In response to Iraq’s invasion of Kuwait on August 2, 1990, the United States (U.S.) began deploying troops to the Arabian Gulf 5 days later in Operation Desert Shield. A total of forty coalition countries eventually deployed military forces to the Gulf region, including troops from the U.S., the United Kingdom, France, and Canada. On January 17, 1991, the air war against Iraq began (Operation Desert Storm), which was followed by a 4-day ground war starting on February 24, 1991. By the end of active hostilities on February 28, 1991, the U.S. had deployed 697,000 troops to the theater of operations. The British deployed approximately 53,000 military personnel, the French 25,000, and the Canadians 4,500. In contrast to previous conflicts, a larger proportion of U.S. troops was from the Reserves and/or National Guard (17 percent) and were women (7 percent). Along with a rapid buildup of Coalition combat forces, an extensive medical care infrastructure and preventive medicine effort was established in the theater of operations. By the end of the GW, VA medical care personnel became concerned about potential health problems of U.S. service members exposed to oil well fire smoke. Consequently, VA developed a proposal to create a clinical registry of GW veterans to evaluate the health problems they were experiencing and to provide better health care for returning troops. This proposal led to the establishment of the VA Persian Gulf War Health Examination Registry, authorized in November 1992 by the “Persian Gulf War Veterans Health Status Act” (Public Law 102-585). The GW examination registry was established after the first Gulf War to identify possible diseases resulting from U.S. military personnel service in certain areas of Southwest Asia. These diseases were endemic to the area or may have been due to hazardous exposures, including heavy metals. Furthermore, air pollutants, i.e., carbon monoxide sulfur oxides, hydrocarbons, particulate matter, and nitrogen oxides, singly or in combination, could have caused chronic health problems.
Due to the un-ignited petroleum and/or smoke from the sabotage of Kuwaiti oil wells, the following health problems are to be considered in veterans of the first Gulf War:
(a) Chronic bronchitis,
(b) Chronic obstructive pulmonary disease,
(c) Pulmonary emphysema,
(d) Bronchial asthmas, and
(e) Lung cancer.
GW veterans reported a wide variety of symptoms and exposures as a consequence of GW service. These include, but are not limited to exposure to:
(a) For veterans of the first Gulf War, oil, smoke, and other petrochemical agents; and
(b) For veterans of all Gulf Wars including OIF, Leishmaniasis (spread by sand flies).
e. OIF. The U.S. began deploying troops to the Gulf region in late 2002. As of May 19, 2004, among 139,778 veterans of OIF who have separated from active military duty, 15 percent (21,021) have sought health care from VA. OIF veterans are presenting to VA with a wide range of both medical and psychological conditions similar to those found in other young military populations. To date, no unusual illnesses have been found among OIF veterans.
f. With the exception of health problems relating to exposure to oil fires, the type of symptoms and exposures listed above may be reported by veterans of OIF. Refer to website www.va.gov/gulfwar/ for health risks details.
g. During the examination process, these exposures and health conditions are identified and documented in the veterans’ health or administrative record as appropriate.
h. The registry containing medical and other data on exposed veterans signals VA’s commitment to address questions concerning possible future effects of air pollutant exposure, other environmental agents, and serve as the basis for future medical surveillance.
REGISTRY EVALUATION
Veterans claiming health conditions related to exposure to toxic substance or environmental hazard must be evaluated clinically by means of a physical examination and appropriate diagnostic studies. Where findings reveal a condition that may require treatment, refer the veteran to the Enrollment Coordinator in the Business Office to determine if the veteran is eligible for treatment.
RESPONSIBILITIES
The GWR is modeled after the Agent Orange and Ionizing Radiation Registries. All VA facility staff must be alerted of the GWR through appropriate internal communications, e.g., medical center memoranda and posters providing names, locations, and office telephone numbers of the Environmental Health (EH) Clinician and EH Coordinator.
(1) The GWR is the responsibility of VA Central Office Environmental Agents Service (EAS), in coordination with:
(a) EH Clinicians;
(b) EH Coordinators; and
(c) The VA Austin Automation Center (AAC), Austin, TX.
(2) The GWR consists of medical examinations and other data of concerned GW participants. The GWR is the most effective means of identifying such concerned veterans.
b. The EAS has the responsibility to develop, coordinate, and monitor VHA activities relating to the GW issue. NOTE: All policy and clinical questions relating to the identity of possible diseases that may result from service of U.S. military personnel in certain areas of Southwest Asia should be referred to EAS.
c. The EH Clinician and EH Coordinator at each VA facility has the responsibility for coordinating the medical and administrative aspects of the registry. They and other medical center staff, play a key role, beginning with the initial contact in:
(1) Providing registry participants with comprehensive health screening examinations at no cost.
(2) Advising veterans of examination results; and
(3) Reporting examination findings to the AAC via website: http://vaww.registries.aac.va.gov .
d. There is a time lapse between the date of examination and the processing of examination results. Accordingly, analyses used in speeches or presentations needs to be qualified to avoid misleading or misinforming the audience.
GULF WAR REGISTRY (GWR) EXAMINATION
Purpose. This paragraph sets forth clinical and administrative policies related to the maintenance of VHA’s GWR Program for physical examination of concerned veterans. NOTE: Active duty military personnel who served in Southwest Asia are eligible to participate in the GWR Program.
Eligibility Criteria. VA must provide a GWR examination to veterans who request the examination and who served on active military duty in Southwest Asia during the GW which began in 1990, and continues to the present {per 38 U.S.C. § 101(33)} including OIF. NOTE 1: The Business Office (163) should be consulted to determine whether each veteran applying for this examination meets pertinent eligibility requirements.
(1) This includes service in one or more of the following areas:
(a) Iraq,
(b) Kuwait,
(c) Saudi Arabia,
(d) The neutral zone (between Iraq and Saudi Arabia),
(e) Bahrain,
(f) Qatar,
(g) The United Arab Emirates,
(h) Oman,
(i) Gulf of Aden,
(j) Gulf of Oman, and
(k) Waters of the:
1. Persian Gulf,
2. Arabian Sea; and
3. Red Sea.
NOTE: Veterans who served in Afghanistan (Operation Enduring Freedom) are not eligible for GWR examinations. Information on Afghanistan or other combat areas can be accessed on website http://vaww.vhaco.va.gov/vhahq/publicat.htm.
(2) Eligible GW and/or OIF veterans applying for treatment in a VA medical center and/or outpatient clinic need to be encouraged to undergo an initial (i.e., “first-time”) GWR examination. NOTE: The protocol for conducting the physical examination and ordering diagnostic studies is contained in Appendix B.
(3) Veterans need to be advised that the registry examination or treatment does not constitute a formal claim for compensation.
(a) Although the results of a GWR examination may be used to support a compensation claim, the examination will not in and of itself be considered such a claim.
NOTE: If a compensation examination is performed for a GW veteran and the veteran requests inclusion in the GWR, it is not necessary to schedule an additional registry examination as long as the information is sufficient to adequately complete the registry examination questions included in website http://vaww.registries.aac.va.gov .
(b) Veterans who wish to submit a claim for conditions possibly related to GW service need to do so via the normal claims process through a Veterans Service Representative (VSR) at the nearest VA medical center or regional office. For further assistance, the veteran may call one of the following toll-free numbers:
1. Veterans Health Benefits Service Center 1-877-222-VETS (8387), or
2. VA Helpline 1-800-749-8387.
c. Program Management. For current information and program activities, EH Clinicians, EH Coordinators, and Business Office employees need to receive and familiarize themselves with quarterly mail-outs, the EAS website www.va.gov/environagents/ and www.va.gov/gulfwar/, and various materials distributed by VA Central Office. In addition, all program officials need to attend the periodic EAS conference calls from VA Central Office.
d. Responsibilities. The EH Clinician, or designee, EH Coordinator, and Business Office staff play a significant role in determining the perceptions veterans have concerning the quality of VA health care services and of their individual treatment by VA health care providers.
(1) EH Clinician Responsibilities
(a) The EH Clinician, or designee, is responsible for clinical management of the veteran on the registry and will serve as their primary health care provider unless another has been assigned. The EH Clinician serves in an advisory capacity for the administrative management of the program, discusses with the patient the results of the examination(s) and as appropriate providing follow-up visits and/or possible referrals to other tertiary medical centers or War Related Illness and Injury Study Centers (WRIISCs).
NOTE: Some veterans who return from combat missions may experience persistent, unexplained, disabling symptoms. VA’s WRIISCs are VA’s response to this important health issue. VA primary care providers examining eligible combat veterans with undiagnosed illnesses can request a veteran’s evaluation at one of the Centers. Refer to VHA Handbook 1303.5 and website http://www.va.gov/environagents for WRIISC referral protocol and brochures and view the VHA video entitled “War and Health: Treating War-Related Illnesses at VA’s WRIISCs,”which describes the clinical, risk communication, education and research programs of the WRIISCs. This video also illustrates the type of patient for whom referral may be indicated.
(b) Major essential responsibilities of the EH Clinician include:
1. Counseling the veteran as to the purpose of the physical registry examination;
2. Providing focused initial registry examination and continuum of care if assigned responsibility as the primary care clinician to those symptomatic veterans experiencing multiple symptoms after their GW experience;
3. Conducting and documenting the physical registry examination in the veterans’ health or administrative record, as appropriate.
4. Providing a complete medical history including:
a. Family;
b. Occupation;
c. Social, including tobacco, alcohol, and drug use;
d. Civilian exposure to possible toxic agents;
e. Psychosocial condition; and
f. Review of systems.
5. Completing all elements of the registry examination, then reviewing and reporting the code sheets to the AAC via website http://vaww.registries.aac.va.gov no later than 10 working days after initial examination.
6. Personally discussing with each veteran the findings of the physical registry examination and completed diagnostic studies. The interview must be conducted in such a way as to encourage the veteran to discuss any health concerns, as well as concerns expressed by family members. NOTE: When a follow-up examination is recommended by the EH Clinician, the EH Clinician serves as the primary care provider to the veteran, unless another primary care clinician has been assigned.
7. Personally discussing each veteran’s need for a follow-up examination either recommended by EH Clinician or requested by the veteran.
8. Documenting these discussions and/or findings in each veteran’s health record.
9. Encouraging the veteran to contact a VA medical center to document additional diagnoses in an appropriately titled progress note in the veterans’ health record if the veteran is subsequently diagnosed with a significant health problem by a non-VA physician. This new diagnosis must be submitted over the non-VA physician’s signature and on official letterhead and subsequently transmitted to AAC via website http://vaww.registries.aac.va.gov for inclusion in the registry database.
10. Preparing and signing a follow-up letter to each veteran explaining the results of the examination and associated laboratory tests. NOTE: Sample follow-up letters are provided in Appendixes D and E.
a. These letters are to be mailed to the veteran within 2 weeks of the initial examination appointment. For any examination where there is a new diagnosis, another letter is to be mailed within 2 weeks. The only exception to this timeframe is when a consultation at a specialty clinic is requested as part of the initial examination process. This exception suspends, but does not remove the requirement for the follow-up letter. The follow-up letter is to be sent no later than 2 weeks after the consultation.
b. A copy of this dated and signed letter must be filed and/or scanned into the veteran’s health record.
c. It is essential that this letter be written in language that can be easily understood by the veteran. Inappropriate wording could unduly alarm or confuse the veteran. NOTE: A great deal of sensitivity and care must be exercised in the preparation of this correspondence.
d. The letter must explain that:
(1) If the veteran who was examined has no detectable medical problems, the follow-up letter needs to so indicate and suggest that the veteran contact the nearest VA health care facility if health problems appear later.
(2) If it is determined upon examination that the veteran does have medical problems, it is not necessary to specify the problems in the letter.
(a) The veteran needs to be advised in the letter that the recent examination indicated a health condition or problem which may require further examination and/or treatment.
(b) If the veteran is eligible for VA medical treatment, the letter needs to so advise and recommend that the veteran seek follow-up medical care at the VA medical facility.
(c) If the veteran is not eligible for treatment, the letter needs to so advise and recommend that the veteran seek appropriate medical care elsewhere.
(3) The examination does not automatically initiate a claim for VA benefits. For information relating to claims, refer the GW veterans to a VSR at the nearest VA medical center or regional office.
(4) The results of the examination must be maintained by VA and will be available for future use as needed.
(5) If the veteran changes place of residence, the veteran needs to provide the new address to the EH Coordinator and report the new address to the AAC as a Type E entry via website http://vaww.registries.aac.va.gov .
(2) EH Coordinator Responsibilities
(a) The EH Coordinator is responsible for the administrative management of the program, including:
1. Completing Registry Code Sheets (see App. C),
2. Scheduling of appointments,
3. Monitoring timeframe compliance, and
4. Reviewing records for accuracy and completeness.
(b) The EH Coordinator is specifically responsible for:
1. Scheduling. Facilities need to make every effort to give each veteran a GWR examination within 30 days of the request date. If numerous consultations are required, whenever possible, all of these should be scheduled on the same day, so that the veteran will not be unduly inconvenienced. When it is not possible to provide all consultations on the same day, the EH Coordinator, or the scheduler, needs to work with the veteran to minimize the number of disruptions in the veteran’s life. If a medical center fails to meet the time standard of 30 calendar days from date of request, the medical center Director must explore all alternatives; i. e., referrals to other VA facilities, additional staff hours to perform these examinations; and the possibility of the use of fee-basis sources or contracting out some or all examinations with volume health care providers, to bring the medical center in line with the time standard. If, after these alternative measures have been explored and the time standard still cannot be met, an exemption needs to be requested by contacting EAS, VA Central Office (202) 273- 8463 or (202) 273-8465.
2. Disseminating Information. It is important that each GW veteran be fully advised of the GWR examination. Facility staff are encouraged to fully communicate all aspects of the GWR examination by any appropriate means. The following alternatives might be considered:
a. Upon distribution by VA EAS, provide each GW veteran, reporting to the outpatient area, with the following: NOTE: Information Bulletin (IB) 10-41 and IB 10-42 are also available in Spanish.
(1) “Gulf War Review,” newsletter;
(2) IB10-41, “VA Gulf War Veterans’ Illnesses, Questions and Answers,” which describes the purpose of the examination and its limitations;
(3) IB 10-42, “Gulf War Research – A Report to Veterans,” which is for veterans specifically interested in research; and
(4) If appropriate, IB 10-166, “Operation Iraqi Freedom/Enduring Freedom Review.”
NOTE: These publications are accessible on website: www.va.gov/gulfwar/. Any questions and/or answers can be further clarified by the examining physician prior to and during the course of the physical examination.
b. EH Coordinators provide each veteran with a brief oral explanation of the purposes of the GWR and the examination process and respond to any questions the veteran might have. This can be accomplished during the EH Coordinator’s initial contact with the veteran.
3. Data Entry Completion
a. The EH Coordinator, or designee, must complete the demographic sections of the Gulf War registry code sheet and ensure that all information is entered into the AAC database via website http://vaww.registries.aac.va.gov before the veteran is referred to the clinician for the examination.
b. The EH Clinician completes the Symptoms and Exams Section of the Gulf War registry code sheet. These data may be entered by the clinician or EH Coordinator. NOTE: It is preferable that the clinician enter the data to ensure accuracy and timeliness.
c. In the event that a veteran requests a GWR examination, but does not wish to be included in the registry database, a registry examination needs to be performed. In the “Remarks” indicate the current date and note that the veteran chose not to participate in the registry. This Gulf War code sheet needs to be filed in the veteran’s administrative or health record, as appropriate. Do not transmit this code sheet to the AAC.
e. Establishing, Updating, Retaining and Disposition of Health Records
(1) The EH Coordinator must establish a health record on each registry participant if one does not already exist. VA Form 10-9009B, Gulf War Identification Sticker, must be affixed to the front of the paper health record, if appropriate, or posting “Gulf War Registry Examination,” in CPRS.
(2) These GWR records are subject to the same retention and disposition policies as other medical record files, i.e., Records Control Schedule (RCS) 10-1. The GWR examination information (registry code sheet, progress notes, laboratory reports and other pertinent examination documentation) must be made part of the perpetual medical record following the same retention requirements specified for VA Agent Orange and Ionizing Radiation examinations.
f. Incarcerated Veterans
(1) GWR examinations may be provided to incarcerated veterans. The examination may be provided either in the prison or jail, or in the VA facility.
(2) If an incarcerated veteran is accepted for an GWR examination, VA may conduct such an examination in a VA facility, but only after the veteran has been released by an official under circumstances where there is no obligation placed on VA to exercise custodial restraint, or to ensure the return of the veteran to custody upon completion of the examinations. VA is encouraged to work with said penal institution to avoid potential disruptions at the VA medical center upon reporting for the examination (example, the wearing of prison uniforms and restraints are to be discouraged).
NOTE: The clinic Director, or designee, must notify the civil authorities when the GWR examination is completed.
(3) A bill is not issued to the penal institution for the GWR examination of an incarcerated veteran conducted at a VA facility.
(4) For purposes of entry into the GWR, VA medical facilities can provide assistance to penal authorities or institutions agreeable to conducting examinations to veterans. NOTE. VA will not reimburse the penal authorities when they conduct these GWR examinations.
(a) Copies of this Handbook 1303.2, GW registry examination code sheets, etc., must be provided to penal institutions upon request.
(b) Penal authorities must be advised at the time of such requests, that the results of the examinations provided at their institutions are to be returned to the VA facility of jurisdiction for inclusion, on the veteran’s behalf, in VA's GWR.
(c) A recommendation can be made to the penal institution to retain a copy of the examination documents submitted to VA. NOTE: Such documents need to be maintained by penal authorities and provided to the individual upon release from the penal institution.
g. Veterans With Other Than Honorable Discharges. The requirements of M-1, Part I, Chapter 4, apply to veterans with less than honorable discharges applying for GWR examinations.
h. Active Duty Military Personnel. When active duty members of the uniformed services apply to VA facilities for a GWR examination, the Department of Defense (DOD) must authorize and provide the appropriate DOD Form 2161, Referral for Civilian Care, or equivalent form, requesting this examination, or DOD must provide services under an existing DOD-VA sharing agreement. The requirements of M-1, Part I, Chapter 15, regarding the authorization and billing from the appropriate branch of service apply. NOTE: VA facilities need to reference the current directive providing the interagency billing rates.
(1) Procedures for processing the examination are the same as those for a veteran participating in this program.
(2) A military facility may perform the GWR examination according to VA instructions or the corresponding military instructions. NOTE: DOD has established a Hotline, telephone number 1-800-796-9699, to direct active duty personnel to military hospitals for medical examinations and provide other related information. An additional telephone number has been established as the veteran’s Direct Hotline (1-800-472-6719) for GW veterans to call with their recollection of "incidents" that might be related to health problems.
(3) Military facilities may obtain the pertinent VA administrative issue and appropriate forms from the nearest VA site. The VA Medical Center, 50 Irving Street, N.W., Washington, DC 20422, Attn: Environmental Health Coordinator (136), is the processing center for all active duty members of uniformed services stationed overseas. Military facilities must complete GWR examination worksheets with exception of the facility number, suffix (if applicable) and county and state. This information will be completed by the VA EH Coordinator.
(4) Military facilities must provide completed copies of the code sheets, physical examination, laboratory tests, etc., to the nearest VA medical center or outpatient clinic. The EH Coordinator must:
(a) Complete the GWR data code sheets to include facility number (and suffix, if applicable), and county and state codes.
(b) Transmit the code sheet data to the AAC via website: http://vaww.registries.aac.va.gov .
(c) Establish a health record, if one does not already exist, and maintain in the paper administrative health record or scanned and attached to an appropriately titled CPRS Progress Note; and
(d) If requested, and only with a written authorization (release of information) from an active duty member or other legal authority as outlined in VHA Handbook 1605.1, VA may supply a copy of these medical records to the military facility.
i. Updating EH Clinician and EH Coordinator Appointments. Separate listings of EH Clinician and EH Coordinators are maintained within EAS.
(1) In an effort to keep these listings current, facilities are required to notify the EAS of any changes in the status of appointments of the EH Clinician and/or the EH Coordinator at their respective facilities.
(2) As changes in designation occur, submit in writing the name, title, mail routing symbol, and telephone numbers including area code, to the Environmental Health Coordinator (131), EAS, VA Central Office, 810 Vermont Avenue, N.W., Washington, DC 20420 (Facsimile Number 202-273-9080). NOTE: In order to provide current GW information to concerned VA Registry Staff, it is important that any changes in designation of EH Clinicians and EH Coordinators at VA facilities be provided to VA Central Office (131) as they occur.
GULF WAR UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)
a. Background
(1) Many of the almost 690,000 personnel who served in the GW have reported health problems since their return to the United States. While most of the health problems of these veterans have been diagnosed as conditions that are readily definable, some veterans have unexplained illnesses that developed after their Gulf War service. These GW veterans seen by VA EH Clinicians have complex, multifaceted health problems that provide difficult diagnostic challenges. Veterans are understandably frustrated that definitive answers regarding the cause(s) of their problems are not immediately forthcoming.
(2) VA and DOD working cooperatively developed a Uniform Case Assessment Protocol (UCAP) for the evaluation of these GW veterans who after a thorough routine medical evaluation are determined to have unexplained illnesses (see App. F). NOTE: This UCAP grew out of the medical experience in diagnostic evaluation of GW veterans seen at VA Referral Centers. (These Centers were discontinued and replaced with War Related Illness and Injury Study Centers expanding their mission to offer similar comprehensive clinical care to combat veterans of all eras, as described in VHA Handbook 1303.5.) The protocol was then further refined and adapted for use by both VA and DOD facilities. DOD’s similar protocol is identified as Comprehensive Clinical Evaluation Program (CCEP).
(3) The UCAP includes a group of supplemental baseline laboratory tests and consultations which needs to be provided to every veteran with debilitating unexplained illness. It gives guidelines for the minimum diagnostic work-up for the most frequent complaints experienced by GW or OIF veterans with unexplained illnesses. This protocol utilizes validated and readily available diagnostic tests to thoroughly evaluate each of the common symptoms reported by GW and OIF veterans.
(4) The concept behind the protocol was to identify previously unrecognized major diagnostic entities which could provide an explanation for the symptoms commonly reported in GW veterans with unexplained illnesses. NOTE: It should be emphasized that the protocol is not designed to be all-encompassing; therefore, it needs to be carried out with a high degree of clinical judgment. All significant symptoms and abnormalities not specifically outlined in the protocol must be fully evaluated according to the medical judgment of the EH or Primary Care clinicians directing the work-up. The information gathered by this process is to be entered into a computerized database at http://vaww.registries.aac.va.gov .
b. Authority. The UCAP for GW veterans with unexplained illnesses was administratively established by the Under Secretary for Health to assist in addressing the unique health concerns of the GW veterans. On November 2, 1994, Public Law (Pub. L.) 103-446 amended Title 38 United States Code (U.S.C.) 1117 implementing the uniform and comprehensive medical evaluation protocol for the GW veterans.
c. Scope. All VA health care facilities must examine the available services for GW and OIF veterans to ensure that quality outreach, diagnostic, and treatment services are furnished as intended. If these services cannot be provided by the local VA facility, a mechanism must be developed to provide these services by contract, sharing agreements, or referral to other VA facilities.
d. Responsibilities
(1) EH Clinicians. The responsibility of the EH Clinician is to:
(a) Conduct the Registry examination (Phase I), which is the first step toward diagnosis of the health problems of a GW or OIF veteran; and
(b) If a diagnosis is not readily apparent after conducting routine medical evaluations, to initiate the UCAP, (Phase II) using the protocol provided in Appendix G.
(2) EH Coordinators. The EH Coordinator is responsible for:
(a) Following the reporting instructions as included in Appendix G.
(b) Providing accurate coding of both symptoms and diagnoses, and when questions arise about these items consult with EH Clinician, or designee.
(c) Completing and transmitting the UCAP to the AAC website at: http://vaww.registries.aac.va. gov
MEDIA AND OTHER EXTERNAL CONTACTS
a. Media Contacts. Reports of Contact from various media sources (e.g., radio, television, newspapers, etc.) concerning GWR Program activities are to be referred by phone to the facility Public Affairs Officer. Interviews are not to be given unless approved by the medical center Public Affairs Officer who may appropriately coordinate response with the regional VA public affairs representative.
b. Contacts to Advise Centers of “Special Cures” for Gulf War-Related Illnesses. Medical centers can expect, on occasion, to be contacted by private sector physicians, researchers, and the general public with information regarding “quick cures” for GW- related illnesses. Such individuals need to be advised that:
(1) There are medically accepted mechanisms to introduce new clinical treatments;
(2) All new treatments suggested must be reviewed by a formally-designated Human Subjects Review Committee;
(3) It is important to have independent confirmation of treatment efficacy;
(4) Provisions exist to permit the originator of new therapies to retain professional credit and be appropriately compensated; and/or
(5) The individual might want to consider presenting the “new approach” at a VA or medical school Grand Rounds or Staff Review Committee meeting.
(6) In general, VA cannot fund experimental treatments of veterans at non-VA facilities.
DEFINITIONS AND ACRONYMS
1. AAC - The Office of Financial Management, Austin Automation Center (AAC) in Austin, TX. It is the location of the computerized registry for code sheet data collection and database entry.
5. CARC - Chemical Agent Resistant Compound paint.
6. CBC - Complete Blood Count.
7. CHR - Consolidated Health Record. A file containing medical records relating to patient identity, diagnosis, prognosis or treatment at Department of Veterans Affairs (VA) facility.
8. CPK - Creatine Phosphokinase.
9. CPRS - Computerized Patient Record System.
10. CT - Computed Tomography.
11. D.O. - Doctor of Osteopathy.
12. DOD - Department of Defense.
13. DOD Form 2161, “Referral for Civilian Care.”
14. DSM-III-R - Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised.
15. DU - Depleted Uranium.
16. EAS - Environmental Agents Service - EAS (131), VA Central Office, has the responsibility to coordinate and monitor all VHA activities, research and otherwise, relating to the Gulf War issue.
17. ECG - Electrocardiogram.
18. EEG - Electroencephalogram.
19. EGD - Esophagastroduodenoscopy.
20. Environmental Health (EH) Clinician - The EH Clinician is a physician that is responsible for the clinical management of the Gulf War (GW) Program at each VA medical facility.
21. EH Coordinator - The EH Coordinator is a non-clinician staff member responsible for the administrative management of the program at each VA facility.
22. EMG - Electromyogram.
23. ENG - Electronystamogram.
24. Examinations
a. Initial. The first physical examination which is completed, transmitted and entered in the GW registry database, located at the AAC, via website http://vaww.registries.aac.va.gov .
b. Follow-up. Examination performed subsequent to the initial (first) examination and entered in GW registry website http://vaww.registries.aac.va.gov .
25. Facility - Any VA entity that provides GW Registry examinations to GW veterans.
26. GI - Gastrointestinal.
27. GW - Gulf War.
28. GWR - Gulf War Registry - is a computerized index of veteran participants, is managed centrally by the EAS in VA Central Office. The coded findings of GWR Program physical examinations and related diagnostic results are entered into a database by the VA facility staff via website http://vaww.registries.aac.va.gov.
29. GYN - Gynecology.
30. Hct - Hematocrit.
31. Hgb - Hemoglobin.
32. HIV - Human Immunodeficiency Virus.
33. IB-10-41 - VA Information Bulletin (IB) entitled “Gulf War Veterans’ Illnesses, Questions and Answers.”
34. IB 10-42 - “Gulf War Research – A Report to Veterans.”
36. ICD-9-CM - The current issue of the International Classification of Diseases, 9th Edition, Clinical Modification provides standardized classification of diseases.
37. IgG - Immunoglobulin G.
38. KIA - Killed in Action.
39. KTO - Kuwait Theater of Operations.
40. LDH - Lactic Acid Dehydrogenase.
41. LP - Lumbar Puncture.
42. MIA - Missing in Action.
43. MOS - Military Occupational Specialty.
44. M.D. - Doctor of Medicine.
45. MRI - Magnetic Resonance Imaging.
46. MSLT - Multiple Sleep Latency Test.
47. NCV - Nerve Conduction Velocity.
48. OIF - Operation Iraqi Freedom.
49. O&P - Ova and Parasites.
50. P.A. - Physician’s Assistant.
51. PFT - Pulmonary Function Test.
52. Plt - Platelet.
53. PPD - Purified Protein Derivative.
54. PTF - Patient Treatment File.
55. PTSD - Post-traumatic Stress Disorder.
56. Persian Gulf Area of Service. For eligibility purposes, active military duty in Southwest Asia during the Gulf War would include service in one or more of the following areas: Iraq, Kuwait, Saudi Arabia, the neutral zone (between Iraq and Saudi Arabia), Bahrain, Qatar, the United Arab Emirates, Oman, waters of the Persian Gulf, Red Sea, Arabia Sea, and Gulfs of Aden and Oman.
57. (Persian) Gulf War Period of Service. Public Law 102-25 established a (Persian) Gulf War period of service that affects persons serving on active duty as of August 2, 1990. The wartime period of service continues until terminated by Presidential proclamation or by law.
58. Records Control Schedule (RCS) 10-1. Provides instructions for record retention and disposition.
59. RHP - Reproductive Health Problems.
60. SCID - Structured Clinical Interview for DSM-III.
61. SCUDS - The common name for Soviet designed surface to surface missiles.
65. SMA (6/12) - SMA is a Manufacturer’s Trademark for a Chemistry Analyzer.
66. SSN - Social Security Number.
67. T4 - Thyroxine Total Serum.
68. TB - Tuberculosis.
69. TSH - Thyroid Stimulating Hormone.
70. UCAP - Uniform Case Assessment Protocol.
71. UGI - Upper Gastrointestinal.
72. VA - Department of Veterans Affairs.
73. VBR - Veterans Benefits Representative.
74. VDRL - Venereal Disease Research Laboratory.
75. VHA - Veterans Health Administration.
76. VA Form 10-9009B - Identification Sticker entitled “Persian Gulf.”
77. WBC - White Blood Cells.
PROTOCOL FOR CONDUCTING THE PHYSICAL EXAMINATION AND ORDERING DIAGNOSTIC STUDIES
1. It is essential that a complete medical history, physical examination and interview be performed and documented on appropriate forms. The required forms that must be fully completed are: VA Form 10-9009a (July 1995), Gulf War Registry Code Sheet; dated follow- up letters which must be maintained in the paper administrative health record or scanned and attached to an appropriately titled CPRS Progress Note; and all medical records of the registry examination, i.e., Standard Form (SF) 88, Report of Medical Examination, and SF 509, Progress Notes (for follow-up) which must be maintained within CPRS.
NOTE: This should be accomplished by or under the direct supervision of the Environmental Health (EH) Clinician. Examination data will be recorded in the veteran’s medical record as routinely as done for any other medical examination.
The complete medical history needs to address the following:
(a) Family history;
(b) Occupational history;
(c) Social history including tobacco, alcohol, drug use;
(d) Civilian exposure(s) history to possible toxic agents;
(e) Psychosocial history; and
(f) Review of systems.
2. The person actually performing the physical examination will be identified by name, signature and title (i.e., Doctor of Osteopathy, Doctor of Medicine, Physician’s Assistant, etc.).
3. When a GWR examination is done as part of a compensation and pension examination, the physical examination will be done by/or under the direct supervision of the EH Clinician or designee.
4. The physician should be aware of the variety of exposures endemic to the GW area. These are listed in Appendix C. There has been a wide distribution of major categories of diagnosis reported by VA EH Clinicians; however, no significant variation in occurrence of major categories of medical problems has been identified. We are listing below (for informational purposes) some of the health problems and/or diseases that should be considered:
NOTE: Recommended coding (refer to International Classification of Diseases, Current Edition)
Complaints Symptom Code Diagnosis Diagnostic Code (If confirmed) (1) Other Symptoms involving: Nervous and Musculoskeletal Systems for Pain in the joint 78199 Arthralgia 71940-71949
(3) Insomnia with sleep apnea 78051 Sleep Apnea 99001 or 78053
DIAGNOSIS
(1) Amebiasis
(2) Apnea, sleep
(3) Arthralgia
(4) Asthma
(5) Brill’s Zinsser disease (recrudescent typhus)
(6) Bronchiectasis
(7) Bronchopneumonia, organism unspecified
(8) Brucellosis
Chronic obstructive pulmonary disease, not elsewhere classified
(10) Chronic bronchitis
(11) Chronic Fatigue Syndrome
(12) Chronic Laryngotracheitis
(13) Chronic respiratory conditions due to fumes and vapors
(14) Emphysema
(15) Fibromyalgia
(16) Giardiasis
(17) Leishmaniasis
(18) Malaria
(19) Other and unspecified diseases of upper respiratory tract
(20) Pneumoconiosis due to other silica or silicates
(21) Pneumoconiosis, unspecified
(22) Unspecified chronic respiratory disease
(23) Respiratory conditions due to unspecified external agent
(24) Sandfly fever (phlebatomus fever)
(25) Schistosomiasis (bilharziasis)
(26) Toxoplasmosis
(27) Typhoid fever, also carrier - V02.1
(28) Tuberculosis, specify variant(s)
(29) Viral hepatitis
(30) Memory loss
(31) Polyneuropathy
(32) Skin rash
(33) Adjustment disorder, including Post Traumatic Stress Disorder (PTSD)
(34) Alcohol dependence syndrome
(35) Drug dependence
5. In gathering these data, it is important to determine and record, the:
a. Time of onset of the symptoms or conditions,
b. Intensity,
c. Degree of physical incapacitation, and
d. Details of any treatment received.
6. Each veteran will be given the following baseline laboratory studies (Phase I Registry Examination):
a. Complete Blood Count (CBC);
b. Blood and serum screening tests (SMA-6, SMA-12 or equivalent) including glucose, electrolytes or equivalent blood chemistries and enzyme studies; and
c. Urinalysis.
7. Appropriate additional diagnostic studies should be performed and consultations obtained as indicated by the patient’s symptoms and the physical and laboratory findings.
NOTE: If individuals have unexplained illnesses, after a Phase I registry examination is performed, a Phase II examination is conducted according to the judgment of the EH Clinician or Primary Care Clinician (see par. 9 and App. G, for instructions).
a. Other diagnostic studies, such as pulmonary function test, sperm counts, should be performed if medically indicated.
b. Laboratory tests results should be filed in the CHR and/or CPRS.
INSTRUCTIONS FOR COMPLETING VA FORM 10-9009a GULF WAR REGISTRY CODE SHEET, PHASE 1
1. General Instructions for completing Department of Veterans Affairs (VA) Form 10-9009 (July 1995).
a. Electronic entry of Gulf War Registry (GWR) code sheet data should be completed and transmitted to the Austin Automation Center (AAC), Austin, TX database via website http: //vaww.registries.aac.va.gov. Instructions for accessing this website are included on the home page. The home page includes a User’s Guide, Frequently Asked Questions, Validation Reports, and Logon functions. Edits are automatically accomplished at the time of entry. The completed registry code sheet must be maintained in the paper administrative health record or scanned and attached to an appropriately titled Computerized Patient Record System (CPRS) progress note.
NOTE: As of September 30, 2003, the AAC no longer accepts hard copies of code sheets mailed to their offices in Austin, TX.
b. Follow instructions carefully to ensure that all data fields are accurately completed.
(1) Part I of the code sheet may be completed in the presence of the veteran.
(2) Parts II and III of the code sheet should be completed at the time of the examination by the Environmental Health (EH) or Primary Care Clinician and coded by appropriate staff, either the EH Coordinator and Coding Clerk. NOTE: Careful attention should be paid to assigning the correct code for both complaints (symptoms) and diagnosis. International Classification of Diseases, Clinical Modification, 9th Edition (ICD-9-CM) code 78999, for uncodable complaints (symptoms), should be assigned only after all coding possibilities have been thoroughly explored. The indiscriminate use of ICD-9-CM code 78999 may result in skewed or misleading statistics.
2. Instructions for Completing Part I (Initial Examination)
a. Item 1. Facility Number and Suffix. Facility Number and Suffix. Enter facility code as listed on website http://vaww.aac.va.gov/npcd/facility_quick_reference.asp or http://vaww.aac.va. gov/npcd/new/Stations.php .
b. Item 2. Last Name of Veteran. Enter veteran’s current last name. Do not use apostrophe and/or hyphen in the name. If the last name is followed with JR, SR, I, II, III, do not use commas, etc.
c. Item 3. First Name of Veteran. Enter veteran’s first name.
d. Item 4. Middle Name of Veteran. Enter veteran’s middle name or initial.
e. Item 5. Type of Examination. The following are transaction types that appear at the registry logon:
A - Initial Examination. The veteran’s first Gulf War (GW) examination. If an initial examination code sheet has already been entered for the veteran, “A” is not available.
B – Deletes an entire initial examination that was originally submitted through the manual batch process. Do not use this to delete an initial examination that was entered via the website. If the transaction was entered using the registries website, simply edit the original transaction. This will automatically create a Type “B” that deletes the original and adds the corrected transaction to the master file.
C - Follow-up Examination. The veteran’s second and subsequent GWR examination. Entering data for the first follow-up examination is required. Data from subsequent follow-up code sheets will not be entered or transmitted to the AAC unless a diagnostic code differs from previously submitted code sheets.
NOTE: Consultations relating to the initial or first-time examination are not considered follow- up examinations for the purpose of this registry.
D - Deletes an entire follow-up examination that was originally submitted through the manual batch process. Do not use this to delete a follow-up examination that was entered via the website. If the transaction was entered using the registries website, simply edit the original transaction.
E - Transmits a change in demographics, i.e., name, address, or date of birth. Enter “E,” and complete items with name, Social Security Number (SSN), date of birth, and address. No other items need to be completed.
I - To include those veterans whose names are not on the GWR but would like their name and address included on a mailing list for the “Gulf War Review” newsletter.
P - To include diagnoses submitted by a private physician, on the physician’s letterhead paper, and signed by that physician, certifying the accuracy of the diagnoses.
X - Identifies and verifies that a registry participant is deceased. Complete items with the name, SSN, and date of birth. No other items need to be completed.
f. Item 6. SSN. The SSN that is entered at Registry Search via http://vaww.registries.aac.va. gov , appears in these spaces.
g. Item 7. Date of Birth. Enter numerical equivalent for the month, day, and four-digit year (e. g., 01/19/1960).
h. Item 8. Permanent address. Enter veteran’s permanent street address.
8a = Enter veteran’s city or town. 8b = Enter County and State. 8c = Enter zip code of permanent residence (National Zip Code Directory). 8d = Optional (Extended Zip Code). 8e = The user does not enter the County and State Code, as they are entered automatically.
i. Item 9. Race or Ethnicity. Enter from the pull-down menu.
j. Item 10. Marital Status. Enter one of the following codes from the pull- down menu:
1 = Married 2 = Divorced 3 = Separated 4 = Widowed 5 = Single, Never Married
k. Item 11. Sex. Enter one of the following codes from the pull-down menu:
M = Male F= Female
l. Item 12. Current Status. Enter one of the following codes from the pull-down menu:
1 = Inpatient 2 = Outpatient 3 = Incarcerated 4 = Active Duty (Outpatient) 5 = Active Duty (Inpatient)
m. Item 13. Branch of Service. If veteran was in more than one branch of service, enter the latest GW service. Enter one of the following codes:
1 = Army (including Reserves and National Guard) 2 = Air Force (including Reserves and National Guard) 3 = Navy (including Reserves) 4 = Marine Corps 5 = Coast Guard 6 = Other (e.g., Public Health Service, National Oceanic and Atmospheric Administration)
n. Item 14, 14A, and 14B. Military Service in Persian Gulf.
(1) Enter one of the following codes from the pull-down menu:
Y = Yes (If yes, list the dates of veterans last two periods of service in Persian Gulf.) N = No (If the veteran did not serve in Persian Gulf, the veteran is not eligible for a GWR examination.)
(2) Item 14A. Enter the numerical equivalent of the month and also two digits of the year of last period of service in Persian Gulf (e.g., from 02/91 to 05/91).
(3) Item 14B. If veteran had two or more periods of service in Persian Gulf, the longest period of service should be entered. If only one period of service in Persian Gulf, enter in 14A and leave 14B blank.
o. Item 15, 15A, and 15B. In What Area(s) Did Veteran Serve?
(1) Item 15A. Enter one of the following codes from the pull-down menu:
1 = Combat Zone 2 = Other Land Area 3 = Sea Duty
(2) Item 15B. If other service is indicated or, if the response is “Don’t Know” enter appropriate code from pull-down menu.
4 = Other (Specify i.e., Air Force: Ground or Air Crew, etc.) 5 = Don’t Know
p. Item 16, 16A-16E. Military Units, Military Occupational Specialty (MOS) and MOS-Different Duties.
(1) Item 16A. Military Units. Enter the military unit in which the veteran served. Specify complete unabbreviated title, i.e., company, battalion, corps, ship, division, etc., (e.g., Company C, 1st Battalion, 4th Army).
(2) Item 16B. Military Occupational Specialty (MOS): Enter the veteran’s MOS.
(3) Item 16C. Were actual duties different from MOS? Enter one of the following codes from the pull-down menu: If no, go to Item 16E.
Y = Yes N = No
(4) Item 16D. If yes, enter actual duties that were different from MOS.
(5) Item 16E. Enter the name of unit with which the veteran had the longest and next to longest period of service while in the Persian Gulf.
NOTE: Items 16A and 16E: These units could be different from the one to which the veteran was assigned if the veteran was on detached duty.
q. Items 17, 17A, and 17B. Last two periods of service, (if different from 14A and 14B). Enter the numerical equivalent of the month and the last two digits of the year for the last two periods of service regardless of whether or not they were in the Persian Gulf (e.g., from 12/90 to 04/91 and 9/90 to 11/90). If veteran did not have more than one period of service, leave blank. For active duty military personnel, enter date when service began (e.g., 12/90) and enter nines (e.g., 99/99) to indicate the veteran is still actively serving in the military.
r. Items 18, 18A-18Z1. Veteran’s Exposure to Environmental Factors. Enter the following codes from pull-down menu: Y = Yes N = No
(1) Item 18A. Are you currently smoking cigarettes? If no, go to Item 18D.
(2) Item 18B. If yes, how many years have you been smoking cigarettes? Enter number of years.
(3) Item 18C. If yes, on the average, how many packs are you smoking per day?
(4) Item 18D. Have you smoked cigarettes in the past? If no, go to Item 18G.
(5) Item 18E. If yes, how many years did you smoke?
(6) Item 18F. If yes, on the average how many packs did you smoke per day?
(7) Items 18G-Z1. While in the Persian Gulf do you believe you were exposed to any of the following? Enter the following codes from the pull-down menus:
Y = Yes N = No U = Unknown
(8) Item 18G. Smoke from oil fires?
(9) Item 18H. Smoke or fumes from tent heaters?
(10) Item 18I. Cigarette Smoke (passive) from others?
(11) Item 18J. Diesel and/or other petrochemical fumes?
(12) Item 18K. Exposure to burning trash and/or feces?
(13) Item 18L. Skin exposure to diesel or other petrochemical fumes?
(l4) Item 18M. Chemical Agent Resistant Compound (CARC) paint?
(15) Item 18N. Other paints and/or solvents and/or petrochemical substances?
(16) Item 18O. Depleted uranium?
(17) Item 18P. Microwaves?
(l8) Item 18Q. Personal pesticide use, including creams, sprays, or flea collars?
(19) Item 18R. Nerve gas or other nerve agents?
(20) Item 18S. Drug (pyridostigmine) used to protect against nerve agents?
(21) Item 18T. Mustard gas or other nerve agents?
(22) Item 18U. Ate or drank food contaminated with smoke, oil or other chemical?
(23) Item 18V. Ate food other than provided by Armed Forces?
(24) Item 18W. Bathed in or drank water contaminated with smoke, oil or other chemical?
(25) Item 18X. Bathed in water other than provided by Armed Forces?
(26) Item 18Y. Immunization against anthrax?
(27) Item 18Z. Immunization against botulism?
(28) Item 18Z1. Enter other exposures.
s. Items 19A-F. Gulf War Experience. Did you have any of the following experiences while in the Persian Gulf? Enter codes from the pull-down menus:
(1) Item 19A. Did you ever go on combat patrols or have other very dangerous duty? Enter one of the following codes:
1 = No 2 = 1-3 times 3 = 4-12 times 4 = 13-50 times 5 = 51 times, or more 6 = Unknown (2) Item 19B. As far as you know, were you ever under enemy fire, including Soviet designed surface to surface missiles (commonly known as SCUDS)? Enter one of the following codes:
1 = Never 2 = less than 1 day 3 = less than 1 week 4 = 1-4 weeks 5 = 4 weeks or more 6 = Unknown
(3) Item 19C. What percentage of people in your unit (your immediate group) were Killed in Action (KIA), wounded or Missing In Action (MIA)? Enter one of the following codes:
(4) Item 19D. How often did you see someone hit by incoming or outgoing rounds? Enter one of the following codes:
1 = Never 2 = 1-2 times 3 = 3-12 times 4 = 13-50 times 5 = 51 times or more 6 = Unknown
(5) Item 19E. How often were you in danger of being injured or killed (i.e., pinned down, overrun, ambushed, near miss, etc.)? Enter one of the following codes:
1 = Never 2 = 1-2 times 3 = 3-12 times 4 = 13-50 times 5 = 51 times or more 6 = Unknown
(6) Item 19F. Witnessed chemical alarms? Enter one of the following codes:
Y = Yes N = No U = Unknown
t. Item 20. Veteran’s Health (Veteran’s evaluation) Item 20A. Enter one of the following codes from pull-down menu that best describes veteran’s health after GW Service:
1 = Very good 2 = Good 3 = Fair 4 = Poor 5 = Very poor
u. Item 21. Veteran's Functional Impairment
(1) Item 21A. Enter code that describes veteran’s assessment of the veteran’s functional impairment, after GW Service, using one of the following assessment codes from the pull- down menu:
1 = No impairment 2 = Slight impairment 3 = Moderate impairment 4 = Severe impairment
(2) Item 21B. How many workdays were lost by veteran due to illness in the past 90 days? Enter number of days lost.
v. Item 22. Evidence of Birth Defects and Infant Death(s) among veteran’s children and problems with pregnancy and infertility NOTE: Birth defects are any structural, functional, or biochemical abnormality at birth whether genetically determined or induced during gestation that is not due to injuries suffered during birth.
(1) Item 22A. How many children does the veteran have? If none, go to 22C.
(2) Item 22B. Birth Defects. How many of these children were born with birth defects? Enter number of children. If none, go to Item 22C.
(a) Item 22B1. How many of these children were conceived before and/or after the veteran’s GW service? If none, go to Item 22B2.
(b) Item 22B1(a). If yes, enter the maternal age at conception of first child conceived before GW service.
(c) Item 22B2. How many children were conceived during or after the veteran’s GW service? If none, go to Item 22C.
(d). Item 22B2(a) If yes, Enter the maternal age at conception of first child conceived during or after the veteran’s GW service.
(3) Item 22C. Infertility (Problems of veteran or spouse becoming pregnant). NOTE: Infertility=relative sterility defined as inability to conceive after 12 or more months of intercourse without use of contraception when neither spouse is surgically sterilized. Has veteran or spouse had infertility problems? Enter one of the following codes:
Y = Yes N = No (If No, go to Item 22D.)
(a) Item 22C1. Has veteran or spouse had infertility before GW service? Enter one of the following codes:
Y = Yes N = No (If No, go to Item 22C2.)
(b) Item 22C1(a). Enter the maternal age during first attempts to conceive.
(c) Item 22C2. Has veteran or spouse had infertility after return from GW service? Enter one of the following codes:
Y = Yes N = No (If No, go to Item 22D.)
(d) Item 22C2(a). Enter the maternal age during first attempts to conceive.
(4) Item 22D. Miscarriage(s). NOTE: Miscarriages are spontaneous expulsion of the products of conception before 20 weeks of gestation (spontaneous abortion). Has veteran or spouse had miscarriage(s)? Enter one of the following codes:
Y = Yes N = No (If No, go to Item 22E.)
(a) Item 22D1. If yes, has veteran or spouse had miscarriage(s) before GW service? Enter one of the following codes:
Y = Yes N = No (If No, go to Item 22D2.)
(b) Item 22D1(a). If yes, enter the maternal age at conception.
(c) Item 22D2. Has veteran or spouse had miscarriage(s) after return from GW service? Enter one of the following codes:
Y = Yes N = No (If No, go to Item 22E.)
(d) Item 22D2(a). If yes, enter the maternal age at conception.
(5) Item 22E. Still Birth(s). NOTE: Still births are births after 20 weeks of gestation of an infant who showed no evidence of life after birth. Has veteran or spouse had still birth(s)? Enter one of the following codes:
Y = Yes N = No (If No, go to Item 22F.)
(a) Item 22E1. Has veteran or spouse had still birth(s) before GW service? Enter one of the following codes:
Y = Yes N = No (If No, go to Item 22E2.)
(b) Item 22E1(a). Enter the maternal age at conception of the still born child.
(c) Item 22E2. Has veteran or spouse had still birth(s) after return from GW service? Enter one of the following codes: Y = Yes N = No (If No, go to Item 22F.)
(d) Item 22E2(a). If yes, enter the maternal age at conception of the still born child. Enter age.
(6) Item 22F. Infant Death(s). NOTE: Death that occurred within 1 year of birth among babies born alive. Has veteran or spouse had babies with infant death(s)? Enter one of the following codes:
Y = Yes N = No (If No, go to Item 22G.)
(a) Item 22F1. Has veteran or spouse had babies with infant death(s) before GW service? Enter one of the following codes:
Y = Yes N = No (If No, go to Item 22F2.)
(b) Item 22F1(a). If yes, enter maternal age at conception of the infant who died.
(c) Item 22F2. Has veteran or spouse had babies with infant death(s) after return from GW service? Enter one of the following codes:
Y = Yes N = No (If No, go to Item 22G.)
(d) Item 22F2(a) Enter the maternal age at conception of the infant who died.
(7) Item 22G. If applicable and the woman veteran reports she was pregnant in the Persian Gulf, record the date of child's birth and hospital of birth to facilitate follow-up, if needed.
3. Instructions for Completing GWR Code Sheet, Part II (Initial Examination). (To be completed by the examining clinician) List up to ten major and current symptoms and/or complaints. If veteran has more than ten, enter most severe. Any additional symptoms should be entered under Remarks, Item 32.
NOTE: Coders, use ICD-9-CM “Symptom” codes from the current ICD-9-CM codebook. For uncodable symptoms use “78999.” For no known complaints, use “78000.” However, ICD-9- CM code 78999 should only be used if all possible codes have been reviewed; if necessary, seek physician consultation to make a correct choice.
a. Item 23. Date of Examination. Enter the numerical equivalent for the month, day, and year in that order (e.g., 9/22/1992).
b. Item 24. Total Number of Veteran’s Complaints.
c. Item 25, 25A-M. Veteran’s Complaints, Month and Year of Onset, Duration in Months, Whether Symptom is Currently Present, and Most Severe Complaint.
(1) Items 25A-J.
(a) Describe veteran’s complaints/symptoms.
(b) State ICD-9-CM codes.
(c) State duration in Months.
(d) State whether the symptom is still present, using the following codes: Y=Yes or N=No from the pull-down menu.
(e) State month and year of onset.
(2) Item 25K. Most Severe Symptom/Complaint. Enter the Item code from pull-down menu for most severe symptom (Symptom from Items A-J, which the veteran considers the most severe; i.e., the chief complaint).
d. Item 26, A-S. Diagnostic workup/consultation. Enter one of the following codes from pull- down menus:
(18) Item 26R. Other. Were any additional workups and/or consultations performed as part of GWR examination which were not listed in Items 26A-Q. Enter one of the following codes from pull-down menu: Y = Yes N = No
(19) Item 26S. Specify on code sheet any additional workups and/or consultations performed as part of GWR registry examination that were not listed in Item 26A-Q.
e. Item 27, 27A-B. Diagnoses. Item 27A. List up to ten major definite medical diagnoses on lines 27A-J. The examining physician will select the ten most significant and/or serious in the examining physician’s opinion, listing the primary diagnosis in Item A. Any additional diagnosis (es) must be included in patient’s medical record. Coders are to code each diagnosis listed from the current ICD-9-CM codebook. Leave blank if no diagnosis is made. Do not repeat or enter symptom codes already listed under Item 25A-J.
f. Item 28. No Diagnosis Made. If no diagnosis is made, enter a “1,”otherwise leave this block blank. This item must be considered in conjunction with Item 27, “Diagnoses.” A “1” needs to be entered for Item 28 only when no diagnosis is given in Item 27 indicating that no significant defect, disease, injury, or history of a relevant diagnosis in the past is detected.
g. Item 29, 29A-F. Disposition. Enter one of the following codes from the pull-down menu: Y = Yes, or N = No.
(1) Item 29A. Examination completed?
(2) Item 29B. Hospitalized at the VAMC for further tests?
(3) Item 29C. Hospitalized at the VAMC for treatment?
(4) Item 29D. Referred for outpatient care?
(5) Item 29E. Referred to private physician, non-VA clinic or non-VA hospital?
(6) Item 29F. Biopsy?
h. Item 30. Phase I examination, refer to paragraph 5, has been completed and the physician has determined that veteran has unexplained illness. Enter one of the following codes from the pull-down menu: Y = Yes; or N = No.
i. Item 31. Has Phase II examination been initiated? Enter the following codes from the pull- down menu: Y = Yes; N = No.
j. Item 32. Remarks. Utilize this section for any additional information.
k. Item 33. Name of Examiner. Enter full name of examiner.
l. Item 34. Title of Examiner. Full title of examiner.
m. Item 35. Signature of Examiner. Signature of examiner, if electronic signature is available. Item 35a. Signature of Physician. Signature of EH Clinician, if electronic signature is available.
4. Follow-up Examinations. Follow-up examinations should be entered into the GWR using Type C. The instructions for completing Parts I, II and III are available via website http://vaww. registries.aac.va.gov . Only the first follow-up examination is entered into the GWR unless subsequent follow-up examination data contains new diagnoses. EXAMPLE GULF WAR REGISTRY FOLLOW-UP LETTER (MEDICAL PROBLEMS INDICATED) DEPARTMENT OF VETERANS AFFAIRS Medical Center Anywhere, U.S.A. Zip In Response Reply To:
(Date)
(Name/Address)
Dear __________________:
We sincerely appreciate your recent participation in the Department of Veterans Affairs (VA) Gulf War 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 that may have resulted from service in Southwest Asia during the Gulf War and/or Operation Iraqi Freedom.
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 (telephone number) at the earliest possible time to cancel and reschedule.
The results of your examination will be maintained by VA and will be available for future use as needed. If you have any questions or concerns about your Gulf War Registry examination, please contact the Veterans’ Environmental Health Coordinator at (telephone number) for assistance.
Whether you are eligible for cost-free treatment or will be responsible for co-payments will be determined by your income and other factors unless the VA determines that your health problems are service connected. You may wish to file a claim for compensation to establish possible service connection. The injury or illness need not have been incurred in combat; the law requires only that a disease or disability was incurred or aggravated during military service.
Please remember that this examination does not automatically initiate a claim for VA benefits. If you wish to file a claim, please contact the nearest VA Regional Office. In your area, the Regional Office is located at (address). Their telephone number is (telephone number). If you need any further assistance, you may contact one of the following toll-free numbers:
(1) Veterans Benefits Representative: 1-800-827-1000 (for information on filing claims); (2) Veterans Health Benefits Service Center: 1-877-222-VETS (8387) or (3) VA Helpline: 1-800-749-8387.
An outreach program has been implemented by which VA notifies all individuals listed in the registry of significant VA activities, including the health consequences of military service in the Gulf War theater of operations during the Gulf War or Operation Iraqi Freedom. You will be receiving a “Gulf War Review” which is published periodically by VA’s Environmental Agents Service. A copy of this “Review” is enclosed for your reference.
For other veterans who served on active duty in a designated theater of combat operations after the Persian Gulf War or in combat against a hostile force during a period of hostilities after November 11, 1998, VA is authorized to provide a broad range of health care services to them for a 2-year period following separation from military service.
We trust this information is helpful to you. Once again, your participation in the registry is appreciated.
Sincerely yours,
(Signature) Name of Environmental Health Clinician
Enclosure
EXAMPLE GULF WAR REGISTRY FOLLOW-UP LETTER (NO MEDICAL PROBLEMS INDICATED) DEPARTMENT OF VETERANS AFFAIRS VA Medical Center Anywhere, U.S.A. Zip
In Response Reply To: (Date)
Name/Address
Dear ___________________:
We sincerely appreciate your recent participation in the Department of Veterans Affairs (VA) Gulf War (GW) 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 that may have resulted from service in Southwest Asia during the Gulf War or Operation Iraqi Freedom (OIF).
As discussed at the conclusion of your visit, results of your examination and laboratory tests indicate that there are no detectable medical problems. At this time you have no reason to be concerned about any adverse health effects resulting from your service in the Persian Gulf. However, in the future if you have a medical problem, I would encourage you to seek the help and advice of Environmental Health Clinicians or Coordinators at the nearest VA medical center or outpatient clinic. You may reach us at (telephone number).
The results of your examination will be maintained by VA and will be available for future use as needed.
Please remember that this examination does not automatically initiate a claim for VA benefits. If you wish to file a claim 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). VA may pay compensation for current disability due to any injury or disease that was incurred or aggravated during military service. The condition does not have to be related to combat.
If you need any further assistance, you may call one of the following toll-free numbers:
(1) Veterans Benefits Representative: 1-800-827-1000 (for information on filing claims) (2) Veterans Health Benefits Service Center: 1-877-222-VETS (8387) or (3) VA Helpline: 1-800-749-8387
An outreach program has been implemented by which VA notifies all individuals listed in the registry of significant VA activities, including the health consequences of military service in the Gulf War theater of operations during the Gulf War. You will be receiving a “Gulf War Review” which is published periodically by VA’s Environmental Agents Service. A copy of this “Review” is enclosed for your reference.
For other veterans who served on active duty in a designated theater of combat operations after the Persian Gulf War or in combat against a hostile force during a period of hostilities after November 11, 1998, VA is authorized to provide a broad range of health care services to them for a 2-year period following separation from military service.
We trust this information is helpful to you. Once again, your participation in the registry is appreciated.
Sincerely yours,
______(Signature)_____________________ Name of Environmental Health Clinician
Enclosure
UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)
1. Phase I-Level Laboratory Evaluations
a. Complete Blood Count (CBC),
b. Urinalysis, and
c. Blood Chemistry - SMA-6. (SMA is a Manufacturer’s Trademark for a Chemistry Analyzer)
2. Phase II-Level Evaluation Protocol. Phase II-Level Evaluations are recommended for those veterans after complete clinically-indicated evaluations are conducted and the clinician determines that the patient has an unexplained illness. Individuals who, after completing Phase I or registry evaluations, have a disability and do not have a clearly defined diagnosis which explains their symptoms, must receive the following supplemental baseline laboratory tests and consultations.
(14) Tuberculosis (TB) skin test Purified Protein Derivative (PPD).
b. Consultations, to include:
(1) Dental, but only if participant’s annual screening is not done.
(2) Infectious Disease.
(3) Psychiatry, but only with physician-administered instruments.
(a) Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM III-R). NOTE: Delete modules for mania and psychosis.
(4) Neuropsychological Testing, but only as indicated by a psychiatry consult.
c. Symptom-specific Examination. Individuals who have the following symptoms need to have the listed minimum work-up.
(1) Diarrhea, to include:
(a) Gastrointestinal (GI) consult,
(b) Stool for Ova and Parasites (O&P),
(c) Stool Leukocytes,
(d) Stool culture,
(e) Stool volume,
(f) Colonoscopy with biopsies, and
(g) Esophagastroduodenoscopy (EGD) with biopsies and aspiration.
(2) Abdominal pain to include:
(a) GI consult,
(b) EGD with biopsy and aspiration,
(c) Colonoscopy with biopsy,
(d) Abdominal Ultrasound,
(e) Upper Gastrointestinal (UGI) series with small bowel follow-through, and
(f) Abdominal Computed Tomography (CT) Scan.
(3) Headache
(a) Magnetic Resonance Imaging (MRI) of the head, and
(b) Lumbar Puncture (LP) to include:
1. Glucose,
2. Protein,
3. Cell Count,
4. VDRL,
5. Oligoclonal (lgG),
6. Myelin basic protein,
7. Opening pressure, and
8. Neurology.
(4) Muscle Aches and/or Numbness
(a) Electromyogram (EMG), and
(b) Nerve Conduction Velocity (NCV).
(5) Memory Loss, only if verified by neuropsychological testing, to include:
(a) Magnetic Resonance Imaging (MRI),
(b) LP, NOTE: See tests on headache evaluation.
(c) Neurology consult,
(d) Neuro-psychological testing,
(6) Vertigo and/or Tinnitus, to include:
(a) Audiogram,
(b) Electronystamogram (ENG), and
(c) Brainstem Auditory Evoked Response (BAER).
(7) Chronic Fatigue, to include:
(a) Polysomnography, and
(b) Multiple Sleep Latency Test (MSLT).
(8) Chronic Cough and/or Shortness of Breath, to include:
(a) Pulmonary Consult,
(b) Pulmonary Function Test (PFT) with exercise and Arterial Blood Gases (ABG),
(c) If routine PFT’s are negative, perform Methacholine challenge test, and
(d) Bronchoscopy with biopsy and/or lavage which is to be considered if PFTs are normal.
(9) Chest Pain and/or Palpitations, to include:
(a) Electrocardiogram (ECG),
(b) Exercise Stress Test, and
(c) Holter monitor.
(10) Skin Rash, to include:
(a) Dermatology consult, and
(b) Consider a biopsy.
(11) Reproductive Concerns, to include for:
(a) Males, an urology consult; and
(b) Females, a gynecology (GYN) consult.
(c) Additional elements recommended for the evaluation of Gulf War veterans with complaints of Reproductive Health Problems (RHP):
1. Detailed genitourinary history and/or problems, e.g.,:
a. Sexual,
b. Genitourinary symptoms,
c. Menstrual,
d. Contraceptive practices,
e. Pregnancy-related,
f. Conception,
g. Birth defects,
h. Congenital disorders,
i. Menopause,
j. Prior infections,
k Prior surgery, and
l. Exposures to toxic agents, etc.
2. Detailed genital and/or pelvic examination.
3. Laboratory and ancillary testing, e.g.;
a. Pap tests; and
b. Tests for genitourinary infections.
4. Urologist consultation for male veterans who have RHP that cannot be diagnosed or managed successfully by primary care practitioners.
5. Gynecology consultation for female veterans who have RHP that cannot be diagnosed or managed successfully by primary care practitioners.
(d) Additional elements for evaluation of Gulf War veterans with complaints of infertility.
1. Detailed menstrual and reproductive history (such as the Infertility Questionnaire utilized by Walter Reed Army Medical Center).
2. Semen analysis, e.g.:
a. Volume,
b. pH,
c. Liquefaction,
d. Sperm concentration,
e. Motility,
f. Progressive motility,
g. Sperm viability,
h. Leukocytes, and
i. Morphology.
3. Referral to an infertility specialist or program.
(e) Additional elements for evaluation of GW veterans with complaints related to birth defects or genetic disorders in offspring conceived during or after GW service.
1. Detailed history of congenital or genetic disorders (such as the Patient Genetic Screen Questionnaire utilized by Walter Reed Army Medical Center).
2. Detailed occupational exposures questionnaire (such as Worker and Supervisor Questionnaires utilized by National Naval Medical Center).
3. Referral to a genetic disease specialist or program.
INSTRUCTIONS FOR COMPLETING GULF WAR UNIFORM CASE ASSESSMENT PROTOCOL (UCAP), PHASE II, PART III
1. General Instructions for Completing Department of Veterans Affairs (VA) Gulf War Registry Examination, Uniform Case Assessment Protocol (UCAP), Phase II.
a. The Phase II examination needs to be offered to all eligible Gulf War (including Operation Iraqi Freedom) veterans with unexplained illnesses. The Phase II examination needs to be performed after the completion of the Phase I registry examination and a thorough clinically- based evaluation of the veteran’s symptoms as deemed necessary by the examining physician.
b. Phase II needs to be performed at the local VA medical facility or if the medical expertise is unavailable, local referral must be made to the nearest regional tertiary care center or War Related Illness and Injury Study Center (WRIISC). NOTE: Refer to VHA Handbook 1303.5 or website www.va.gov/environagents and video entitled War and Health: Treating War-Related Illnesses at VA’s WRIISCs.
2. Instructions for Completing Part III, Phase II
a. Tests and Consultations. Only those entries which are related to the veteran’s symptoms and deemed necessary by the examining physicians need to be completed; leave test and consult questions that are not applicable blank Select either (Y)es or (N)o from the pull-down menu. NOTE: Refer to website http://vaww.registries.aac.va.gov for instructions.
(1) Item 1. Were the following tests performed? Enter one of the following codes from the pull-down menu:
(4) Item 4. Tuberculosis (TB) Skin Test Purified Protein Derivative (PPD)?
(5) Item 5. Chest X-ray?
(6) Item 6. Psychiatric Consultation?
(a) Item 6A. Structured Clinical Interview for Diagnosis (SCID) for Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R). Was the SCID interview given?
(b) Item 6B. Clinical Administered Post-traumatic Stress Disorder (PTSD) Scale (CAPS). Was the CAPS performed?
(c) Item 7. List of Diagnoses. Designated physician staff or clinical staff are to provide narrative description of diagnoses. If none, leave blank. NOTE: Coders: Enter International Classification of Diseases, Clinical Modification, 9th Edition (ICD-9) codes as required.
b. SYMPTOM-SPECIFIC EXAMINATIONS, PHASE II NOTE: Complete only those questions which are appropriate to the veteran’s symptoms; otherwise leave these blank.
(a) If there was a medical indication, was this examination performed?
(b) List of Diagnoses and ICD-9 codes.
(4) Item 11. Diarrhea and/or Abdominal Pain.
(a) Did patient receive a GI (Gastroenterology) consult?
(b) List Diagnoses and ICD-9 codes.
(5) Item 12. Headache and/or Memory Loss.
(a) Did patient receive neurology consult?
(b) List Diagnoses and ICD-9 codes
(6) Item 13. Muscle Aches or Numbness.
(a) Did patient receive a neurology consult?
(b) List Diagnoses and ICD-9 codes.
(7) Item 14. Chronic Fatigue.
(a) Did patient receive consult(s) relating to chronic fatigue?
(b) List Diagnoses and ICD-9 codes.
(8) Item 15. Joint Pain.
(a) Rheumatology Consult. Did patient receive rheumatology consult?
(b). List Diagnoses and ICD-9 codes.
(9) Item 16. Chronic Cough and/or Shortness of Breath.
(a) Pulmonary Consult. Did patient receive pulmonary consult?
(b) List Diagnoses and ICD-9 codes.
(10) Item 17. Skin Rash.
(a) Dermatology Consult. Did patient receive a dermatology consult?
(b) List Diagnoses and ICD-9 codes.
(11) Item 18. Vertigo and/or Tinnitus.
(a) Audiology consult? Did patient receive an audiology consult?
(b) List Diagnoses and ICD-9 codes.
(12) Item 19. Chest Pain and/or Palpitations.
(a) Cardiology Consult. Did patient receive a cardiology consult?
(b) List Diagnoses and ICD-9 codes.
(13) Item 20. Reproductive Concerns.
(a) Did male patient receive a urology consult?
(b) Did female patient receive a gynecology consult?
(c) List Diagnoses and ICD-9 codes.
(14) Item 21. Final Diagnoses. List up to ten major definite medical diagnoses, with the primary diagnosis listed on line 21A with ICD-9 codes. If no diagnosis is made, leave these lines blank as well as the ICD-9 codes.
(15) Item 22. After completing the Uniform Case Assessment Protocol (UCAP), Phase II, Part III, does the physician feel that the veteran has an unexplained illness? Enter either Y(es) or N (o) from the pull-down menu.
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