)

Section 502-Government Markers for Marked Graves at Private Cemeteries (Amends 38 U.S.C. § 2306)

Section 503-Increase in Amount of Assistance for Automobile for Certain Disabled Veterans (Amends 38 U.S.C. § 3902)

Section 504-Extension of Limitation on Pension for Certain Recipients of Medicaid-Covered Nursing Home Care (Amends 38 U.S.C. § 5503)

Section 505-Prohibition on Certain Benefits to Fugitive Felons (Adds a New 38 U.S.C. § 5313B)

Section 505-Limitation on Payment of Compensation for Veterans Remaining Incarcerated Since October 7, 1980 (Amends 38 U.S.C. § 5313)

Implementation of These Statutory Changes

Questions?

This letter will be rescinded January 17, 2004.



        /s/
        Ronald J. Henke, Director
        Compensation and Pension Service

*******************************************************************


January 17,2002

Director (00/21/27)             In Reply Refer To: 211C
All VA Regional Offices and Centers     Fast Letter 02-03

SUBJ: Additional Procedures for Type 2 Diabetes Awards for Earlier Effective Date Pursuant to Nehmer v. U.S. Veterans' Admin.


Background Information

Fast Letter 01-94 established procedures for reviewing certain Type 2 diabetes awards for possible entitlement to an earlier effective date pursuant to court orders in the case of Nehmer v. U.S. Veterans' Admin., C.A. No. C-86-6160 (TEH) (N.D. Cal.).  This letter provides additional information and instructions for review of those claims.  Failure to comply with these instructions will be considered an error under the Systematic Technical Accuracy Review (STAR) program.


Additional Claims for Review

In November, we sent each Regional Office a list of cases that had to be re-adjudicated under Nehmer v. Veterans Administration and Fast Letter 01-94.  VBA's Data Management Office has recently identified some additional diabetes cases that must be re-adjudicated under Nehmer.  We will be sending a list of these cases to each Regional Office, in an MS Excel spreadsheet format.


Change in End Product Credit

We have determined that additional work credit is appropriate for re-adjudication of cases under Nehmer.  >From now on, you should take the following work credit, as shown in the chart below.  You are not entitled to an end product 020 for Nehmer cases where an earlier effective date was previously granted.

DecisionWork CreditIf an earlier effective date is granted under Nehmer, thenProcess the award under end product 020If an earlier effective date is denied under Nehmer, thenPCLR end product 683

You should take the 020 when an earlier effective date is granted, even if an end product is pending for some other claim (e.g., claim for service connection of a knee condition) in a Nehmer veteran's case.


Important Reminder

In order for VA to track our progress in reviewing these diabetes cases, in conjunction with the Nehmer stipulation, you must follow the procedures previously outlined in Fast Letter 01-94:

What annotations are required if I am using RBA 2000 ?
Insert "Nehmer granted" after the diagnosis, in the coded conclusion. 
Example:
7913            Diabetes Mellitus (herbicide) (Nehmer granted)
40% from 03-01-88

What annotations are required if I am using the "old" RBA ?
All Nehmer diabetes ratings must be uploaded into the Oracle database.
The "Nehmer granted" phraseology must be inserted in both the "decision" portion and the coded conclusion of the rating decision.

Deadlines for Re-adjudication

The Department of Justice recently signed a stipulation with the attorneys for the plaintiff class in the Nehmer case.  This requires VA to re-adjudicate these cases within a series of deadlines:

On or before March 1, 2002, a total of 6,500 cases must be completed.

On or before April 15, 2002, a total of 10,000 cases must be completed.

On or before June 1, 2002, all 13,500 cases must be completed.

You should therefore continue to make the re-adjudication of these cases a high priority.  In order to ensure we meet these deadlines, we plan to periodically monitor the Regional Offices' progress in completing these cases.


Revised Notification Requirements

The stipulation mentioned above requires two changes to the notification procedures set forth in Fast Letter 01-94, as explained below.

1.  Paragraph 6 of Fast Letter 01-94 stated that if you conclude that a claimant is not entitled to an earlier effective date under Nehmer (because, e.g., benefits have already been awarded from the correct effective date), you do not need to do a rating decision or send any disallowance notice to the claimant.  Effective immediately, this instruction is changed as follows.  In cases where an award is reviewed under Fast Letter 01-94 and you determine there is no entitlement to an earlier effective date, send the claimant a notice containing the following language:

Pursuant to a court order in the case of Nehmer v. U.S. Veterans' Admin., C.A. No. C-86-6160 (TEH) (N.D. Cal.), we have reviewed your award of service connection for Type 2 diabetes to determine whether you may be eligible for an earlier effective date for benefits.  Under Nehmer an earlier effective date may be granted if a prior claim for service connection for Type 2 diabetes was filed or denied between September 25, 1985 and July 9, 2001.  We have concluded that you are not eligible for an earlier effective date because you did not have a prior claim filed or denied during this period.

You do not need to do a rating decision in these cases.  Continue to follow the procedures in Fast Letter 01-94 for annotating the most recent diabetes rating decision.  This notice requirement applies only to Type 2 diabetes cases reviewed on or after the date of this letter.  You do not need to send this notice in cases where review under Fast Letter 01-94 has already been completed.

2.  Paragraph 7 of Fast Letter 01-94 requires that the award letter concerning an earlier effective date assigned under Nehmer include the following language:  "These retroactive benefits are being paid to you as a result of the United States District Court's order in Nehmer v. U.S. Veterans' Admin.  Payment for any period before July 9, 2001 may be subject to recovery by VA in the event the United States Court of Appeals overturns the district court's order.   Recovery of this payment may include the withholding of future benefit payments until the retroactive amount has been recovered in full."  Effective immediately, this language is to be included only if the effective date assigned is between January 4, 1994 and July 9, 2001.  If you assign an effective date prior to January 4, 1994 for Type 2 diabetes, do not include this statement regarding possible recoupment of benefits.


Who to Contact for Help?

If you have questions concerning this letter, please contact the person listed on the Calendar page for this date (http://vbaw.vba.va.gov/bl/21/Calendar/index.htm).


                                                        /s/
                                                Ronald J. Henke, Director
                                                Compensation and Pension Service
PAGE  3

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Sent: Thursday, January 17, 2002 3:21 PM
Subject: Herbicide Exposure in Vietnam


January 17, 2002

Director (00/21)        In Reply Refer To: 211
All VBA Regional Offices and Centers    Fast Letter 02-04


SUBJ:  Public Law 107-103, Veterans Education and Benefits Expansion Act of 2001
There are a number of changes in this new law that impact veterans' benefits programs.  This letter identifies these changes and gives initial processing guidance.

Section 201-Presumptions Based on Herbicide Exposure in Vietnam (Amends 38 U.S.C. § 1116)

Section 202-Gulf War Veterans' Chronic Disabilities (Amends 38 U.S.C. § 1117)

 

Section 203-Protection of Service-Connected Status for Gulf War Veterans Participating in Medical Research (Amends 38 U.S.C. § 1117)

Section 204-Repeal of Limitation of Benefits for Incompetent Institutionalized Veterans (Amends 38 U.S.C. § 5503)

Section 206-Presumption of Permanent and Total Disability for Veterans Applying for Nonservice-Connected Pension-Nursing Home Patients and SSA Disabled (Amends 38 U.S.C. § 1502)

Section 207-Elimination of Permanent and Total Disability Requirement for Nonservice-Connected Pension Applicants Who Are Age 65 or Over (Adds a New 38 U.S.C. § 1513)

Section 304¾Improvement of Veterans Outreach Programs (amends 38 U.S. Code
§ 7722)

Section 501-Increase in Burial Benefits (Amends 38 U.S.C. §§ 2307 and 2303)

Section 502-Government Markers for Marked Graves at Private Cemeteries (Amends 38 U.S.C. § 2306)

Section 503-Increase in Amount of Assistance for Automobile for Certain Disabled Veterans (Amends 38 U.S.C. § 3902)

Section 504-Extension of Limitation on Pension for Certain Recipients of Medicaid-Covered Nursing Home Care (Amends 38 U.S.C. § 5503)

Section 505-Prohibition on Certain Benefits to Fugitive Felons (Adds a New 38 U.S.C. § 5313B)

Section 505-Limitation on Payment of Compensation for Veterans Remaining Incarcerated Since October 7, 1980 (Amends 38 U.S.C. § 5313)

Implementation of These Statutory Changes

Questions?

This letter will be rescinded January 17, 2004.



        /s/
        Ronald J. Henke, Director
        Compensation and Pension Service

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Department of Veterans Affairs VHA HANDBOOK 1302.1
Veterans Health Administration Transmittal Sheet
Washington, DC  20420 September 29, 2000
 

AGENT ORANGE REGISTRY (AOR) PROGRAM PROCEDURES
 

1.  REASON FOR ISSUE: This Veterans Health Administration (VHA) Handbook establishes procedures for the Department of Veterans Affairs (VA), VHA, Environmental Agents Service (EAS), Agent Orange Registry (AOR) Program.  This handbook includes information regarding special eligibility for VA care for veterans exposed to Agent Orange which contains the contaminant dioxin.

2.  SUMMARY OF MAJOR CHANGES: This Handbook constitutes a total revision of M-10, Part I, Chapters 1 and 2, dated May 16, 1994.  The principal changes involve:

 a.  Adding new conditions since the 1994 publication of M-10, Part I, e.g., prostate cancer and peripheral neuropathy (transient acute or sub-acute), that VA now presumes to be service-connected for Vietnam era veterans who served in the Republic of Vietnam between 1962 and 1975.

 b.  Providing Agent Orange registry examinations to veterans who may have been exposed to Agent Orange during their military service in Korea specifically during 1968 or 1969.

 c.  Evaluating and documenting Vietnam veterans for their risk factors to Hepatitis C and if necessary, based on these risk factors, providing antibody testing (see App. A).

 d.  Revising the Agent Orange Code sheet to reflect the changes.

 e.  Clarifying questions relating to reproductive concerns of Vietnam veterans.

3.  RELATED ISSUES:  VHA Directive 1302.

4.  RESPONSIBLE OFFICIALS:  The Director, EAS (131), is responsible for the contents
of this VHA Handbook.  Questions may be referred to that individual at VHA Headquarters.   NOTE:  Questions relating to eligibility for VA care, including enrollment, are to be directed to the eligibility staff at each facility and on the Intranet at http://www.va.gov/health/elig

5.  RESCISSIONS:  This VHA Handbook rescinds Manual M-10, Environmental Medicine, Part I, Agent Orange Program, Chapters 1 and 2, dated May 16, 1994.
 

6.  RECERTIFICATION:  This document is scheduled for recertification on or before the last working day of September 2005.
 
 

 
 S/ Frances Murphy, M.D. for
 Thomas L. Garthwaite, M.D.
 Acting Under Secretary for Health

Distribution:  RPC: 0005
FD
 

Printing Date:  10/00

 
CONTENTS

AGENT ORANGE REGISTRY (AOR) PROGRAM PROCEDURES

PARAGRAPH PAGE

1.  Purpose   1

2.  Authority   1

3.  Scope (Vietnam Veterans)   2

4.  Registry Examinations   2

5.  Evaluation of Condition (Vietnam Veterans)   2

6.  Eligibility Criteria   3

7.  Program Management   4

8.  Registry Physician (RP) Responsibilities   4

9.  Registry Coordinator (RC) Responsibilities   7

10.  Active Duty Military Personnel   9

11.  Incarcerated Veterans   10

12.  Veterans with Other than Honorable Discharges   11

13.  Conducting the Physical Examination   11

14.  Reporting Requirements   14

15.  Records Control and Retention   15

16.  Education and Training   16

APPENDICES

A  Hepatitis C:  Standards for Provider Evaluation and Testing   A-1

B  Sample Agent Orange Follow-up Letter (Medical Problems
          Indicated) (Vietnam Veterans)   B-1

 

PARAGRAPH PAGE

APPENDICES Continued

C  Sample Agent Orange Follow-up Letter (Medical Problems
          Indicated) (Korea Veterans)   C-1

D  Sample Agent Orange Follow-up Letter (No Medical Problems)
           (Vietnam or Korea Veterans)   D-1

E  Definitions and Acronyms   E-1

F  Instructions for Completing VA Form 10-9009 (July 2000), Agent Orange Registry
 Code Sheet   F-1

G  Sample of Completed VA Form 10-9009 (July 2000)
        Agent Orange Code Sheet   G-1

H  Instructions for Processing Code Sheets   H-1

I  Sample of Completed VA Form 7252, Transmittal Form for Use in Shipment of
 Tabulating  Data   I-1

 

AGENT ORANGE REGISTRY (AOR) PROGRAM PROCEDURES

1.   PURPOSE

 This Veterans Health Administration (VHA) Handbook sets forth clinical and administrative policies related to the maintenance of the VHA Agent Orange Registry (AOR) program of physical examinations for eligible, concerned, Vietnam veterans who served in the Republic of Vietnam between 1962 and 1975 and veterans who served in Korea during 1968 or 1969 who may have been exposed to dioxin or other toxic substance in a herbicide or defoliant.

2.  AUTHORITY

 a.  Registry Examinations

 (1)  Under section 703 of Public Law 102-585 (1992), the Secretary of Veterans Affairs may provide, upon request, a health examination, consultation, and counseling to a veteran who is eligible for listing or inclusion in any health-related registry administered by the Secretary of Veterans Affairs that is similar to the Persian Gulf War Veterans Health Registry.  Accordingly, the Department of Veterans Affairs (VA) will provide veterans who served in Korea in 1968 or 1969, who request an AOR Examination with such an examination and will include the results of such examination in the AOR.

 (2)  Furthermore, Public Law 100-687, “Veterans’ Judicial Review Act of 1988,” requires the Secretary of the Department of Veterans Affairs (VA) to organize and update the information contained in the VA AOR to enable VA to notify Vietnam era veterans who served in the Republic of Vietnam of any increased health risks resulting from exposure to dioxin or other toxic agents.  NOTE:  VA will continue to meet this mandate and extend it to include all other veterans who qualify for inclusion and participation in the AOR, i.e., veterans who served in Korea in 1968 or 1969.

 b.  Special Treatment Authority (Vietnam Veterans)

 (1)  Congress granted special eligibility for VA care to qualifying Vietnam veterans possibly exposed to dioxin during their service in Vietnam.  In accordance with Title 38 United States Code (U.S.C.) 1710(a)(2)(F) and 1710(e)(1)(A), Vietnam veterans exposed to dioxin are eligible for hospital care, medical services, and nursing home care for any disability, notwithstanding that there is insufficient medical evidence to conclude that such disability may be associated with dioxin exposure.  Thus, veterans who are not entitled to a presumption of service-connection for a disability(s) may nonetheless have mandatory eligibility for VA health care for the disability if it is found by VA to be possibly associated to dioxin exposure during service in Vietnam.

 (2)  The special treatment authority is limited by statute to those veterans who:

 (a)  Served on active duty in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975.

 (b)  The Secretary of Veterans Affairs finds may have been exposed to dioxin and/or were exposed during such service to a toxic substance found in a herbicide or defoliant used for military purposes during such period; and

 (c)  Have conditions for which the National Academy of Sciences (NAS) found evidence of a possible association with herbicide exposure excluding gastrointestinal tumors (stomach cancer, pancreatic cancer, colon cancer, rectal cancer); and brain tumors for which the NAS found limited evidence of no association.

NOTE:  The special treatment authority (in 38 U.S.C. 1710(a)(2)(F), 1710(e)(1)(A)] discussed in subparagraph 2b(1)), does not extend to veterans who served in Korea who may have been exposed to Agent Orange.

3.  SCOPE (VIETNAM VETERANS)

 It is VHA policy that registry examinations will be provided to any Vietnam era veteran who served in the Republic of Vietnam between 1962 and 1975 regardless of length of service (i.e., 1 hour, 1 day, 1 month, 1 year, etc.).  Verification of service during the Vietnam era will be required.  NOTE:  Inasmuch VA presumes that a veteran was exposed to phenoxy herbicides during any service in Vietnam, a verified claim of such in-country service constitutes the required contention of exposure and establishes eligibility for registry examinations within these provisions.

4.  REGISTRY EXAMINATIONS

 The registry examination protocol for veterans exposed to dioxin or other toxic substance in a herbicide or defoliant is described in paragraph 13.  NOTE:  Veterans eligible for inclusion in the AOR do not need to be enrolled in VA health care to receive the registry examinations.  No copayments are required for the standard examination protocol or any associated medically appropriate follow-up diagnostic evaluations.

5.  EVALUATION OF CONDITION (VIETNAM VETERANS)

 a.  Registry Examinations Findings.  Where the findings of the registry examination reveal a condition requiring treatment, it is essential that the responsible staff physician make a determination and document whether the condition is possibly related to Agent Orange exposure or resulted from a cause other than the specified exposure.

 b.  Priority Treatment.  Vietnam veterans claiming health conditions related to Agent Orange exposure will be evaluated clinically by means of a physical examination and appropriate diagnostic studies (see par. 13).

 (1)  In making this determination, the physician will consider that the following types of conditions are not ordinarily considered to be due to such exposure:

 (a)  Congenital or developmental conditions; e.g., scoliosis.

 (b)  Conditions which are known to have existed before military service.

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

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

 (e)  Common conditions having a well-recognized clinical course; e.g., inguinal hernia, acute appendicitis, etc.

 (2)  Although the types of conditions listed in subparagraph 5b(1) are not ordinarily considered to be due to Agent Orange exposure, if the staff physician finds that a veteran requires care under this provision for one or more of those conditions, the physician is to seek guidance from the facility Chief of Staff (COS) and the Registry Physician (RP) regarding the authorization for treatment.  The decision and its basis will be clearly documented in the medical record and chart by the RP.

6.  ELIGIBILITY CRITERIA

 a.  Any Vietnam era veteran, male or female, who had active military service in the Republic of Vietnam between 1962 and 1975 (these dates are inclusive for the registry and not to be confused with eligibility dates for health care services as indicated in subpar. 2b) and /or Korea during 1968 or 1969, expressing a concern relating to exposure to herbicides, is encouraged to participate in the AOR Program, which includes a thorough medical examination.

 b.  A veteran who did not serve in Vietnam or Korea is not eligible for the Agent Orange Registry examination.  Exposure to Agent Orange or any of the other classes of herbicides used elsewhere, other than Vietnam or Korea, does not confer eligibility for purposes of the AOR.  NOTE:  Such individuals may have been permanently assigned elsewhere other than the Republic of Vietnam during the Vietnam era (e.g., Cambodia, Thailand, Japan, at sea, etc.) and/or Korea; however, the crucial factor is that the veteran had served "in-country,” i.e., Vietnam and/or Korea)

 c.  Veterans are advised that participation in the AOR examination program does not constitute a formal claim for compensation.  Although the results of such an AOR examination may be used to support a compensation claim, the examination will not in and of itself be considered such a claim.  Veterans are advised of the routine procedure to file a claim through the Veterans Benefits Counselor (VBC) at the nearest VA facility, medical center or regional office.

 d.  Title 38 U.S.C. Section 1803, provides benefits for children of Vietnam veterans who are born with spina bifida.  VA must provide health care benefits for a child born with spina bifida or any disability that is associated with such condition.  The term “child,” with respect to a Vietnam veteran, means a natural child of the Vietnam veteran, regardless of age or marital status, who was conceived after the date on which the veteran first entered the Republic of Vietnam during the Vietnam era.  The term “Vietnam veteran” means a veteran who performed active military, naval, or air service in the Republic of Vietnam during the Vietnam era.  The spina bifida conditions covered apply with respect to all forms and manifestations of spina bifida except spina bifida occulta.  NOTE:  For information about this program, contact the local regional office at 1-800-827-1000.

7.  PROGRAM MANAGEMENT

NOTE:  The RP, Registry Coordinator (RC), and health administration staff of each VA facility are often the first points of contact for veterans requesting registry examinations.  They play a significant role in determining the perception veterans have concerning the quality of VA health care services and of their individual treatment by VA health care providers. These individuals should be well informed of the policies and procedures of this Agent Orange Program to provide good management and quality health care for this veteran population.

 a.  RP.  An RP and one or more alternates will be designated by the COS and approved by the Director at each facility.

 b.  RC.  An RC and alternate(s) will be designated by administrative staff assigned by the facility Director.  Final approval rests with the facility Director’s office.

 c.  RP and RC Listings.  Separate listings of the RPs and RCs are maintained by the Environmental Agents Service (EAS).  In an effort to keep these listings current, facilities are mandated to notify EAS of changes as they occur in status of the RPs and RCs at their respective facilities and/or satellite clinics. These listings will include the name, title, mail routing symbol, address, commercial telephone, and FAX numbers with area code, and are to be submitted, in writing, to EAS (131), Department of Veterans Affairs, 810 Vermont Avenue, NW, Washington, DC  20420.

8.  REGISTRY PHYSICIAN (RP) RESPONSIBILITIES

 The RP is responsible for clinical management and will serve in an advisory capacity for the administrative management of the program.  Major responsibilities include:

 a.  Counseling.  The RP advises the veteran that the examination cannot detect the presence of dioxin in the body nor determine whether adverse health effects or potential health problems are related to Agent Orange.

 b.  Documenting the Physical Examination.  NOTE:  If a compensation examination is performed for a veteran and the veteran requests inclusion in the AOR, it is not necessary to perform an additional registry examination as long as the demographic and medical information is sufficient to adequately complete the AOR code sheet for submission to the Austin Automation Center (AAC).  The RP must:

 (1)  Conduct and document the physical examination in the medical record and/or in the Consolidated Health Record (CHR) at the time of the visit.

 (a)  Perform a complete medical history to include information about:

 1.  Family;

 2.  Occupation;

 3.  Social history noting tobacco, alcohol, and drug use;

 4.  Civilian exposure to possible toxic agents; and

 5.  Psychosocial history.

 (b)  If a non-VA doctor subsequently diagnoses a veteran with a significant health problem, the physician must encourage the veteran to contact a VA medical center to include additional diagnoses in the CHR and AOR.

 1.  This new diagnosis must be submitted over a non-VA physician's signature and on official letterhead.

 2.  A code sheet identified as “follow-up examination Type C” will be completed with this diagnosis and subsequently forwarded to the AAC for inclusion in the AOR.

 (2)  Review and complete Part I of VA Form 10-9009 (July 2000), Agent Orange Registry Code Sheet, if necessary (see App. E).

 (3)  Complete Part II of VA Form 10-9009 (July 2000) (see App. E).

 (4)  Review the records of every Vietnam or Korea veteran examined to ensure that a complete physical examination was performed and documented.
 
 (5)  Personally discuss with each veteran the:

 (a)  Findings of the physical examination and completed diagnostic studies.  NOTE:  The interview will be conducted in such a way as to encourage the veteran to discuss health concerns, as well as those of family members, as they relate to herbicide exposure.  This information will be documented in the veteran's CHR.

 (b)  Need for follow-up examination either recommended by the RP or requested by the veteran.

 (c)  Preparing and Signing Follow-up Letter.  The RP will ensure that an appropriate personalized follow-up letter, explaining the results of the examination and laboratory studies, has been signed and mailed to the veteran (see App. A and App. B).  NOTE:  It is essential that this letter be written in language that can be easily understood by the veteran.  Inappropriate wording could unduly alarm or confuse the veteran.  A great deal of sensitivity and care should be exercised in the preparation of this correspondence.

 1.  Follow-up letters will be mailed to the veteran within 2 weeks of the initial examination appointment.  The only exception to this timeframe will be when a consultation at a specialty clinic is requested as part of the initial examination process.  This exception suspends, but does not remove, the requirement for the follow-up letter.  The follow-up letter will be sent within 2 weeks after the consultation.

 2.  A dated copy of the follow-up letter must be filed in the veteran's CHR.

 3.  The follow-up letter will explain that:

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

 b.  If it is determined upon examination that the veteran does have medical problems, it is not necessary to specify the problems in the letter.  The veteran should be advised in the letter that the recent examination indicated a health condition and/or problem, which may require further examination and/or treatment.  NOTE:  Depending on the seriousness of the condition identified, the RP should phone the veteran to discuss the examination findings.  Clinical judgment should be exercised.

 c.  If the veteran is eligible for VA medical treatment, the letter should so state and provide the name of a contact person, including telephone number, within the facility.

 d.  If the veteran is not eligible for VA treatment, e.g., the veteran  is not enrolled for VA health care, the letter should so advise and recommend that the veteran seek appropriate medical care elsewhere.

 e.  If the problem(s) is (are) not necessarily related to possible Agent Orange exposure, the letter should also explain that there is considerable research underway to learn more about the possible long-term health effects of Agent Orange exposure.  Currently, the following conditions have been presumptively recognized as service connected (SC) for the treatment of veterans who served in Vietnam (not Korea):

 (1)  Chloracne;

 (2)  Non-Hodgkin's lymphoma;

 (3)  Soft-tissue sarcoma;

 (4)  Hodgkin's disease;

 (5)  Porphyria Cutanea Tarda (PCT);

 (6)  Respiratory cancers (lung, larynx, trachea and bronchus);

 (7)  Multiple myeloma;

 (8)  Prostate cancer;

 (9)  Peripheral neuropathy, transient acute and sub-acute; and

 (10)  Spina bifida (except spina bifida occulta) is presumptively recognized in the offspring of Vietnam veterans as due to herbicide exposure.

NOTE:  Other conditions may be recognized in the future.

 d.  Reviewing records.  The RP reviews records of every Vietnam or Korea veteran examined to ensure that a complete physical examination was performed and documented and that the veteran has been appropriately notified of the examination results.

9.  REGISTRY COORDINATOR (RC) RESPONSIBILITIES

 The RC is responsible for the administrative management of the program, including:

 a.  Scheduling of Appointments.  Facilities are to make every effort to give each veteran an AOR examination within 30 days of the request date.  NOTE:  Consideration should be given to offering examinations (initial and/or follow-up) evenings or weekends to further convenience veterans.

 b.  Monitoring Timeframe Compliance

(1)  Follow-up Letters.  Mail to veteran within 2 weeks of initial registry examination.

(2)  Registry Examination Appointment.  Schedule within 30 days of request date.

 (3)  VA Staff (RC and RP) Changes.  Advise VHA Headquarters (131) as they occur.

 (4)  Registry Code Sheets (VA Form 10-9009, (July 2000)) for Initial and Follow-up Examinations.  Mail to the AAC by the workdays indicated in Appendix E.

 (5)  Invalid Registry Code Sheets (VA Form 10-9009 (July 2000)).  Correct and mail to the AAC 10 workdays following receipt from the AAC.

 c.  Reviewing Records for Accuracy and Completion.  All required records, e.g., computerized or card file records, follow-up letters, transmittal forms, registry code sheets of veteran participants, and CHRs are to be completed and reviewed for accuracy.

 d.  Collecting Data for Reporting Purposes.  Required registry data should be obtained from the veteran or family, entered on the AOR code sheets and submitted to the AAC for entry into the AOR dataset.  The AAC will provide the AOR data reports to VHA Headquarters based on VA facility input.

 e.  Disseminating Information.    It is important that each veteran be fully advised of the AOR examination program.  Facility staff are to fully communicate all aspects of the AOR examination program by an appropriate means, some of which are listed as follows:

 (1)  The RC is required to provide veterans reporting to the Outpatient and/or Admission area with a copy of the VA publication Agent Orange Review and upon request, or in response to questions, the Agent Orange Briefs and Agent Orange – General Information.  NOTE:  These publications and other informational materials are to be displayed in prominent areas (outpatient clinics, admission areas, etc.) to ensure availability to Vietnam veterans, Korea veterans, and other interested individuals.  Future issues of the Agent Orange Review will include information relating to use of the herbicide Agent Orange used by the Republic of Korea troops along the Korean Demilitarized Zone (DMZ) in 1968 and 1969.

 (a)  The Agent Orange Review is a VA EAS publication, published periodically, to provide information on Agent Orange and related matters to veterans, their families, and others with concerns about herbicides used in Vietnam.  NOTE:  The Agent Orange Review should be included as a supplement to an application for examination.

 (b)  The Agent Orange Briefs consist of a series of fact sheets prepared and distributed periodically to VA facilities by EAS, VHA Headquarters, Washington, DC.  The fact sheets are designed to answer questions relating to the purpose of the examination, its limitations (i.e., explains that the examination cannot detect the presence of dioxin in the body nor determine whether adverse health effects or potential health problems are related to exposure, etc.) and a variety of related matters.

 (c)  Veterans are to be provided the opportunity to view historical Agent Orange Program videotapes (available at VA medical center libraries) by making arrangements for viewing with the facility Librarian.

 (2)  The RC receives all Agent Orange-related inquiries.

 (3)  The RC provides copies of VA Agent Orange Briefs and Agent Orange Reviews (prepared and provided to VA facilities by EAS, VHA Headquarters, Washington, DC) to all telephone callers.

 (4)  The RC posts and communicates the names, locations, and office telephone numbers of the RP and the RC to concerned VA facility staff.   NOTE:  An appropriate method of communicating is the use of medical center memoranda providing registry policy and procedures and those responsible for carrying out these policies.

 f.  Maintaining a Computerized Record or Card file.  The RC must establish and maintain a computerized record (or alpha card file) of all registry participants.  Each record prepared is to include the veteran’s:

 (1)  Full name,

 (2)  Address,

 (3)  Telephone number,

 (4)  Date of birth,

 (5)  Social Security Number (SSN),

 (6)  Date of initial examination (including date submitted to the AAC for entry into the registry), and

 (7)  Date(s) of subsequent follow-up examination (including date submitted to the AAC for entry into the registry).

 g.  Completing Code Sheet.  The RC completes Part I of VA Form 10-9009 (July 2000), before the veteran is referred to the clinician for the examination (see App. E), assuring its accuracy.  To further ensure the form's completeness, the clinical examiner will review the form and, if necessary, enter missing items at the veteran's direction.

 h.  Establishing and Updating the CHR.  The RC will establish a medical record if one does not already exist.  VA Form 10-1079, Emergency Medical Identification, should be affixed to the front of the record and the word "Herbicides" circled.  All veterans participating in the registry will have VA Form 10-1079 affixed to the front of the CHR.  Completed VA Form 10-9009 (July 2000), dated follow-up letters, all medical records of registry examinations, and laboratory and/or test results will be maintained in the veteran's CHR.  These are to be maintained in a separate section of the CHR, identified as AOR records.

 i.  Tracking Active Duty Military.  Tracking active duty military personnel who apply for the AOR Examination.

10.  ACTIVE DUTY MILITARY PERSONNEL

 a.  When active duty members of the uniformed services apply to VA facilities for an Agent Orange examination, the Department of Defense (DOD) must provide VA with appropriate authorization, i.e., DOD Form 1161, Referral for Civilian Care.

NOTE:  The requirements of M-1, Part I, Chapter 15, regarding the authorization and billing from the appropriate branch of service, apply.

 (1)  The procedures for processing the examination are the same as those for a veteran participating in this program.
 
 (2)  A military facility may perform the Agent Orange examination according to VA instructions.

 (3)  Military facilities may obtain the pertinent VA directive and samples of appropriate forms from the nearest VA facility.  Military facilities will complete code sheets with exception of the following items, which will be filled in by VA coding clerks:

  Blocks  Code Identifier
  2-7  Facility Number and/or Suffix
  149-153 County and State
  228-242 Classification of Diseases, 9th Edition, Clinical Modification
       (ICD-9-CM) of the veterans symptom and/or complaint
  277-291 ICD-9-CM for diagnoses
  293-297 ICD-9-CM for neoplasia diagnoses

 (4)  The completed code sheet, copies of the physical examination, laboratory tests, etc., must be forwarded to the nearest VA medical center or outpatient clinic.

 b.  The RC will:

 (1)  Prepare a computerized record (or a colored card) for the file, with similar data as for a veteran.  Label the record or card "Active Duty;"

 (2)  Complete code sheet with identifier codes specified in subparagraph 10a(3);

 (3)   Submit legible copy of code sheet to the AAC, in accordance with instructions; and

 (4)   Maintain the medical documents and original code sheets in a CHR folder, which will be available if or when the individual is discharged from the service and reports for treatment as a veteran.

11.  INCARCERATED VETERANS

 a.  Incarcerated veterans may be accepted for registry examinations in VA facilities.  A veteran in the custody of penal authorities, or under criminal charges, does not forfeit any right to registry examinations by VA.  Contact the appropriate facility Health Administration Service (HAS) to see if the veteran is eligible for this examination.

 b.  VA will not bill the Bureau of Prisons for the AOR examinations of incarcerated veterans.

 c.  For purposes of entry into the AOR, VA medical facilities can provide assistance to penal authorities or institutions agreeable to providing examinations at the penal institution, without VA reimbursement.

 (1)  Copies of directives, code sheets, etc., will be provided to penal institutions upon request.

 (2)  Penal authorities must be advised at the time of such requests that the results of the examinations provided at their institutions must be returned to the VA medical facility of jurisdiction for inclusion on the veteran’s behalf, in VA's AOR.

 (3)  A recommendation can be made to the penal institution to retain a copy of the examination documents submitted to VA.  NOTE:  Such documents should be maintained by penal authorities until release of the individual from the penal institution.

12.  VETERANS WITH OTHER THAN HONORABLE DISCHARGES

 The requirements of M-1, Part I, Chapter 4, or appropriate Handbook and Directive, apply to veterans with less than honorable discharges applying for AOR examinations.

13.  CONDUCTING THE PHYSICAL EXAMINATION

 a.  It is essential that a complete medical history, physical examination, and interview be performed and documented on appropriate medical record standard forms, by or under the direct supervision of the RP.  A digital rectal examination (DRE) of the prostate should be included as part of the physical examination of a male veteran, if the veteran makes an informed decision to undergo prostate cancer screening.

 b.  The person actually performing the physical examination will be identified by signature and title (Doctor of Osteopathy (D.O.), Doctor of Medicine (M.D.), Physician's Assistant (P.A.), Nurse Practitioner, etc.).  Examinations completed by someone other than a physician must be completed by medical personnel privileged to do physical examinations.  A physician's countersignature (preferably the RP's) is required on all examinations completed by an individual other than a physician.

 c.  When an AOR examination is done as part of a compensation and pension (C&P) examination, the physical examination will be done by or under the direct supervision of the RP.

 d.  Special attention will be given to those organs and/or systems that may be affected by exposure to herbicides containing Agent Orange.  Particular attention will be paid to:

 (1)  Skin Examination

 (a)  Detection of chloracne, a skin condition which has been associated with acute exposure to Agent Orange and other herbicides containing dioxin; and

 (b)  PCT, a disorder which is characterized by thinning and blistering of the skin in sun-exposed areas (only genetically predisposed individuals have been shown to develop PCT after exposure to dioxin).

 (2)  Soft Tissue Sarcoma

 (3)  Lymph Nodes and Organs

 (a)  Non-Hodgkin's lymphoma, and

 (b)  Hodgkin’s disease.

 (4)  Respiratory System

 (a)  Cancer of the lung,

 (b)  Cancer of the larynx,

 (c)  Cancer of the trachea, and

 (d)  Cancer of the bronchus.

 (5)  Hematologic System and Bone.  Multiple myeloma.

 (6)  Prostate Cancer.  Screening of Vietnam veterans for prostate cancer:

 (a)  “Veterans and Agent Orange:  Health Effects of Herbicides Used in Vietnam (1994),” “Veterans and Agent Orange: Update 1996,” and “Veterans and Agent Orange:  Update 1998,” which are Institute of Medicine (IOM) reports, concluded that there is "limited and/or suggestive evidence of an association" between exposure to herbicides used in Vietnam and the development of prostate cancer.  Because of the provisions of the law and the IOM findings, VA has established a presumption that prostate cancer is related to exposure to herbicides in Vietnam.  As a result of the establishment of this presumption, it is anticipated that many Vietnam veterans will seek advice about screening for prostate cancer.

 (b)  While prostate cancer is one of the most serious malignancies for American men in terms of the number of cases and mortality, the value of performing screening tests on asymptomatic individuals remains controversial.  The medical and scientific evidence supporting various screening tests is far from conclusive and recommendations of major groups regarding prostate cancer screening differ.

 (c)  For instance, DRE has limited sensitivity and specificity for detecting early prostate cancer resulting in many false-positive and false-negative findings.  Conversely serum Prostate Specific Antigen (PSA) is very sensitive for detecting prostate cancer, but it is not very specific, since it may be elevated with benign prostate conditions.  More definitive evaluation of individuals with positive screening tests, such as the performance of transrectal biopsies, carries the risk of morbidity from the procedure as well as causing anxiety for the patient.

 (d)  The ultimate benefit of early detection and treatment of prostate cancer in asymptomatic men is unclear.  Prostate cancer may not become clinically important for many afflicted individuals; surgery and other treatments all carry significant risks of serious complications (including incontinence, impotence, and death) and optimal therapy is uncertain.

 (e)  Clinicians must respond to the values of the individual patient, which are based on the individual patient’s background, experience, and perspective.  Since Vietnam veterans may be eligible for compensation if they are diagnosed with prostate cancer, considerations other than purely clinical issues may be important to them.  Clinicians need to be prepared to explain the available evidence, and deal with patient requests that may diverge from a path based exclusively upon scientific data.

 (f)  If a Vietnam veteran requests a prostate cancer screening exam (DRE, transrectal ultrasound, and/or PSA) after the controversy regarding the value of such testing has been explained to him, it is recommended that the RP honor the veteran's request.

 (7)  Peripheral Nervous System.  Acute and sub-acute peripheral neuropathy.  NOTE:  Peripheral neuropathy has been noted to develop after acute exposure to dioxin; however, there is no evidence that this persists beyond the sub-acute period.

 e.  In gathering medical history data, it is important to determine and record:

 (1)  The time of onset of the veteran’s symptoms or conditions,

 (2)  Intensity,

 (3)  Degree of physical incapacitation, and

 (4)  Details of any treatment received.

 f.  Each veteran will be given the following base line laboratory studies:

 (1)  Chest X-ray (as determined to be medically necessary);

 (2)  Complete blood count;

 (3)  SMA-6, SMA-12, or equivalent blood chemistries and enzyme studies; and

 (4)  Urinalysis

 (5)  Hepatitis C Screening (see Att. A), with the patient’s consent.  NOTE:  Hepatitis C has particular import for VA because of its prevalence in VA’s service population.

 g.  Appropriate additional diagnostic studies will be performed and consultations obtained as indicated by the patient's symptoms, the physical examination, and the laboratory findings.

 h.  Non-routine diagnostic studies, such as sperm counts, will be performed only if medically indicated.

 i.  Laboratory test results must be filed in the CHR.

NOTE:  RPs should not obtain blood or serum and/or adipose tissue for analysis of TCDD.  Surgical procedures will not be performed to obtain tissue for the purpose of TCDD analysis.  Serum dioxin has no clinical value and is currently recommended only as a part of a well-designed research study.

14.  REPORTING REQUIREMENTS

 a.  Code Sheet Submission

 (1)  Reports Control Number 10-0102 applies to this reporting requirement.

 (2)  A monthly submission of VA Form 10-9009 will be made to the AAC, according to the mailing schedule (see App. H).

 (3)  Medical data is not to be attached to the submitted code sheets.

 (4)  One legible copy is to be sent to the AAC, and the original filed in the veteran’s CHR.

 (5)  Code sheets are to be alphabetized by the veteran’s last name.

 (6)  Two copies of VA Form 7252, Transmittal Form for Use in Shipment of Tabulating Data, will be used to transmit code sheets.

 b.  Monthly Statistical Report

 (1)  Submit statistical information using VA Form 7252, as indicated (see example in App. I).

 (2)  The “cumulative count” figure is the total number of veterans who have had registry examinations for the calendar year.

 (3)  Negative Reports.  Negative reports are not required; i.e., if there were no examinations or code sheets processed for the month.

 c.  RP and RC Listings.  Separate listings of the RPs and RCs are maintained by EAS, VHA Headquarters.  In an effort to keep these listings current, facilities are required to notify EAS, VHA Headquarters, in writing, of any changes at their respective facilities and/or satellite clinics.
 

 d.  Forms Acquisition

 (1)  Forms indicated in this handbook may be obtained from the Forms and Publication Depot through local channels.  NOTE:  VA Form 30-7252 has been changed to VA Form 7252.  The form itself has not been revised.

 (2)  Facilities can use either form when submitting reports.  VA Form 10-9009 is available on the Intranet at http://vaww.va.gov/forms/medical/searchlist.asp

15.  RECORDS CONTROL AND RETENTION

 a.  Records Control

 (1)  An CHR will be established if one does not exist.

 (2)  A locator record will be created for the card file.

 (3)  VA Form 10-1079, Emergency Medical Identification, sticker will be affixed to the front of the CHR and the word "Herbicides" circled.

 (4)  The code sheet will be prepared with one copy.

 (a)  The original code sheet and the laboratory test results, progress notes, dated follow-up letters, etc., will be filed in the CHR, and

 (b)  A legible copy of the code sheet will be sent to the AAC in Austin, TX, for entry into the
AOR master record.

 b.  Records Retention.  AOR examination documents become part of the patient’s CHR, i.e.,
medical records, and are retained in accordance with VHA Records Control Schedule (RCS)
10-1.  This includes:

 (1)  VA Form 10-9009,

 (2)  Progress notes,

 (3)  Laboratory reports,

 (4)  Patient locator cards,

 (5)  X-rays,

 (6)  Follow-up letters; and

(7)  Any other documentation that may have been part of an AOR examination.

16.  EDUCATION AND TRAINING

 a.  Current information on the status of the Agent Orange Program is to be presented to VA medical center staff (e.g., at staff conferences or grand rounds), veterans service organizations, and community groups.  NOTE:  This is an excellent means of exchanging ideas in a continuing effort to update and provide quality management of the Agent Orange Program.

 (1)  Historical videotapes may be utilized in orienting new employees, physicians, and any other personnel with this program responsibility.

 (2)  VA Agent Orange Briefs and Agent Orange Reviews, prepared and distributed periodically to all VA facilities by EAS, VHA Headquarters, are another training resource.  Current and back issues of this material are available on-line at http://www.va.gov/agentorange/default.htm.

 (3)  Telephone conferences with VA medical facilities are held periodically by EAS, VHA Headquarters.  NOTE:  Minutes of these telephone conferences, research journal reprints, current Agent Orange Briefs and Reviews and other education items are distributed to all VA facilities by EAS, VHA Headquarters.  In the near future, a Continuing Medical Education (CME) program guide for Agent Orange veterans’ health will be issued.  This will ensure that VA physicians are well informed regarding the latest developments of Vietnam and Korea veterans’ health issues.

 b.  Education and training should ensure the successful accomplishment of the following goals for VHA staff.  They will be able to:

 (1)  Communicate effectively with special program participants by understanding the individual needs of specific groups of veterans.

 (2)  Acquire an in-depth knowledge of the specific processes, designated responsibilities, and time standard requirements of the Agent Orange Program.
 

 

HEPATITIS C:  STANDARDS FOR PROVIDER EVALUATION AND TESTING

1.  Hepatitis C virus (HCV) infection was first recognized in the 1970’s, when the majority of transfusion-associated infections were found to be unrelated to hepatitis A and B, the two hepatitis viruses recognized at the time. This transmissible disease was then simply called “non-A, non-B” hepatitis.  Sequencing of the HCV genome was accomplished in 1989, and the term hepatitis C was subsequently applied to infection with this single strand ribonucleic acid (RNA) virus.  The genome of HCV is highly heterogeneous and, thus, the virus has the capacity to escape the immune surveillance of the host; this circumstance leads to a high rate of chronic infection and lack of immunity to reinfection.  Reliable and accurate (second generation) tests to detect antibody to HCV were not available until 1992, at which time an effective screening of donated blood for HCV antibody was initiated.
 
2.  HCV infection is now recognized as a serious national problem.  Nearly 4 million Americans are believed to be infected, and approximately 30,000 new infections occur annually.  Only about 25 to 30 percent of these infections will be diagnosed.  HCV is now known to be responsible for 8,000 to 10,000 deaths annually, and this number is expected to triple in the next 10 to 20 years.

3.  Hepatitis C has particular import for the Department of Veterans Affairs (VA) because of its prevalence in VA’s service population.  For example, a 6-week inpatient survey at the VA Medical Center, Washington, DC, revealed a prevalence of 20 percent antibody positivity.  A similar investigation at the VA Medical Center, San Francisco, CA, found 10 percent of inpatients to be antibody-positive.  Veterans Health Administration (VHA) Transplant Program data reveal that 52 percent of all VA liver transplant patients have hepatitis C.  An electronic survey of 125 VA medical centers, conducted by the Infectious Disease Program Office from February through December of 1997, identified 14,958 VA patients who tested positive for hepatitis C antibody.  Clearly, HCV infection is becoming a leading cause of cirrhosis, liver failure, and hepatocellular carcinoma.  The incidence and prevalence rates are higher among nonwhite racial and ethnic groups.

4.  HCV is transmitted primarily by the parenteral route.  Sources of infection include transfusion of blood or blood products prior to 1992, injection drug use, nasal cocaine, needlestick accidents, and, possibly, tattooing.  Sexual transmission is possible, and while the risk is low in a mutually monogamous relationship, persons having multiple sexual partners are at higher risk of infection.

5.  After infection, 90 percent of HCV infected patients will develop viral antibodies within 3 months.  The disease becomes chronic in 85 percent of those infected, although one-third will have normal aminotransferase levels.  The rate of progression is variable, and chronic HCV infection leads to cirrhosis in at least 20 percent of infected persons within 20 years; 1 to 5 percent of those infected will develop hepatocellular carcinoma.

6.  At present, treatment for HCV infection is limited, consisting primarily of administration of interferon alpha, with or without the addition of ribavirin. The treatment benefits some patients and appears to alter the natural progression of the disease, although evidence is lacking that it will translate into improvements in quality of life or reduction in the risk of hepatic failure.  Current regimens include the use of 6 or 12-month courses of interferon alpha, with or without ribavirin.  The recent National Institutes of Health Consensus Statement on Hepatitis C concluded that liver biopsy should be performed prior to initiating treatment.  If little liver damage is apparent, therapy need not be initiated; treatment is probably appropriate for those with significant histologic abnormalities.  However, data presented at this Consensus Conference indicated that significant uncertainty remains regarding indications for treatment.

7.  A number of serologic tests are available for diagnosis and evaluation of HCV infection.  Enzyme immunoassays (EIA) are “first line” tests, and are relatively inexpensive.  They contain HCV antigens and detect the presence of antibodies to those antigens.  Recombinant immunoblot assays (RIBA) contain antigens in an immunoblot format, and are used as supplemental or confirmatory tests.  Viral RNA can be detected by reverse-transcription polymerase chain reaction (PCR) testing.  Quantitative HCV RNA testing uses target amplification PCR or signal amplification (branched deoxyribonucleic acid (DNA)) techniques.

8.  The EIA tests have sensitivities in the range of 92 to 95 percent.  Specificities depend on the risk stratification pre-testing.  That is, in blood donors with no risk factors, 25 to 60 percent of positive EIA are also positive by PCR for viral RNA.  About 75 percent of low risk donors with positive EIA and RIBA will be positive by PCR.  Positive EIA tests should be confirmed by RIBA.  If that is also positive the patient has, or has had, HCV infection.  In high-risk patients who are EIA positive, particularly if there is evidence of liver disease, supplemental testing with RIBA or HCV RNA analysis is probably unnecessary.  Quantitative RNA tests may be useful in the selection and monitoring of patients undergoing treatment.

9.   All patients will be evaluated with respect to risk factors for HCV, and this assessment documented in the patient’s chart.  Based upon those risk factors, antibody testing should be utilized as elaborated in the following algorithm.
 
HEPATITIS C VIRUS ANTIBODY SCREEENING
FOR THE VETERAN POPULATION
HISTORY OF POSITIVE TEST FOR
HEPATITIS C VIRUS ANTIBODY
 
 

YES                                                                                   NO
 

PRESENCE OR HISTORY OF ANY OF THE FOLLOWING:
 
1. Transfusion of blood or blood products prior to 1992
2. Injection illicit drug use - past or present – any number of injections – skin or intravenous site
3. Unequivocal blood exposure on or through skin or mucous membrane – medical worker, combat casualty care, needlestick injury
4. Multiple sexual partners – past or present
5. Hemodialysis
6. Tattoo or repeated body piercing
7. Intranasal cocaine use – past or present
8. Unexplained liver disease
9. Unexplained abnormal ALT value
10. Intemperate alcohol use
  11.  Vietnam veterans

YES      NO

   Low priority for HCV antibody screening; not
Recommend:                                                 recommended unless at patient’s request

1.  Counseling for risk behavior
2.  Screening HCV antibody (e.g., EIA)
3.  Measure ALT if not yet done
 

HCV antibody positive                                       HCV antibody negative

Perform confirmatory test (e.g., RIBA)
if low-risk patient or normal ALT
 

Test positive                            Test negative

Patient unlikely to have true positive HCV antibody  Repeat testing based on individual risk

Individual patient care decisions
regarding counseling, further testing
and potential treatment options are
necessary.  These should be based upon
current literature or performed within
approved research protocols
 
 
SAMPLE AGENT ORANGE FOLLOW-UP LETTER
 (MEDICAL PROBLEMS INDICATED)
(VIETNAM VETERANS)

(Date)
(Name/Address)

Dear:

 We are happy that you have chosen to participate in the Department of Veterans Affairs (VA) Agent Orange Registry.  This effort should prove to be helpful in assisting us to serve you and other veterans who are concerned about the possible health problems which might have resulted from military service in the Republic of Vietnam during the Vietnam era (between 1962 and 1975).

 As discussed at the conclusion of your visit, results of your examination and laboratory tests showed certain problems (optional-- these findings may be described in lay terms).  In view of these findings, we have scheduled you for treatment of these health problems on (  date).  If for any reason you cannot keep this appointment, please call (  phone number  ) at the earliest possible time to cancel and reschedule.)

 The results of your examination will be maintained by VA.  If you have any questions or concerns about your Agent Orange Registry examination, please contact the Registry Coordinator at (  phone number  ).

 If a non-VA physician subsequently evaluates you, you are encouraged to provide VA with any additional diagnoses.  This information will be included in your medical record as well as the Agent Orange Registry.

 Please remember that this examination does not automatically initiate a claim for VA benefits.  If you wish to file a claim for compensation to establish possible service-connection, please contact your nearest VA Regional Office.  In your area, the Regional Office is located at (  address  ).  Their telephone number is ( phone number  ).  Compensation claims need not be filed specifically for injury or illness incurred in combat; the law requires only that a disease or disability was incurred or aggravated during military service.  If you need any further assistance, you may contact a Veterans Benefits Counselor by calling the VA toll-free telephone number 1-800-827-1000.

 An outreach program has been implemented in which VA notifies all individuals listed in the Agent Orange Registry of significant VA activities, including the health consequences of military service during the Vietnam era.  Since you are now automatically included in our Agent Orange Registry, you will be receiving an "Agent Orange Review" published periodically by VA's Environmental Agents Service.  If you have a change of address, please contact the Registry Coordinator at this medical center.

 We trust this information is helpful to you.  Once again, your participation in the Agent Orange Registry is appreciated.
 

  Sincerely,

  ___________(Name)__________
   Agent Orange Registry Physician

 

NOTE:  If the veteran is not eligible for VA treatment (e.g., not enrolled for VA health care) we recommend the following follow-up letter for Korea veterans.

SAMPLE AGENT ORANGE FOLLOW-UP LETTER
 (MEDICAL PROBLEMS INDICATED)
(KOREA VETERANS)
 

(Date)
(Name/Address)

Dear:

 We are happy that you have chosen to participate in the Department of Veterans Affairs (VA) Agent Orange Registry.  This effort should prove to be helpful in assisting us to serve you and other veterans who are concerned about the possible health problems which might have resulted from military service in Korea (1968 or 1969).

 As discussed at the conclusion of your visit, results of your examination and laboratory tests showed certain problems (optional-- these findings may be described in lay terms).  Since you are not currently eligible for VA treatment, we recommend that you apply for enrollment in VA health care, or contact your private physician as soon as possible to provide the necessary health care.  We will be pleased to discuss your medical problems with this individual and provide copies of your medical records to confirm our diagnosis.   Also, the results of your examination will be maintained by VA.  If you have any questions or concerns about your Agent Orange Registry examination, please contact me at (   phone number  ).

 You may contact the Agent Orange Registry Coordinator at  (   phone number   ) for information on how to enroll.

 If a non-VA physician subsequently evaluates you, you are encouraged to provide VA with any additional diagnoses.  This information will be included in your medical record as well as the Agent Orange Registry.

 Please remember that this examination does not automatically initiate a claim for VA benefits.  If you wish to file a claim for compensation to establish possible service-connection, please contact your nearest VA Regional Office.  In your area, the Regional Office is located at (  address  ).  Their telephone number is (  phone number  ).  Compensation claims need not be filed specifically for injury or illness incurred in combat; the law requires only that a disease or disability was incurred or aggravated during military service.  If you need any further assistance, you may contact a Veterans Benefits Counselor by calling the VA toll-free telephone number 1-800-827-1000.

 An outreach program has been implemented in which VA notifies all individuals listed in the Agent Orange Registry of significant VA activities, including the health consequences of military service in Korea.  Since you are now automatically included in our Agent Orange Registry, you will be receiving an "Agent Orange Review" published periodically by VA's Environmental Agents Service.  If you have a change of address, please contact the Registry Coordinator at this medical center.

 We trust this information is helpful to you.  Once again, your participation in the Agent Orange Registry is appreciated.
 

  Sincerely,

  ___________(Name)__________
   Agent Orange Registry Physician
 
 

 

SAMPLE AGENT ORANGE FOLLOW-UP LETTER
 (NO MEDICAL PROBLEMS)
(VIETNAM OR KOREA VETERANS)

(Date)
(Name/Address)

Dear              :

 We are happy that you have chosen to participate in the Department of Veterans Affairs (VA) Agent Orange Registry Program.  This effort should prove to be helpful in assisting us to serve you and other veterans who are concerned about the possible health problems which may have resulted from exposure to Agent Orange while serving in Korea (1968 or 1969) and/or the Republic of Vietnam during the Vietnam era (between 1962 and 1975).

 As discussed at the conclusion of your visit, results of your examination and laboratory tests indicate that there are no detectable medical problems.  At this time you have no reason to be concerned about any adverse health effects resulting from your service in Vietnam and/or Korea.  However, in the future if you have a medical problem, I would encourage you to seek the help and advice of your nearest VA medical center or outpatient clinic.  You may reach us at telephone number (  phone number  ).

 The results of your examination will be maintained by VA.

 If a non-VA physician subsequently evaluates you, you are encouraged to provide VA with any additional diagnoses.  This information will be included in your medical record as well as the Agent Orange Registry.
 
 An outreach program has been implemented in which VA notifies all individuals listed in the Agent Orange Registry of significant VA activities, including research on the health consequences of military service in Korea and/or the Republic of Vietnam during the Vietnam era.  Since you are now included in our Agent Orange Registry, you will be receiving an "Agent Orange Review" which is published periodically by VA's Environmental Agents Service.  If you have a change of address, please contact the Registry Coordinator at this medical center.

 We trust this information is helpful to you.  Once again, your participation in the Agent Orange Registry is appreciated.

  Sincerely,

  ___________(Name)__________
   Agent Orange Registry Physician
 

DEFINITIONS AND ACRONYMS

1.  Austin Automation Center (AAC).  The AAC is the location in Austin, TX, where code sheets are collected and entered into the computerized registry.

2.  Agent Orange.  Agent Orange is a term used to describe a herbicide or defoliant, used in Vietnam and Korea.  It was composed of two active ingredients, 2,4-D and 2,4,5-T.  The name "Agent Orange" came from the orange stripe on the storage drums.

3.  Agent Orange Master Record Type (MRT).  The MRT is generated on microfiche by the automated Agent Orange system after processing of the code sheets (transactions) submitted by facilities to the AAC.

4.   Automated Management Information System (AMIS).

5.  Agent Orange Registry (AOR).  The AOR is a computerized index of veteran participants, and the coded findings of the Agent Orange Program physical examinations, including related diagnostic results.  This AOR is managed centrally by the Environmental Agents Service (EAS) in the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Headquarters and entered into a database by the AAC.

6.  Chief of Staff  (COS).

7.  Consolidated Health Record (CHR).  The CHR is a file containing medical records relating to patient identity, diagnosis, prognosis, or treatment at a VA health care facility.

8.  Defoliant.  A defoliant is a chemical preparation used to defoliate plants.

9.  Defoliate.  Defoliate means to lose leaves or to strip off leaves; to destroy an area of jungle, forest, etc., by chemical sprays in order to remove places of concealment of enemy forces.

10.  Department of Defense (DOD).

11. Department of Veterans Affairs (VA).

12.  Digital Rectal Examinations (DRE).

13.  Dioxin (2,3,7,8-tetrachlorodibenzo-para-dioxin; also abbreviated TCDD).  Dioxin is an impurity created in the manufacturing process for producing Agent Orange.

 14.  Demilitarized Zone (DMZ)

 15.  Doctor of Osteopathy (D.O.).
 

16.  Doctor of Medicine (M.D.).

17.  DOD Form 2161, Referral for Civilian Care.

18.  Environmental Agents Service (EAS).  The EAS, VHA Headquarters, has the responsibility to coordinate and monitor all Veterans Health Administration activities, research and otherwise, relating to the Agent Orange issue.  All policy and clinical questions relating to the potential effects of herbicides should be referred to this office.  NOTE:   Questions relating to eligibility of veterans or treatment of active duty personnel should be referred to the Health Administration Service (10C3), VHA Headquarters.

19.  Facility.  A facility is a VA entity that provides AOR examinations to Vietnam veterans or veterans who served in Korea in 1968 or 1969.

20.  Follow-up Examination.  The follow-up examination is an examination that is performed subsequent to the initial (first) examination and offered to both Vietnam and Korea veterans.  Copies of code sheets for the first follow-up examinations are to be submitted to the AAC.  Code sheets for subsequent follow-up examinations, if performed, do not have to be submitted to the AAC unless there is a change to the diagnosis.

21.  Health Administration Service (HAS).

22.  Herbicide.  A herbicide is a substance or preparation used to destroy vegetation.

23.  Initial Examination.  The initial examination is the first physical examination provided to eligible Vietnam veterans or veterans who served in Korea in 1968 or 1969.  Completed copies of code sheets for this examination are sent to the AAC for the purpose of entering a veteran into the AOR system.  The original code sheet is filed in the veteran’s CHR.

24.  Non-Service Connected (NSC).

25.  National Academy of Sciences (NAS).

26.  Nurse Practitioner (NP).

27.  Patient Treatment File (PTF).

28.  Physician's Assistant (P.A.).

29.  Porphyria Cutanea Tarda (PCT).  PCT is a liver disorder characterized by thinning and blistering of the skin in sun-exposed areas.

30.  Prisoner of War (POW).

31.  Registry Coordinator (RC).  The RC is the individual (non-physician) responsible for administrative management of the Agent Orange Program at each VA medical facility.

32.  Registry Physician (RP).  The RP is the physician responsible for clinical management of the Agent Orange Program at each VA medical facility.

33.  Records Control Schedule 10-1 (RCS 10-1).  The RCS 10-1 is a document supplying information regarding Veterans Health Administration record retention and disposition.

34.  2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD).  TCDD is an abbreviation for the dioxin, a contaminate of some herbicides used in the Republic of Vietnam and on a strip of land just south of the demilitarized zone (DMZ) and north of the Civilian Control Line in Korea.

35.  The International Classification of Diseases - 9th Edition, Clinical Modification (ICD-9-CM).  The ICD-9-CM provides standardized classification of diseases.

36.  Toxicity.  Toxicity is the relative or specific degree of being harmful.

37.  Service connected (SC).

38.  Social Security Number (SSN).

39.  Form 10-9009 (July 2000), Agent Orange Registry Code Sheet.  Formerly VA Form 10-9009 (January 1994).

40.  VA Form 7252.  The VA Form 7252, May 1989, is the transmittal form for use in shipment of tabulating data.  NOTE: VA Form 7252, May 1989was previously numbered VA Form 30-7252.

41.  Veterans Benefits Administration (VBA).

42.  Veterans Benefits Counselor (VBC).

43.  Veterans Health Administration (VHA).

44.  Veterans Integrated Service Network (VISN).

 

INSTRUCTIONS FOR COMPLETING VA FORM 10-9009 (July 2000)
 AGENT ORANGE REGISTRY CODE SHEET

1.  General Instructions for Completing VA Form 10-9009 (July 2000)

 a.  A legible copy of the original code sheet must be prepared and submitted to the Austin Automation Center (ACC), Austin, TX, in the initial and the first follow-up examinations (if required).  The original code sheet will be filed in the medical record after verification for correctness by the AAC.  Additional follow-up examinations, as required, will continue to be documented and filed in the Consolidated Health Record (CHR).  A code sheet will be prepared for the first follow-up examination and a copy submitted to the AAC.  All subsequent code sheets for follow-up examinations will not be submitted to the AAC, with unless a diagnostic code differs from previously submitted code sheets.  In that case, a code sheet will be prepared and submitted for entry into the Agent Orange Registry (AOR).

 b.  Print clearly using a BLACK ballpoint pen or a BLACK felt-tipped pen.  Follow instructions carefully to ensure that all data fields are accurately completed.  Enter one letter or number per block.  The numeric zero must be slashed "0."  For registry coding purposes, use the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) codes.

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

 (2)  Part II of the code sheet should be completed at the time of the examination by the Registry Physician (RP).  A completed Part II will be returned to the coding clerks or other appropriate staff for assignment of the ICD-9-CM codes to Items 22, 28-29.

NOTE:  Careful attention should be paid to assigning the correct code for both complaints (Item 22) and diagnosis (Items 28-29).  Code 78999, for uncodable complaints (symptoms), is to be assigned only after all coding possibilities have been thoroughly explored.  The indiscriminate use of 78999 may result in skewed or misleading statistics of minimal value.

2.  Instructions for Completing Part I

 Item 1.  Facility Number and Suffix - Blocks 2 –7.  Enter facility code as listed in MP-6, Part XVI, Supplement Number 4.1, Appendix A.  Use the Automated Management Information Systems (AMIS) suffix (BY, BZ, etc) to indicate your satellite facility.  DO NOT USE Q, R, S.

 Item 2.  Last Name of Veteran - Blocks 8-33.   Beginning in Block 8, enter veteran's last name.  Do not use accent marks in the name or skip blocks between the letters of the last name.  Skip a block if the last name is followed with a suffix, such as JR, SR, I, II, III, etc.

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

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

 Item 5.  Type of Exam - Block 59.  The following transaction type should be entered in Block 59 as appropriate:

 A = Initial examination.  Veteran's first Agent Orange examination.

 B = To delete an entire initial examination with a noted error, after it has been accepted into the registry, resubmit to the AAC a copy of the original code sheet, white-out the “A” in Block 59 and replace it with a "B."  When you are assured that the initial examination data has been deleted from the registry database, submit another code sheet with the correct information with an "A."  All fields must be completed on a resubmission.  The code sheets may be shipped in the same batch.  Examples of this usage are incorrect diagnosis, military statistics, Social Security Number (SSN), etc.

 C = Follow-up examination.  Veteran's second Agent Orange examination.  A copy of the code sheet for first follow-up examination must be submitted to the AAC.  Additional follow-up examinations, as required, will continue to be documented in the CHR, and a code sheet will not be prepared or submitted to the AAC with the following exception: if a diagnostic code differs from previously submitted code sheets, then a code sheet should be prepared and submitted for entry into the AOR.

NOTE:  Consultations relating to the initial or first time examination are not considered follow-up examinations for the purpose of this registry.

 D = To delete an entire follow-up examination with a noted error, after it has been accepted into the registry, resubmit a copy of the original code sheet, white-out the “C” code in Block 59, replacing it with a "D."  When you are assured that these data have been removed from the AAC registry database, submit another code sheet with the correct information with a "C."  All fields must be completed on resubmission.

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

 I = To include those veterans whose names are not on the AOR but who would like their names and addresses included on a mailing list for the “Agent Orange Review.”

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

 
 Item 6.  SSN - Blocks 60-69

 a.  Shaded Block 60 is to be used ONLY if a pseudo SSN is being submitted.  In this event, the letter "P" will be entered in Block 60.  The AAC will enter the pseudo SSN.  Leave Block 60 blank when the actual SSN is used.
 b.  Beginning in Block 61 enter the veteran's actual SSN.

NOTE:   See MP-6, Part XVI, Supplement Number 41, Chapter 2, for instructions on pseudo SSN assignment.

 Item 7.  Service Serial Number - Blocks 70-79.  Beginning in Block 70 enter the Service Serial Number.  Unused blocks remain blank.  If the serial number begins with "US" Blocks 72-79 must be completed.  Fill unused block(s) with "0" for this instance only.  If the serial number is unknown, enter a "U" in Block 70.  Unused blocks remain blank.

 Item 8.  Date of Birth - Blocks 80-87.  Beginning in Block 80 enter numerical equivalent for the month, day and 4 digit year (e.g., 01/19/1950).  All blocks must be completed.

 Item 9.  Permanent Address.- Blocks 88-153

 a.  Blocks 88-113. Beginning in Block 88 enter veteran's permanent street address.

 b.  Blocks 114-139.  Beginning in Block 114 - Enter veteran's city or town.

 c.  Blocks 140-144.  Enter ZIP Code of permanent residence (National ZIP Code Directory).

 d.  Blocks 145-148.  Remain blank.  (Future extended ZIP Code)
 
 e.  Blocks 149-151.  Enter appropriate county code as listed in VHA Manual M-1, Part I, Chapter 18, Appendix A or appropriate Handbook and Directive.

 f.  Blocks 152-153.  Enter appropriate State code (see VHA Manual M-1, Pt. I, Chapter 18, App. A) or appropriate Handbook and Directive.

 Item 10.  Race and/or Ethnicity - Block 154.  Enter one of the following codes in Block 154:

 1 = American Indian or Alaskan Native
 2 = Asian or Pacific Islander
 3 = Black, Not of Hispanic Origin
 4 = White, Not of Hispanic Origin
 5 = Hispanic
 6 = Unknown

 Item 11.  Marital Status - Block 155.  Enter one of the following codes in Block 155:

 1 = Married
 2 = Divorced
 3 = Separated
 4 = Widowed
 5 = Single, Never Married

 Item 12.  Sex - Block 156.  Enter one of the following codes in Block 156:

 M = Male
 F = Female

 Item 13.  Current status - Block 157.  Enter one of the following codes in Block 157:

 1 = Inpatient
 2 = Outpatient
 3 = Incarcerated
 4 = Active Duty, Inpatient
 5 = Active Duty, Outpatient

 Item 14.  Branch of Service - Block 158.  If the veteran was in one of the following branches of service, enter the appropriate code.  If the veteran served in more than one branch of service which includes either Code 1 (Army) or Code 4 (Marine Corps) enter 1 or 4, otherwise retain previous code.  If the veteran served both in the Army and Marine Corps, enter the code for the service in which the veteran had the longer duration of duty in Vietnam.  If veteran served in Korea in 1968 or 1969, use Code 6 = Other.

 1 = Army
 2 = Air Force
 3 = Navy
 4 = Marine Corps
 5 = Coast Guard
 6 = Other

 Item 15, 15A, and 15B.  Military Service in Vietnam or Korea - Blocks 159

 A.  Enter one of the following codes in Block 159:

 Code: 1= Vietnam

 Code 2 = Korea (1968 or 1969)

 Code 3 = Both

 Code 4 = Neither.  NOTE:  If the veteran did not serve in Vietnam or Korea, the veteran is not eligible for an Agent Orange examination.

 B.  Item 15A - Enter the numerical equivalent of the month and the last four-digit year of first longest period of service in Vietnam (e.g., from 02/1968 to 09/1969) or Korea ( e.g. 1/1968 to 12/1969) in Blocks 160 through 171.

 C.  Item 15B - If the veteran had two or more periods of service in Vietnam or Korea, the second longest period of service should be entered in Blocks 172 through 183.  If only one period of service in Vietnam or Korea, enter in 15A and leave 15B blank.

 Item 16.  In What Corps or Area Did the Veteran Serve - Block 184-189.  Enter one of the following codes in Blocks 184-189:  (Use “Y” in Block 189 (Code 6 = Other) for Korea and list area(s) under Item 33 “Remarks.” )

 Y = Yes, N = No or U = Unknown

 (1)  Block 184 =    I Corps
 (2)  Block 185 =    II Corps
 (3)  Block 186 =    III Corps
 (4)  Block 187 =    IV Corps
 (5)  Block 188 =    Sea Duty
 (6)  Block 189 =    Other (If “Y”is entered in Block 189, list the other area(s) under Item 33  “Remarks.”

 Item 17.  Military Units.   Enter the military unit in which the veteran served in Vietnam and/or Korea. Specify complete unabbreviated title, i.e., company, battalion, corps, ship, division, etc. (e.g., Company C, lst Battalion, 4th Army).

 Items 18, 18A and 18B.  Last Two Periods of Service - Blocks 190-213.  Enter the numerical equivalent of the month and the four digit year of the last two periods of service if other than Vietnam or Korea (e.g., from 11/1967 to 11/1969 and 10/1965 to 10/1967).  If the veteran did not have more than one period of service, leave 18B blank.

 Items 19, 19a -19e.  Exposure to Agent Orange - Blocks 214-218.  Enter one of the following codes in Items A through E, Blocks 214-218, that most appropriately describes the veteran's exposure to Agent Orange.  All blocks must be completed.

 1 = Definitely yes
 2 = Not sure
 3 = Definitely no

 A.  I was involved in handling or spraying Agent Orange.
 B.  I was not directly sprayed but was in a recently sprayed area.
 C.  I was exposed to herbicides other than Agent Orange
 D.  I was directly sprayed with Agent Orange.
E. I ate food or drink that could have been sprayed with Agent Orange.

Item 20.  Veteran's Health - Block 219.  Enter one of the following codes in Block 219 which best describes how the veteran perceives the veteran's own health status:

 1 = Very good
 2 = Good
 3 = Fair
 4 = Poor
 5 = Very poor

3.  Instructions for Completing Part II.   Information coded by coding clerks or other designated personnel needs to be done in conjunction with that indicated by the RP in Part II, Items 22a-c, 28a-c, and 29.

 Item 21.  Date of Exam - Blocks 220-227.  Enter the numerical equivalent for the month, day, and year (e.g., 09/22/1986).  All blocks must be completed.

 Item 22.  Veteran's Complaints - Blocks 228-242

 A.  Lines 22a-c. - Provide a narrative of the veteran's three major complaints.

 B.  Lines 22a-c - Blocks 228-242 are to be used for coding purposes.  For uncodeable symptoms, use "78999" only when all other ICD-9-CM codes have been thoroughly researched and the ICD9 code book referenced.  If there are no known complaints, use "78000".  NOTE:  Coding will be completed by coding clerks or designated personnel.

 C.  Lines 22d.  List any additional complaints which are not listed in 22 a-c.  No ICD-9-CM codes are required.

 Item 23.  Chief Complaint - Block 243.  Enter one of the following codes if the veteran attributes chief complaint to Agent Orange Exposure:   Y = Yes      N = No     U = Unknown

 Item 24.  Number of Complaints - Blocks 244-245.  Enter the total number of complaints the veteran has indicated.  This number does not have to correlate to the three complaints described in Item 22.  If the veteran has no complaints, enter a "0" and make certain that "78000" is entered in Item 22a, Blocks 228-232.

 Item 25.  Evidence of Birth Defects among the Vietnam Veteran’s Children - Blocks 246-267 (This section does not apply to those veterans who served in Korea in 1968 or 1969.)
 
 Item 25A.   How many children does veteran have? -  Blocks 246-247.  Enter the number of children the veteran has in Blocks 246-247.  If none, enter slash zeros and go to Item 26.
 Item 25B.  How many of these children were born before the veteran’s military service in the Republic of Vietnam?    Blocks 248-249.  in Blocks 248-249.  If none, enter slash zeros and go to Item 25G.

 Item 25C.  How many of the children born before the veteran’s military service in the Republic of Vietnam showed evidence of spina bifida?   Blocks 250-251.  Enter the number of children born before the veteran’s military service in the Republic of Vietnam who showed evidence of spina bifida in Blocks 250-251.  If none, enter slash zeros and go to Item 25E.

 Item 25D.  State mother’s age at conception of first child conceived before the veteran’s military service in the Republic of Vietnam showing evidence of spina bifida.  Blocks 252-253.  If  a veteran has a child (ren) conceived before the veteran’s military service in the Republic of Vietnam who showed evidence of spina bifida (Item 25C), enter the mother’s age at conception of the first child with spina bifida in Blocks 252-253.
 
 Item 25E.  How many of the children born before the veteran’s military service in the Republic of Vietnam showed evidence of other birth defects?  Blocks 254-255.  Enter the total number of children born before the veteran’s military service in the Republic of Vietnam  who showed evidence of other birth defects in Blocks 254-255.  If none, enter slash zeros and go to Item 25G.

 Item 25F.  State mother’s age at conception of first child conceived before the veteran’s military service in the Republic of Vietnam showing evidence of other birth defects.  Blocks 256-257.  If the veteran has a child or children conceived before the veteran’s military service in the Republic of Vietnam who showed evidence of other birth defects (Item 25E), enter the mother’s age at conception of the first child conceived with birth defects in 256-257.

 Item 25G.  How many children were born during or after the veteran’s military service in the Republic of Vietnam?  Blocks 258-259.  Enter the total number of children that were born during or after the veteran’s military service in the Republic of Vietnam in Blocks 258-259.  If none, enter slash zeros and go to Item 26.

 Item 25H.  How many of these children born during or after the veteran’s military service in the Republic of Vietnam showed evidence of spina bifida?  Blocks 260-261.  Enter the total number of children born during or after the veteran’s military service in the Republic of Vietnam who showed evidence of spina bifida in Blocks 260-261.  If none, enter slash zeros, and go to Item 25J.

 Item 25I.  State mother’s age at conception of first child conceived during or after the veteran’s military service in the Republic of Vietnam showing evidence of spina bifida.   Blocks 262-263.  If veteran has a child or children born during or after the veteran’s military service in the Republic of Vietnam who showed evidence of spina bifida (Item 25H), enter the mother’s age at conception of first child showing evidence of spina bifida in Blocks 262-263.

 Item 25J.  How many of the children born during or after the veteran’s military service in the Republic of Vietnam showed evidence of other birth defects?  Blocks 264-265.  Enter the total number of children born during or after the veteran’s military service in the Republic of Vietnam who showed evidence of other birth defects in Blocks 264-265.  If none, enter slash zeros and go to Item 26.

 Item 25K.  State mother’s age at conception of first child conceived during or after the veteran’s military service in the Republic of Vietnam showing evidence of other birth defects.  Blocks 266-267.  If  a veteran has a child or children born during or after the veteran’s military service in the Republic of Vietnam who showed evidence of other birth defects (Item 25J), enter the mother’s age at conception of first child showing evidence of other birth defects in Blocks 266-267.

 Item 26.  Diagnostic Workup/Consultation - Blocks 268-275.  Enter one of the following codes in Blocks 268-275 - all blocks must be completed:

 1 = No workup.  No consultation done.
 2 = Work-up and/or consultation done.  Diagnosis undetermined.
 3 = Work-up and/or consultation done.  Diagnosis established.
 4 = Work-up and/or consultation done.  No diagnosis.
 5 = Work-up and/or consultation in process.  When consultation results have been received, submit follow-up examination code sheet to the AAC within 3 months, stating the work-up and/or consultation is done using Code 2, 3, or 4.
 6 = Work-up and/or consultation scheduled – veteran no-showed.

NOTE:  Code 2 = “Diagnosis undetermined” relates to a veteran with symptoms but a diagnosis cannot be determined.  Code 4 =  “No diagnosis” relates to a veteran without symptoms, who does not have any evidence of illness or other medical condition.

 Item 26A.  Dermatology.     Block 268

 Item 26B.  Pulmonary.         Block 269

 Item 26C.  Reproductive Health.    Block 270

 Item 26D.  Hematology and/or Oncology.   Block 271

 Item 26E.  Urology.   Block 272

 Item 26F.  Neurology.   Block 273

 Item 26G.  ENT.   Block 274

 Item 26H.  Other.    Block 275

NOTE:  Enter either Y=Yes or N= No in Block 275.  If “Yes,” describe under Item 27.

 Item 26 I.  Hepatitis C Screening.  With patient’s consent and consistent with standards for provider evaluation and testing provided in Appendix A.
 
     Use the following codes in Block 276:

 P = Positive      Block 276
 N = Negative
 X = No Screening Performed

 Item 27.  Additional Work-ups and/or Consultations.  Specify any additional work-ups and/or consultations performed as part of Agent Orange examination which were not listed in Item 26.

 Item 28.  Diagnosis - Blocks 277-291

 A.  Provide a narrative of up to 3 major medical diagnoses on lines 28A-C.  Use Blocks 293-297, Item 29, for one case of neoplasia and Blocks 277-291 for any additional cases of neoplasia.

 B.  Blocks 277-291 are to be used for ICD-9-CM coding of each diagnosis listed.  Leave blank if there is no diagnosis.  NOTE:  Diagnostic coding assignment will be completed by coding clerks or designated personnel.

 Item 29.  Evidence of Neoplasia - Block 292.  Enter one of the following codes:

 Y = Yes
 N = No

NOTE:  If yes, ICD-9-CM codes should be listed in Blocks 293-297.  Additional cases of neoplasia may be listed under Item 28, Blocks 277-291.

 Item 30.  No Disease Found - Block 298.  If no disease is found, enter a "1" in Block 298.  Otherwise, leave this block blank.  This item must be considered in conjunction with Item 28, "Diagnosis," and 29, “Evidence of Neoplasia.”   A "1" should be entered for Item 30 only when no diagnosis is given in Item 28 and 29.

 Item 31.  Years of Onset - Blocks 299-314.  For each listed diagnosis in Item 28, enter the four digits of the year of onset; leave blank if year of onset is unknown.

 Items 32a-g.  Disposition - Blocks 315-321.  Enter one of the following codes in Items 32A through 32G, Blocks 315-321, all blocks must be completed:

 Y = Yes
 N = No
 
 A.  Examination completed?
 B.  Hospitalized at VA medical center for further tests?
 C.  Hospitalized at VA medical center for treatment?
 D.  Referred for VA outpatient care?
 E.  Referred to private physician, non-VA clinic or non-VA hospital?
 F.  Biopsy?
 G.  Specimens to be sent to Armed Forces Institute of Pathology (AFIP)?
 
NOTE:  If the veteran has no diagnoses (Items 28-29) and has answered "Yes" under Item 32 (Disposition) in Blocks 317, 318 or 319, explain why in Item 33, "Remarks."

 Item 33.  Remarks  - Block 322.  Utilize this section for any additional information.  Indicate whether you have made any remarks by entering one of the following codes in Block 322:  Y=Yes or N=No.

 Item 34.  Name of Examiner - Print full name.

 Item 35.  Title of Examiner - Full title of Examiner.

 Item 36.  Signature of Examiner - Signature of clinician who conducted exam.

 Item 37.  Signature of Registry Physician.  If the examiner is not the Registry Physician (Item 36), this signature block should be completed by the Registry Physician.

4.  Follow-up Examinations

 a.  In addition to initial registry submissions, VA Form 10-9009 (July 2000), will be completed in reporting the first follow-up examination, and subsequent follow-up examinations if the diagnostic code is different from the previous examinations as follows:

 Items 1 through 13 - these Control Data must be completed.

 Items 14 through 20 - no entry.

 Item 21 - must be completed.

 Items 22 through 33 - may be blank unless there is follow-up data to report in any of these items.

 Items 34 through 36 - must be completed.

 b.  When the follow-up examination is documented on the revised code sheet (July 2000) for a veteran who previously received an initial and/or follow up examination (i.e., recorded on the previous code sheets 1979 through 1994), every attempt should be made to obtain and record the information to complete Items 14 through 20.
 

SAMPLE OF COMPLETED VA FORM 10-9009 (July 2000)
AGENT ORANGE CODE SHEET
 
 

Below is an embedded copy of VA Form 10-9009.  This form can also be found on the VHA Forms Intranet at http://vaww.va.gov/forms/medical/searchlist.asp.  Since this can be used for local reproduction, it has not been completed.
 
 

 
 

 

 
 

 

INSTRUCTIONS FOR PROCESSING CODE SHEETS
 

 1.  Submission of VA Form 10-9009 (July 2000), Agent Orange Registry Code Sheet, to the Austin Automation Center (AAC).  Completed, legible copies of code sheets are submitted to the AAC to be entered into the Agent Orange Registry (AOR).  Code sheets should be thoroughly reviewed to ensure all the required fields are completed.  No medical record documentation is to be attached to these code sheets.

 2.  Batching of Code Sheets

 a.  Code sheets should be stapled in the upper-left hand corner.  Completed code sheets will be batched in groups of no more than 25.  Divisions of a consolidated facility must keep submissions separate, i.e., each batch will include code sheets from one facility.

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

 c.  If a veteran has had two examinations within the same mailing period, that is, an initial and follow-up examination, only the initial examination code sheet should be submitted in the batch.  Hold the follow-up examination code sheet until it is certain the AAC has processed and accepted the initial examination code sheet.  NOTE:  If submitted simultaneously, an error message may occur (see par. 6).

 3.  Transmittal Form

 a.  Two copies of the VA Form 7252, Transmittal Form for the Use in Shipment of Tabulating Data, will accompany each batch of code sheets.  One copy will be retained by the AAC and the other copy will be returned to the transmitting facility to confirm receipt.

 b.  If there were no exams and/or code sheets processed for the month, negative reports or transmittal forms are not required.

 c.  Completion of VA Form 7252 is as follows (see sample App. G):

 Item 1.  Addressee - Department of Veterans Affairs, Austin Automation Center (200/397A), 1615 Woodward Street, Austin, TX  78772-0001, ATTN: Input/Data Entry Contract Control/VADS Function.

 Item 2.  Facility Name and Address - Enter facility name and address.

 Item 3.  Reply Reference - Enter facility number and routing symbol.

 Item 4.  Leave blank.

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

 Item 6.  Dispatch Date - Enter date submitting to the AAC.

 Item 6a.  Final Batch - Leave blank.

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

 Item 8.  Tabulating Data.

 Column A.  Leave blank.

 Column B.  Job Number.  Enter "10" in first segment and "20A1" in second segment.

 Column C.  Description.  first line enter  "AGENT ORANGE," second line enter "Facility Number," third line enter "Month Ending," fourth line enter "Batch Number," and fifth line enter "Code Sheet Count,” and sixth line enter “Cumulative Count” (for calendar year).

 Columns D and E.  Leave blank.

 Item 9.  Remarks.  Enter "VA Form 10-9009's," and provide breakdown of “code sheet count” (Line 5), i.e.,  (5) initial (Type A), (2) follow-up (Type C), and/or (1) deceased (Type X), etc.

4.  Control Log

 a..  An Agent Orange (AGO) control log will be established and maintained at each facility.  As batches are prepared for submission to the AAC, an entry should be made on the batch control log.  Using the control log, assign the appropriate number and record it on the transmittal form.  Begin with batch number 001 for January of each year and continue with sequential numbers throughout the year, i.e., if there are 50 code sheets to be submitted to the AAC during the month of January, two batches will be prepared with the control log numbers 001 and 002.

 b.  Control Log should consist of the following:

 (1)  Facility code number;

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

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

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

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

5.  Mailing

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

          VISNS                 Mailing Date

              1-5                     6th of month
              6-13                 10th of month
              14-17               14th of month
              18-22               18th of month

 b.  The mailing address for the AAC is:

  Department of Veterans Affairs
  Austin Automation Center
  1615 Woodward Street
  Austin, TX  78772-0001
  ATTN:  Input/Data Entry Contract Control/VADS Function

 c.  The AAC will process the data from the code sheets twice monthly (10th and 25th).  The AAC will return all rejected code sheets with the printout "Transaction Report – Invalid Transactions” to the transmitting facility.  Code sheets that are correct and entered into the AGO data set will not be returned to VA facilities, a printout will be returned to the facility entitled, “Transaction Report – Part I – Valid Transactions” identifying the code sheets that were accepted and entered into the AGO dataset.  NOTE:  Rejected Code sheets should be corrected and returned to the AAC within 10 working days following receipt from the AAC.

 d.  It is not appropriate to call the AAC in regard to questions on code sheet completion or correction.  These questions should be referred to the Registry Coordinator (131), VHA Headquarters.

6.  Transaction Reports

 a.  A computerized printout "Transaction Report – Part I – Valid Transactions" will be returned by the AAC to the transmitting facility listing the veteran’s last name, first name, middle initial, Social Security Number, type and date of examination.  Since these code sheets were valid and data entered into the AAC registry, the code sheets will not be returned to the facility of origin.  This printout may include the following information:

 (1)  “Message – Transaction accepted, initial examination already established at (facility number); transaction will be processed as a follow-up examination for your facility.”

 (2)  Action.  This code sheet does not have to be resubmitted to the AAC.  It has been accepted as a follow-up examination.  Indicate facility number where initial examination was obtained on computerized or card file.  Also, the cumulative number of examinations in the monthly statistical report must be adjusted accordingly.

 b.  A computerized printout entitled “Transaction Report – Part II – Invalid Transactions” will
be returned to the transmitting facility with the rejected code sheets.  These printouts will list the veteran’s last name, first name, middle, initial, Social Security Number, type and date of examination and describe the rejected or invalid field name, code sheet location, data, reason for rejection and fields to verify with any additional explanatory information.  NOTE:  Facilities should verify the number of code sheets sent to the AAC against the Transaction Reports.

 c.  Invalid or rejected code sheets where data has not been entered into the dataset are to be corrected as follows:

 (1)  White-out the incorrect entries and enter the correct data with RED pen or RED felt-tipped pen; or

 (2)  Prepare a new code sheet with the corrections in the appropriate field(s).  If a new code sheet is prepared for the return of a correction, do not complete just the corrected field(s), all of the fields must be completed as if it were an initial input.

 b.  Examples of the messages on the “Transaction Report – Part II – Invalid Transaction:”

 (1)  "Rescinded VA Form 10-9009 (Jan 1994), no longer valid.”  Use Revised VA Form 10-9009 (July 2000).

 (2)  “Required entry not made.”

 (3)  “Response must be either a “Y,” “N,” or “U.”

 (4)  “Response must be either a “M” or “F.”

 (5)  “ZIP Code is invalid for State.”

 (6)  “Duplicate Follow-up Segment.”  Action.  This message will appear if the examination date on the code sheet submitted on the veteran is identical to an examination date already existing in the registry.  There is the possibility of a coding or entry error.  Examination date should be verified using the computerized log, the veteran’s medical record, or the AAC printouts.  If there is a duplicate record, it should be deleted by submitting a code sheet in accordance with instructions for deleting a record (see App. D).

 (7)  “No Matching Initial Examination.”  Action.  When deletion of an initial examination record in the registry is attempted, the code sheet submitted with a type “B” must have the identical information as on the original record previously accepted into the registry; otherwise, the deletion process cannot be carried out.  Correct the code sheet and resubmit to the AAC within 10 working days.

7.  Master File List

 a.  Hard Copy Reports.  On a monthly basis, the AAC will provide all facilities with a computerized printout entitled “Examination of Agent Orange Veterans by Facility with Initial and Follow-up Examinations.”  This is a listing of all veterans who have been examined and accepted into the automatic registry system from each submitting facility.  This AAC-generated list will assist in the verification of veterans who have been accepted into the system from each facility.  This list will contain the following information:

 (1)  Veteran’s full name,

 (2)  Social Security Number,

 (3)  Date of examination,

 (4)  Type of examination (initial and/or follow-up).

 b.  Electronic Reports.  If access to a computer and printer is available, there are two preferable electronic options that should be used for online viewing of the bimonthly cycles of the Agent Orange Registry (AOR).

 (1)  Direct computer access to AAC Roger Software Development (RSD) for online report viewing and management software; or

 (2)  Intranet access to the AAC’s RSD Extended Output Solution (EOS) Application Program Interface (API) software that allows Intranet access to reports stored on the RSD spools.  This is not a change to RSD; it is only a new method for accessing the RSD reports.  This user-friendly access provides a Graphical User Interface (GUI) environment with “point and click” access to reports and allows the end user to take advantage of other PC functions while viewing their reports.

 (3)  Access to the AAC’s RSD must be authorized.  VA Form 9957, ACRS Time Sharing Request, should be completed by Registry Coordinators or Physicians requesting access to the RSD.  For further instructions, contact either the AAC (512-326-6661) or EAS (212-273-8463 or 8465)
 

SAMPLE OF COMPLETED VA FORM 7252, TRANSMITTAL FORM FOR USE
IN SHIPMENT OF TABULATING DATA
***********************************************************

of Robert J. Epley
Director, Compensation and Pension Service
Veterans Benefits Administration
Department of Veterans Affairs
Before the House Committee on Government Reform
Subcommittee on National Security, Veterans Affairs,
and International Relations
March 15, 2000

Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to testify today on the Air Force Ranch Hand study and its
impact on veterans' benefits. You have asked that our testimony include
information on the impact of the study on determinations of diseases for
which Vietnam veterans are eligible to receive compensation benefits.
The Department of Veterans Affairs (VA) agrees with the recent
assessment by the General Accounting Office, that its impact on these
determinations has been limited. My testimony will summarize VA's past
use of Ranch Hand and other herbicide study data, and our intentions for
using such data in the future.

Delays in Publication of Ranch Hand Findings

In 1984, Congress passed the Veterans' Dioxin and Radiation Exposure
Compensation Standards Act, Pub. L. No. 98-542. Pursuant to that Act, VA
adopted regulations on how VA would evaluate scientific studies to
determine which diseases are related to veterans' Agent Orange exposure.
VA conducted this ongoing evaluation process throughout the 1980's.

As noted by the General Accounting Office (GAO) in its December 1999
report entitled "Agent Orange: Action Needed to Improve Communications
of Air Force Ranch Hand Study Data and Results" (GAO/NSIAD-00-31), no
Ranch Hand study results were published until 1989, more than seven
years after the study began. While this obviously delayed VA's
opportunity to consider this data in reaching our Agent Orange
compensation decisions, VA did obtain and analyze a significant amount
of other research on the health effects of herbicide exposure during
this time.

The Agent Orange Act of 1991

Section 3 of the Agent Orange Act of 1991, Pub. L. No. 102-4, directed
the Secretary to seek to enter into an agreement with the National
Academy of Sciences (NAS) to review and summarize the scientific
evidence concerning the association between exposure to herbicides used
in support of military operations in the Republic of Vietnam during the
Vietnam era and each disease suspected to be associated with such
exposure. Congress mandated that NAS determine, to the extent possible:
(1) Whether there is a statistical association between the suspect
diseases and herbicide exposure, taking into account the strength of the
scientific evidence and the appropriateness of the methods used to
detect the association; (2) the increased risk of disease among
individuals exposed to herbicides during service in the Republic of
Vietnam during the Vietnam era; and (3) whether there is a plausible
biological mechanism or other evidence of a causal relationship between
herbicide exposure and the suspect disease.

Section 3 of Pub. L. No. 102-4 requires that NAS submit reports on its
activities every two years (as measured from the date of the first
report) for a ten-year period.

Section 2 of Pub. L. No. 102-4 provides that whenever the Secretary
determines, based on sound medical and scientific evidence, that a
"positive" association, (i.e., as defined in the Act, the credible
evidence for the association is equal to or outweighs the credible
evidence against the association), exists between exposure of humans to
an herbicide agent used during the Vietnam War and a certain disease,
the Secretary will publish regulations establishing presumptive service
connection for that disease. Although Pub. L. No. 102-4 does not define
"credible," it does instruct the Secretary to "take into consideration
whether the results [of any study] are statistically significant, are
capable of replication, and withstand peer review.'' Section 2 of Pub.
L.

No. 102-4 also requires that the Secretary's determinations be based on
consideration of the NAS reports and all other sound medical and
scientific information and analyses available to the Secretary. If the
Secretary determines that a presumption of service connection is not
warranted, he must publish a notice of that determination, including an
explanation of the scientific basis for that determination.

VA's Reliance on National Academy of Sciences Reports

NAS issued its initial report, entitled "Veterans and Agent Orange:
Health Effects of Herbicides Used in Vietnam," (VAO) on July 27, 1993.
The Secretary subsequently determined that a "positive" association
exists between exposure to herbicides used in the Republic of Vietnam
and the subsequent development of Hodgkin's disease, porphyria cutanea
tarda, multiple myeloma, and certain respiratory cancers (of the lung,
bronchus, larynx, or trachea). The Secretary also determined that there
was no "positive" association between herbicide exposure and any other
condition, other than chloracne, non-Hodgkin's lymphoma, and soft-tissue
sarcomas, for which presumptions already existed. VA promulgated
regulations implementing its determination.

NAS issued its second report, entitled "Veterans and Agent Orange:
Update 1996'' (Update 1996), on March 14, 1996. The Secretary
subsequently determined that a "positive" association exists between
exposure to herbicides used in the Republic of Vietnam and the
subsequent development of prostate cancer and acute and subacute
peripheral neuropathy in exposed persons. The Secretary further
determined that there was no "positive" association between herbicide
exposure and any other condition, other than those for which
presumptions already existed. VA promulgated regulations implementing
its determination.

Also based on Update 1996, the Secretary determined that a "positive"
association exists between exposure to herbicides used in the Republic
of Vietnam and the subsequent development of the birth defect spina
bifida in the offspring of exposed persons. Based on this finding, the
Secretary and the President sought legislation providing VA benefits for
these children. In October 1996, Congress passed Pub. L. No. 104-204,
which provides health care, a monthly monetary allowance, and vocational
rehabilitation benefits to these children.

Veterans and Agent Orange: Update 1998

NAS issued its third and most recent report, entitled "Veterans and
Agent Orange:Update 1998'' (Update 1998), on February 11, 1999. The
focus of this updated review was on new scientific studies published
since the release of Update 1996 and updates of scientific studies
previously reviewed. In Update 1998, NAS assigned hepatobiliary cancers,
nasal/nasopharyngeal cancer, bone cancer, breast cancer, female
reproductive cancers, urinary bladder cancer, renal cancer, testicular
cancer, leukemia, abnormal sperm parameters and infertility,
motor/coordination dysfunction, chronic peripheral nervous system
disorders, metabolic and digestive disorders (including diabetes
mellitus), immune system disorders, circulatory disorders, respiratory
disorders (other than certain respiratory cancers), and skin cancer to a
category labeled inadequate/insufficient evidence to determine whether
an association exists. This is defined as meaning that the available
studies are of insufficient quality, consistency, or statistical power
to permit a conclusion regarding the presence or absence of an
association with herbicide exposure.

Also in Update 1998, NAS assigned gastrointestinal tumors and brain
tumors to a category labeled limited/suggestive evidence of no
association. This is defined as meaning several adequate studies do not
show a "positive" association with herbicide exposure.

As he did after the release of the prior NAS reports, the Secretary
again formed a VA task force to review the report and pertinent studies
and to make recommendations to assist him in determining whether a
"positive" association exists between herbicide exposure and any
condition. The task force completed that review and submitted its
recommendations to the Secretary.

In the Secretary's judgment, the comprehensive review and evaluation of
the available literature which NAS conducted in conjunction with its
report has permitted VA to identify all conditions for which the current
body of knowledge supports a finding of an association with herbicide
exposure. Accordingly, the Secretary determined that there is no
"positive" association between exposure to herbicides and any other
condition for which he has not previously determined that a presumption
of service connection is warranted. (However, as noted below, the
Secretary requested that NAS conduct an additional review of diabetes
mellitus.)

On November 2, 1999, as required by law, VA published a notice in the
Federal Register that the Secretary of Veterans Affairs, under the
authority granted by the Agent Orange Act of 1991, had determined that a
presumption of service connection based on exposure to herbicides used
in the Republic of Vietnam during the Vietnam era was not warranted for
the following conditions: Hepatobiliary cancers, nasal/nasopharyngeal
cancer, bone cancer, breast cancer, female reproductive cancers, urinary
bladder cancer, renal cancer, testicular cancer, leukemia, abnormal
sperm parameters and infertility, motor/coordination dysfunction,
chronic peripheral nervous system disorders, metabolic and digestive
disorders (other than diabetes mellitus), immune system disorders,
circulatory disorders, respiratory disorders (other than certain
respiratory cancers), skin cancer, cognitive and neuropsychiatric
effects, gastrointestinal tumors, brain tumors, and any other condition
for which the Secretary had not specifically determined a presumption of
service connection is warranted.

This notice also conveyed the Secretary's determination that a new study
concerning the possible association between exposure to herbicides and
diabetes mellitus that was published since NAS completed Update 1998, is
potentially significant. The Secretary has requested NAS to review that
new study and, after reviewing NAS' response, will determine whether a
"positive" association exists between herbicide exposure and diabetes
mellitus.

NAS's Analysis of the Ranch Hand Study

As noted by the General Accounting Office (GAO) in its December 1999
report entitled "Agent Orange: Action Needed to Improve Communications
of Air Force Ranch Hand Study Data and Results" (GAO/NSIAD-00-31), the
three NAS reports on Vietnam veterans and Agent Orange, including their
conclusions on specific diseases, were based on numerous studies besides
Ranch Hand. This fact alone has limited the impact of Ranch Hand on the
NAS' conclusions.

Moreover, to the extent NAS has relied on the Ranch Hand study, NAS has
carefully analyzed both the strengths and weaknesses in the study and
publication of study results. The NAS has included this critical
analysis in all three of its reports. For example, NAS included such
analysis in Veterans and Agent Orange: Health Effects of Herbicides Used
in Vietnam (1993), at pages 231-232, 279-280, 722-724 and 757-763 (this
last section was an appendix entitled, "Methodological Observations on
the Ranch Hand Study"). NAS also included such analysis of the Ranch
Hand study in Veterans and Agent Orange: Update 1996 at pages 293-296.
NAS also included such analysis in Veterans and Agent Orange: Update
1998 at pages 447-449, 453, 457-458, and 498-500.

VA's Recognition of Ranch Hand's Strengths and Weaknesses

As stated in the GAO report, "reports and articles by the Ranch Hand
study comprise only a small fraction of the information the National
Academy of Sciences reviews and the Department of Veterans Affairs then
considers when weighing scientific evidence." The Department agrees with
this GAO assessment.

In the same report, GAO concluded that "the Ranch Hand study has had
almost no impact" on VA determinations on which diseases warrant
presumptive service connection, "because of the small size of the Ranch
Hand population and the relative rarity of many cancers." The Department
agrees that these, and other limitations in the Ranch Hand study noted
by NAS over the years, have made its impact on these determinations very
limited.

VA recognizes that simply comparing the number of studies which found an
association between herbicides and a certain disease, to the number of
studies which did not find an association, is not a valid method for
concluding whether there is a "positive" association between herbicides
and that disease. Differences in statistical significance, confidence
levels, control for confounding factors, bias, and other pertinent
characteristics, make some studies less credible than others. For
example, some studies did not explicitly address the issue of smoking, a
potential confounding factor which may have skewed their results.
Therefore, the Secretary has given the more credible studies more weight
in evaluating the overall weight of the evidence concerning specific
diseases.

VA's Future Use of Ranch Hand and Other Herbicide Study Data

NAS has informed VA that it expects its report on Agent Orange and
diabetes to be issued this spring. After reviewing the report, the
Secretary will determine whether to add diabetes to the list of diseases
for which VA allows a presumption of service-connection. Similarly, when
NAS issues its next comprehensive biennial report, which is expected in
2001, the Secretary will review it to determine which, if any, health
effects should be considered for presumption of service-connection. As
required by law, the Secretary will continue to consider not only the
NAS report, but also all other sound medical and scientific information
and analyses available. Also as required by law, the Secretary will
continue to take into consideration whether the results of any study are
statistically significant, are capable of replication, and withstand
peer review.

Conclusion

In summary, we believe that NAS has done a very credible job of pointing
out the strengths and weaknesses of the Ranch Hand study, as well as the
other research NAS has reviewed. The Department has paid close attention
to these strengths and weaknesses in making its determinations on which
diseases warrant presumptive service connection. We believe that this
process has proven to be effective in forming a solid basis for
compensation for Vietnam veterans.

While we still have work left to do, we feel that over the past decade,
the Department has made significant progress in the compensation of
Vietnam veterans for diseases related to Agent Orange exposure. Mr.
Chairman, as I have said before, we owe veterans and their families the
best service we can provide in the most sensitive, caring way possible
to ensure that they receive benefits in a manner befitting their service
to our Nation.

This concludes my prepared statement. My colleagues and I will be
pleased to answer any questions Subcommittee members might have.
*************************************************************Agent Orange Class Settlement

DR. SMOGER GETS SECOND CIRCUIT TO OVERRULE 1984 AGENT ORANGE CLASS
SETTLEMENT

If you are interested  in having your claim for Agent Orange exposure
investigated or in more information, click on the following:
http://www.soft-vision.net/ao_vets/survey/

Dr. Smoger helps Vietnam veterans.

Bob Van Voris, "Agent Orange Suits Alive, U.S. Court Says: New
Plaintiffs Can't Be Held to 1984 Settlement." The National Law Journal,
Volume 24, Number
16. December 17, 2001
Bob Van Voris, Staff Reporter

Seventeen years after a class action settlement intended to end lawsuits
over Agent Orange, the U.S. Court of Appeals for the 2d Circuit has
ruled that two Vietnam
veterans may sue companies that made the product.

The Nov. 30 decision allows the vets, who developed cancer after the
Agent Orange settlement wound down at the end of 1994, to pursue cases
against more than
a dozen chemical companies, including Dow Chemical Co. And it may open
the door for others who got sick in recent years to sue.  Stephenson v.
Dow Chemical
Co., No. 00-9120.      The case comes at a time when the U.S. Supreme
Court and lower federal courts are limiting judges' ability to fashion
broad mass-tort
settlements.

Agent Orange Settlement

On the eve of trial in 1984, lawyers for the manufacturers and for a
class of American, Australian and New Zealander veterans agreed to a
deal in which the
manufacturers would pay $180 million to veterans who were exposed to
Agent Orange and then died or became ill. Part of the money was set
aside
for vets who became ill in future years, through 1994.

There would be numerous attempts by veterans to undo the settlement or
to sue in spite of it, but none was successful.  "Most other attorneys
thought this was set in
stone," said Gerson Smoger, the Dallas lawyer who
represents plaintiff Joe Isaacson. "But if something is not right and
not fair and not constitutional, a court will be brave enough to
overturn it."

Isaacson served in Vietnam from 1968 to 1969 and was an Air Force crew
chief assigned to a base where planes that sprayed Agent Orange were
based.  In 1996,
he was diagnosed with non-Hodgkins lymphoma.
Daniel Stephenson, whose case was joined with Isaacson's on the appeal,
served from 1965 to 1970, on the ground and as a helicopter pilot. He
was diagnosed
with bone marrow cancer in 1998.

Both men sued, claiming their war-time exposure to Agent Orange caused
them to develop cancer. The Isaacson case, filed in New Jersey state
court, and the
Stephenson case, filed in Louisiana federal court, were eventually
assigned to Brooklyn federal Judge Jack B. Weinstein, who had brokered
the original Agent
Orange class settlement.

Weinstein dismissed both cases last year, holding that they were barred
by the settlement.

The 2d Circuit disagreed, holding that, because Isaacson and Stephenson
were not adequately represented in the 1984 settlement, they could not
be bound by it
now. The court also questioned whether a settlement can ever
constitutionally bind class members who, as in many mass tort cases,
become ill years after a
settlement is approved.

Neither side knows how many veterans may now try to sue based on
diseases they developed in the past few years. Those who do will face
the companies' defense
that they merely carried out government specifications
for making Agent Orange and that, as government contractors, they are
not responsible for any injuries.

Another hurdle for plaintiffs will be to prove that their diseases were
actually caused by Agent Orange. Scot Wheeler, a spokesman for Dow
Chemical, said the issue
is still a controversial one. But Smoger believes
that scientific and epidemiological studies of Agent Orange since 1984
make cases much easier to prove now than at the time of the settlement.

Trial Lawyers for Public Justice, a Washington, D.C., group that has
criticized many class action settlements, filed an amicus brief
supporting the veterans.

"My client is absolutely thrilled" by the ruling, said Smoger.  Wheeler
said that Dow is reviewing the decision and has not yet decided whether
it will appeal.

****************************************************************

Subject: Agent Orange-- Good News


                                        Respond to:
            California Office
3175 Montery, Calif 94802
510-531-4529
Fax 510-531-4377

                  The Smoger Law Firm Building
      13250 Branch View Lane
Dallas, Tex 75234
972-243-5297
Fax 972-243-2666
                                
                                    December 13, 2001


Dear Mrs.Le Fevre,

As you recall, in 1994 I was Counsel for Record in an Amicus brief which we filed before the United States Supreme Court. In that brief, as you may recall, we agrued that the 1984 Class Action settlement was unfaiir to veterans. Unfortunately, the United States Supreme Court at the time refused to hear the case and left Judge Weinstin’s decision in place,continuing the ban on all lawsuits filed against the chemical companies who manufactured Agent Orange and other herbicides for use in Vietnam.

Afterwards, I promised Admiral Zumwalt that I would continue the fight. My law firm, Smoger & Associates, along with Mark Cuker, Esq. and Ron Simon,Esq filed a new case, which Judge Weinstein once again ruled was barred by the prior settlement [even though the setttlement had run out of funds]. We appealed the decision and in May I argued the unfairness of the case to the United States Second Circuit Court of Appeals. Last week, the Second Ciruit did what was right  and reversed Judge Weinstein. Its decision is enclosed.

Veterans who became disabled after 1994 from Agent Orange or were first diagnosed with an Agent  Orange -related disease after 1994 can now sue the manufacturers of these deadly chemicals. If any veteran who fits this description have any questions regarding their rights they can call me.

Additionally, I am writing to say this fight may not be over. The companies that manufactured Agent Orange may still appeal to the en banc Second Circuit or to the United States Supreme.Court. In that case, you might again want your voice to be heard.

Nevertheless, I am thrilled at the result so far in turning around this travesty of justice which sought to leave veterans who have been suffering with deadly and debilitating illnesses without  any hope for compensation from those who made Agent Orange. Again, if you have nay questions, please feel free to contact me,. I just wanted to share this great result with you and again thank you for your previous help.

Very Truly Yours
                                          Smoger & Associates
                                           Gerson H. Smoger 
*****************************************************************
 

Dioxin Update from Seveso

Pier Alberto Bertazzi, Carlo Zocchetti, Stefano Guercilena, Dario, Consonni,
Adriana Tironi, Maria Teresa Landi, and Angela Cecilia Pesatori
Epidemiology 1997;8:646-652

Much to the chagrin of EPA and the International Agency for Research on Cancer (IARC), updated results from the dioxin-exposed Seveso population are in.

In 1976, a chemical facility explosion in Seveso, Italy exposed a large population to relatively high levels of dioxin. Tironi et al. examined cancer mortality in the Seveso population during the period 1976 to 1991.

The study population was classified by estimated exposure: Zone A soil had the highest levels of dioxin; Zone B soil was next; and Zone R soils had the least dioxin. Although the follow-up period is only 15 years (and some cancers take 20 or more years to appear following exposure), the results are interesting.

1. When all types of cancers were grouped into one category, no statistically significant excess of cancer was observed.

2. Of the 78 efforts to find an association with different types of cancer in females,only one association was statistically significant (a relative risk of 6.6 for myeloma). With this type of data dredging, you might expect 3 to 4 statistically significant associations just by chance.

3. Of the 81 efforts to find an association with different types of cancer in males, only three associations were statistically significant (relative risks of 2.9 for rectal cancer, 2.4 for lymphohemopoietic cancer and 3.1 for leukemia). Again, data dredging could easily account for these observed excesses in cancer.

Ironically, IARC has just classified dioxin as a "known human carcinogen?" And EPA could very well follow suit.

But inquiring minds want to know: WHY?

******************************************************************
By THOMAS D. WILLIAMS
Copyright 2001 Hartford Courant Four months after the Pentagon acknowledged
that thousands of U.S. soldiers, sailors and Marines might have been exposed
to dangerous chemical or biological agents during top-secret tests in the
1960s, only a fraction of those possibly affected have been identified and
none has been contacted. The secret tests, which took place aboard ships
primarily in the Pacific Ocean, have been the subject of complaints by a
handful of veterans for more than a decade. Their concerns arose after
military reunions at which the veterans discovered that some of their
shipmates were sick and more than 100 had died. The U.S. Defense Department
began investigating the 1960s-era military files 13 months ago. That was
after CBS News and several members of Congress stirred up a controversy over
the secret U.S. military history of biological and chemical spraying of U.S.
Navy and Marine vessels near Hawaii and California. Neither the Pentagon nor
federal health officials have written to any of the veterans affected to let
them know what they were sprayed with. Federal health officials are preparing
to send out notices to a fraction of them. Veterans advocates say military
and health officials are too slow to assist veterans who could be seriously
ill and without financial resources to pay for health care. Health care costs
are not an issue for Gerald Foster, 65, a retired Navy veteran, but he would
still like to know whether weapons testing contributed to the rare immune
disorder that has crippled his lungs. The Pearl Harbor-based light tug Foster
skippered from 1964 to 1966 was among several vessels sprayed with simulated
and real chemical and biological agents from U.S. aircraft. Foster said his
crew was protected by wearing chemical suits and masks during the spraying.
Caged monkeys were the test subjects. Foster said he believes the sailors
became sick from the toxic chemicals used to clean the tugs after the
spraying. Foster has suffered for 12 years from an unusual disorder, he said.
He walks around breathing heavily with the assistance of a supplemental
oxygen tank. His health care is provided at no cost by the Naval retirement
community where he lives. But Foster said he knows of others involved in the
operations who now have cancer and other diseases who aren't as well cared
for. "All of us should have been monitored, and we were not," he said. "The
crew, these are our people, and we needed to take care of them, and that was
not done. That was just wrong." Vietnam Veterans of America has complained to
Veterans Affairs Department Secretary Anthony J. Principi about the delay in
notification. Rep. Michael Thompson, D-Calif., has pressed Defense Department
officials to explain how far their investigation has reached into military
archives. "Rep. Thompson is very discouraged that it has taken this long to
get information to the veterans," said his spokeswoman Mandy Kenney. Only
three test exercises have been identified by the Defense Department so far.
Using military files on the operations, the department has identified 1,100
service members who were exposed to the hazards. The final toll could be much
higher; the Defense Department said it was investigating beyond those three
projects -- into approximately 110, all told. Representatives for Veterans
Affairs and the Defense Department said delays in notifying veterans are the
result of long, arduous searches through paper files and difficulties in
locating Social Security numbers.
*************************************************

Understanding the Appeal Process,"
VA Pamphlet 01-00-1, January 2000 Edition
http://www.veteransresources.net/
Board of Veterans' Appeals, Part 1
Table of Contents, Who Should Read This Brochure? How Do I Find The Answers To My Questions?
http://www.pva.org/member/appeal.htm
Board of Veterans' Appeals, Part 2
numerous questions answered
http://www.pva.org/member/appeal1.htm
Board of Veterans' Appeals, Part 3
What SHOULD I do? What should I AVOID?
http://www.pva.org/member/appeal2.htm#should
Download files from Veterans Resource page
title 38, court cases, exams, vet laws, advisors benefits training
http://www.veteransresources.net/
Great All Around Veteran Information
advocacy,service officers, search, claims, and other important information
http://www.hadit.com/nojavanavigation.htm
Military and veteran information & assistance
veterance alliance, assistance, and information
http://www.vets.com/
Personal Worksheet for your VA claim
The purpose of this worksheet is to help you keep track of important deadlines and to help guide you in working on your claim.
http://www.vva.org/Benefits/vvgvaclaims.htm#WORKSHEET
Stars and Stripes Answerman: More Guidance On The VCAA
legal guidelines under the Veterans Claims Assistance Act of 2000 (VCAA)
http://www.stripes.com/servlet/News/ViewArticle?articleId=100036668&buildId=100037553
THE HUMANE GUIDE TO VA BENEFITS
OR: YOU'VE DECIDED TO TAKE ON THE GOVERNMENT
http://www.crosswinds.net/~mrmrssarge/PTSD.html
U.S.Veteran (non-governmental) advice
NOTICE OF PROCEDURAL AND APPELLATE RIGHTS
http://web.raex.com/~colombo/vets2/4107.htm
Understanding the Appeal Process
VA Pamphlet 01-00-1, January 2000 Edition
http://www.va.gov/vbs/bva/pamphlet.htm
VA Claims -- Getting Through The Door
The Answer Man John E. Howell Stars and Stripes Veterans' Advocate
http://www.stripes.com/servlet/News/ViewArticle?articleId=100033582&buildId=100033797
VA to Speed Claims Processing with De Novo Review
A de novo review gives you some new opportunities.
http://www.stripes.com/servlet/News/ViewArticle?articleId=100038416&buildId=100038390
VET's HELPING VET'S
Information every VETERAN should have!
http://www.soft-vision.com/tmkc/vetinfo.html
VVA's GUIDE on PTSD
veterans or their survivors seeking VA benefits.
http://www.sni.net/trips/ptsd2.html
VVA's Guide on VA CLAIMS and APPEALS
Step by step process by the Vietnam Veterans of American Organization
http://www.vva.org/Benefits/vvgvaclaims.htm
Veterans Resources Court Cases References
court cases that may help your file
https://members.tripod.com/~VeteransResources/index.html
 
Are Women at Greater Risk for PTSD than Men?
. Females did have higher prevalence of PTSD than males
http://panicdisorder.about.com/health/panicdisorder/gi/dynamic/offsite.htm?site=http%3A%2F%2Fwww.mhsource.com%2Fpt%2Fp980765.html
STAMP:
Survivors Take Action Against Abuse by Military Personnel
http://staaamp.org/
Women Veterans Survive Secret Battle
women veterans suffer from post-traumatic stress disorder
http://www.suite101.com/article.cfm/veterans_health_care/24090
Women Veterans Survive Secret Battle (2)
nature of sexual abuse trauma
http://www.suite101.com/article.cfm/veterans_health_care/24312


Sexual Abuse Awareness for Women Vets
Veterans' Health Care--Women
http://www.suite101.com/article.cfm/veterans_health_care/37030


Violence Against Women in a Special Population: Women Veterans
Katherine Skinner, PhD1
http://apha.confex.com/apha/128am/techprogram/paper_9709.htm


Women Veterans Health
Women Veterans Health Program is committed to addressing the health care needs of women veterans
http://www.va-stars-and-stripes.com/Women_Vets/womenvet2.html

Women who are eligible for VA services
Need Help with VA? Go Here Now! (Part I)
http://www.suite101.com/article.cfm/veterans_health_care/35787



Social Security for PTSD
Military Veterans PTSD Reference Manual Home Page
http://www.ptsdmanual.com/ssapage.htm
analysis of the CFS Ruling for SSDI benefits
Ralph Wilborn has kindly provided this analysis of the CFS Ruling
http://chronicfatigue.about.com/health/chronicfatigue/gi/dynamic/offsite.htm?site=http://www.ssas.com/ssr99%2D2p.htm


Preparing For Your Day In Court
get beyond denial from Social security
http://arthritis.about.com/health/arthritis/library/weekly/aa111898.htm


How to Receive Social Security Disability Benefits
great advice concerning getting claim from SSDI
http://chronicfatigue.about.com/health/chronicfatigue/c/ht/00/07/How_Receive_Social_Security0962933150.htm

Entitlement to an earlier effective date
pension claim
http://www.va.gov/VetApp98/files1/9802684.txt
Entitlement to an effective date earlier
disability retroactive to June 19, 1990 is granted
http://www.va.gov/VetApp98/files3/9822927.txt
Entitlement to an effective date earlier than September
nonservice-connected pension benefits is warranted
http://www.va.gov/VetApp97/files3/9725917.txt
Entitlement to an effective date prior to November
disability pension benefits is warranted
http://www.va.gov/VetApp97/files1/9702278.txt
Female Reproductive Organs -DOCKET NO. 96-35 709
cervical dysplasia.
http://www.va.gov/VetApp99/files4/9934429.txt


Frequently Asked Questions About
Agent Orange

 

 

What was Agent Orange?
Agent Orange was a herbicide developed for military use. Chemically, the product was a 50/50 mix of two herbicides, 2,4,-D (2,4, dichlorophenoxyacetic acid) and 2,4,5-T (2,4,5 trichlorophenoxyacetic acid). These herbicides were both developed as weed killers in the 1940's, and were effective against broad leaf plants and several crops.

 

Why did the military use herbicides?
Herbicides were developed to be deployed in enemy areas to deny cover and concealment to the enemy. In dense terrain particularly, the use of herbicides to destroy covering vegetation was to protect American and allied troops from ambush or other undetected movement of the enemy.

 

Prior to it's introduction for use in Vietnam, was Agent Orange used in the United States?
Yes. During the testing phase of Agent Orange, use tests were carried out at Fort Detrick, Maryland, Eglin Air Force Base in Florida, and Camp Drum in New York. Other testing was also conducted in Thailand in the early 1960's. For information on other herbicides used in Vietnam, go here: The Fifteen Herbicides Used in Vietnam

 

Why was the product called Agent Orange?
The name signifies orange identifying bands that were used on the fifty-five gallon drums the product was shipped in. Other herbicides were also used in Vietnam, and were known by color coded names too, such Agent White, Agent Blue, Agent Purple, Agent Pink and Agent Green were also used.

 

Who were the manufacturers who produced Agent Orange for the military?
Dow, Monsanto, Diamond Shamrock Corporation, Hercules Inc., Uniroyal Inc., T-H Agricultural & Nutrition Company, and Thompson Chemicals Corporation. These companies were subjects of a class action lawsuit filed originally in 1979 and settled out of court in 1987 for $180 million. The official name of the lawsuit was Multidistrict litigation 381 (MDL 381), and was designated In re Agent Orange Product Liability Litigation.

 

I want (or I had) an "Agent Orange Test", sometimes thought to be given by the VA -- What is this?
There is no such thing as an Agent Orange Test. This is often confused with two things:

 

1. The Agent Orange screening physical given at VA Medical Centers: This test is nothing more that a general physical which includes examination, X-rays and blood work. It does not detect Agent Orange exposure. This physical is useful only as any routine physical is useful in early detection of disease or health problems. The VA does keep these results in a registry.

 

2. Dioxin analysis of the blood or fatty tissue: There are sophisticated tests which will measure dioxin levels in both blood and fatty tissues. (Dioxin is the unwanted byproduct in Agent Orange). These tests are research-oriented only, and have never been available on a large-scale or clinical basis. The VA does not perform these tests. Only a few laboratories in the world are able to do this testing, and it is usually quite expensive, around $1500-$2000 per test.

 

Can I sue the government or the chemical companies?
No. Title 38 of the United States Code prohibits veterans from suing the government for injuries suffered while in the military. A class action suit was filed in behalf of veterans in 1979 against the chemical companies and settled out of court. The final funds in this legal action were distributed by 1992. Additional attempts to sue the manufacturers have been attempted, and have been prohibited by the courts. The most strongly fought of these legal battles, Ivy vs. Diamond Shamrock was supported in behalf of the plaintiff by attorney generals in all fifty states, the Supreme Court, however, refused to hear the arguments and that case ended in 1992. In the parlance of the court, the issue is "res judicata" or "the matter is settled".

Click here: U.S. COURT OF APPEALS AFFIRMS VIETNAM VETERANS’ RIGHT TO SUE FOR INJURIES CAUSED BY AGENT ORANGE

VA manual on agent orange

 http://www.va.gov/agentorange/
 

http://www.tlpj.org/tlpjf/pressreleases/56397_1.htm COURT OF APPEALS AFFIRMS VIETNAM VETERANS’ RIGHT TO SUE FOR INJURIES CAUSED BY AGENT ORANGE
 
  http://www.diabetes.org 
    http://www.eatright.org



 http://www.soft-vision.net/ao_vets/survey/          Agent Orange Registry


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