Department of Veterans Affairs M21-1, Part IV, Subpart iiVeterans Benefits Administration June 14, 2018Washington, DC 20420

Key Changes

Changes Included in This Revision

The table below describes the changes included in this revision of Veterans Benefits Manual M21-1, Part IV, “Compensation, DIC, and Death Compensation Benefits,” Subpart ii, “Compensation.”

Notes: The term “regional office” (RO) also includes pension management center

(PMC) and Appeals Resource Center (ARC), where appropriate. Unless otherwise noted, the term “claims folder” refers to the official,

numbered, Department of Veterans Affairs (VA) repository – whether paper or electronic – for all documentation relating to claims that a Veteran and/or his/her survivors file with VA.

Minor editorial changes have also been made to- reorganize/relocate content within M21-1, Part IV, Subpart ii, 1.D so that

it flows more logically- improve clarity and readability- add references- update incorrect or obsolete references- update/remove obsolete terminology, where appropriate- reassign alphabetical designations to individual blocks, where necessary,

to account for new and/or deleted blocks within a topic- update the labels of individual blocks and the titles of topics to more

accurately reflect their content, and- bring the document into conformance with M21-1 standards.

Reason(s) for Notable Change Citation To add a new Block b with information on the verifying stressors in

support of a claim for posttraumatic stress disorder (PTSD). To incorporate a note about establishing claimed stressors,

previously located in old IV.ii.1.D.1.j.

M21-1, Part IV, Subpart ii, Chapter 1, Section D, Topic 1, Block b (IV.ii.1.D.1.b)

To add new Block f with guidance on updating the subject line of a document used to verify a stressor previously located in IV.ii.1.D.1.d.

IV.ii.1.D.1.f

To update guidance on when to request additional stressor information from the Veteran in a PTSD claim.

IV.ii.1.D.2.g

To remove guidance, including the table, on when to develop to the Veteran for PTSD claims as this guidance has been relocated to IV.ii.1.D.2.i.

IV.ii.1.D.2.h

To add new Block i with content, including the table, relocated from IV.ii.1.D.2.h.

To update guidance on PTSD stressor development paragraphs, letter language, and attachments.

To add new development language to be used to develop to the

IV.ii.1.D.2.i

Veteran when the stressor details submitted with the claim cannot be corroborated.

To add a new Topic 3. IV.ii.1.D.3 To relocate old IV.ii.1.D.1.b to a new Block a. To remove guidance on liberalizing legislation as this is a rating

concept covered in III.iv.4.O.

IV.ii.1.D.3.a

To add new Block b with guidance on reviewing for credible supporting evidence of a claimed stressor.

To incorporate guidance on claimed stressors that must be corroborated by credible supporting evidence, previously located in old IV.ii.1.D.1.j.

IV.ii.1.D.3.b

To relocate old IV.ii.1.D.2.l to a new Block c. To update stressor verification procedures. To add notes relocated from old IV.ii.1.D.3.b.

IV.ii.1.D.3.c

To relocate old IV.ii.1.D.1.f to a new Block h. To update guidance on establishing a stressor related to combat,

including removing guidance on when to request an examination as this concept is now covered in new Topic 6.

IV.ii.1.D.3.h

To relocate old IV.ii.1.D.1.g to a new Block i. To update guidance on establishing a stressor related to fear of

hostile military or terrorist activity, including removing guidance on when to request an examination as this concept is now covered in new Topic 6.

To add guidance on the Global War on Terrorism Expeditionary Medal relocated from III.iv.4.O.4.d.

IV.ii.1.D.3.i

To relocate old IV.ii.1.D.1.i to a new Block j. To update guidance on establishing a stressor related to drone

aircraft duties, including removing guidance on when to request an examination as this concept is now covered in new Topic 6.

IV.ii.1.D.3.j

To relocate old IV.ii.1.D.2.h to a new Block l. To update guidance on the minimum information needed to allow

for additional stressor research, including removal on guidance on when to develop to the claimant, as this concept is covered in Topic 2.

To remove the exception about pre-service stressors, as this is a rating concept already covered in III.iv.4.O.

IV.ii.1.D.3.l

To relocate old IV.ii.1.D.3.b to a new Block n. To update guidance on when to refer a claim to the U.S. Army and

Joint Services Records Research Center (JSRRC) Coordinator. To remove guidance relocated to new IV.ii.1.D.3.c.

IV.ii.1.D.3.n

To update guidance on criteria for submission to the National Archives and Records Administration (NARA), JSRRC, or the Marine Corps Archives and Special Collections (MCASC).

IV.ii.1.D.4.b

To update the JSRRC Coordinator review procedures. To delete certain prescriptive job titles, such as “Rating Veterans

Service Representative,” when necessary, as outlining position descriptions falls under the direction and purview of the Office of Field Operations (OFO). Per Compensation Service leadership, such

IV.ii.1.D.4.c

titles have been removed from M21-1 where their inclusion does not meaningfully impact the procedures described.

To remove guidance on submitting a paper request to JSRRC as this guidance is being relocated to III.iii.2.I.

To delete certain prescriptive job titles, such as “Veterans Service Representative,” when necessary, as outlining position descriptions falls under the direction and purview of OFO. Per Compensation Service leadership, such titles have been removed from M21-1 where their inclusion does not meaningfully impact the procedures described.

IV.ii.1.D.4.e

To update guidance on submitting a stressor verification request to NARA to include removing the table.

IV.ii.1.D.4.i

To delete the word “immediate,” when necessary, as outlining timeliness standards falls under the direction and purview of OFO.  Per Compensation Service leadership, such language has been removed from M21-1 where its inclusion does not meaningfully impact the procedures described.

IV.ii.1.D.4.o

To refocus guidance on the development process. To add guidance relocated from old IV.ii.1.D.4.c and l. To delete guidance on stressors that occurred during inactive duty

for training that is duplicative of guidance in III.iv.4.O.3.g.

IV.ii.1.D.5.b

To add new Block c with guidance on claim attributes requirements for personal trauma claims, relocated from old IV.ii.1.D.4.k.

IV.ii.1.D.5.c

To add new Block d containing an overview of the personal trauma claims development procedures.

To add guidance relocated from old III.iv.4.O.4.b and e.

IV.ii.1.D.5.d

To update procedures for contacting the Veteran when military sexual trauma (MST) is claimed, including removing text that is now covered by the new procedures in new IV.ii.1.D.5.d.

IV.ii.1.D.5.f

To update guidance on sending a development letter to the Veteran in an MST claim.

IV.ii.1.D.5.g

To delete the word “immediately,” when necessary, as outlining timeliness standards falls under the direction and purview of OFO. Per Compensation Service leadership, such language has been removed from M21-1 where its inclusion does not meaningfully impact the procedures described.

To update procedures on developing to the Department of Defense (DoD) for MST reports.

IV.ii.1.D.5.h

To update guidance on information required in MST development letters, including removing guidance on claim attributes that has been relocated into new IV.ii.1.D.5.c.

IV.ii.1.D.5.i

To add a new Topic 6. IV.ii.1.D.6 To add a new Block a with content relocated from old III.iv.4.O.5.a. To update guidance on when to order a PTSD examination so that it

aligns with I.1.C on timing of examination requests.

IV.ii.1.D.6.a

To add a new Block b with content on ordering an examination in initial claims for PTSD based on other than personal trauma relocated from old III.iv.4.O.5.b.

IV.ii.1.D.6.b

To relocate old IV.ii.1.D.4.r to a new Block c. To update guidance on ordering a personal trauma PTSD

examinations.

IV.ii.1.D.6.c

Reason(s) for Change CitationTo delete old IV.ii.1.D.1.j as the information was relocated to other blocks within the section.

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To delete a note about updating a document’s subject line, that is now covered in IV.ii.1.D.1.f.

IV.ii.1.D.1.d

To delete old IV.ii.1.D.2.d as this concept is covered elsewhere in the manual.

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To relocate old IV.ii.1.D.1.c-e and h to new Blocks d-g. IV.ii.1.D.3.d-gTo relocate old IV.ii.1.D.3.m to a new Block k. IV.ii.1.D.3.kTo relocate old IV.ii.1.D.2.i to a new Block m. IV.ii.1.D.3.mTo relocate old IV.ii.1.D.3.c to a new Block o. IV.ii.1.D.3.oTo add a third column with references to the existing table. IV.ii.1.D.4.dTo delete old IV.ii.1.D.3.n and o containing information on MCASC as this concept is adequately covered based on the overall updates to this Section and III.iv.4.O.

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To delete old IV.ii.1.D.4.c as the content was incorporated into IV.ii.1.D.5.b.

--

To delete old IV.ii.1.D.4.g as the content was incorporated into IV.ii.1.D.5.h.

--

To delete old IV.ii.1.D.4.i and j as the letter used to develop to DoD for MST reports has been added to the Letter Creator Tool.

--

To delete old IV.ii.1.D.4.l as the content has been incorporated into IV.ii.1.D.5.b and d.

--

To delete old IV.ii.1.D.4.m as the content has either been incorporated into IV.ii.1.D.5.b or was duplicative of guidance covered in III.iv.4.O.3.d.

--

To delete old IV.ii.1.D.4.n as the content was duplicative of III.iv.4.O.3.c.

--

To delete old IV.ii.1.D.4.p as the content has been incorporated into IV.ii.1.D.5.h.

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Authority By Direction of the Under Secretary for Benefits

Signature

Beth Murphy, DirectorCompensation Service

Distribution LOCAL REPRODUCTION AUTHORIZED

Section D. Claims for Service Connection (SC) for Posttraumatic Stress Disorder (PTSD)

Overview

In This Section This section contains the following topics:

Topic Topic Name1 General Information on Developing Claims for SC for PTSD2 Development for Medical Evidence, Service Records, and

Stressor Information3 Concession of an In-Service Stressor34 Requesting Corroboration of an In-Service Stressor45 Developing Claims for SC for PTSD Based on Personal Trauma6 Examinations in Claims for SC for PTSD

1. General Information on Developing Claims for SC for PTSD

Introduction This topic contains general information on developing claims for SC for PTSD, including

developing claims of SC for PTSD due to in-service stressors responsibility for stressor verification when a Veteran’s lay testimony alone may establish an in-service stressor definitions of- engaging in combat with the enemy, and- fear of hostile military or terrorist activity

individual decorations as evidence of combat participation action to take if a Veteran received a combat decoration but does not state

the nature of the stressor establishing a stressor related to fear of hostile military or terrorist activity

and when to schedule an examination examples of service in areas of hostile military or terrorist activity establishing a stressor related to drone aircraft crew member duties and

when to schedule an examination when in-service stressor corroboration is required primary evidence to corroborate a claimed in-service stressor secondary sources of evidence that may corroborate a claimed in-service

stressor, and accepting buddy statements of a fellow Veteran as corroboration of a

claimed in-service stressor, and annotating documents used to concede a stressor.

Change Date October 17, 2017June 14, 2018

a. Developing Claims of SC for PTSD Due to In-Service Stressors

When a Veteran claimsUnder 38 CFR 3.304(f), service connection (SC) for posttraumatic stress disorder (PTSD) associated with an in-service stressor requires, undertake required development of the claim for

credible supporting evidence that the claimed in-service stressor actually occurred

medical evidence diagnosing the condition in accordance with 38 CFR 4.125, and

a link, established by medical evidence, between current symptomatology and the claimed in-service stressor.

References: For more information on establishing SC for PTSD, see

- 38 CFR 3.304(f) , and- 38 U.S.C.1154(b) .

duty to assist with requesting records, see M21-1, Part I, 1.C, and when to request evidence from the Veteran to establish an in-service

stressor, see M21-1, Part IV, Subpart ii, 1.D.2.

b. Responsibility for Stressor Verification

Claims processors must take steps to obtain credible supporting evidence that a claimed in-service stressor occurred, including

obtaining all military or other medical records and additional stressor information, when needed, as noted in M21-1, Part IV, Subpart ii, 1.D.2

attempting concession of the stressor based on the criteria noted in M21-1, Part IV, Subpart ii, 1.D.3, and

performing additional stressor corroboration procedures by the U.S. Army and Joint Services Records Research Center (JSRRC) Coordinator as outlined in M21-1 Part IV, Subpart ii, 1.D.4.

Important: It is the responsibility of Veterans Benefits Administration (VBA) claims processors to establish the occurrence of the event the Veteran claims to have resulted in PTSD. A medical professional makes the determination of whether an event is sufficient to meet the stressor criteria for a diagnosis of PTSD.

Reference: For more information on developing for personal trauma stressors, see M21-1, Part IV, Subpart ii, 1.D.5.

j. When In-Service Stressor Corroboration Is Required

Develop to corroborate the details of a claimed in-service stressor only when

a verified stressor is not otherwise of record, and the claimed stressor does not meet one of the criteria in M21-1, Part III,

Subpart iv, 4.H.3.a.

Examples of claimed stressors that must be corroborated are

a plane crash caused by severe weather a severe motor vehicle accident witnessing the death, injury, or threat to the physical being of another

person caused by something other than hostile military or terrorist activity, and

actual or threatened death or serious injury, or other threat to one’s physical being, caused by something other than hostile military or terrorist activity.

Important: The primary role of the Veterans Service Representative (VSR) in development for stressors is to verify the occurrence of the event the Veteran claims to have resulted in PTSD. The role of the VSR or Rating Veterans Service Representatives (RVSR) is not to determine whether the event is sufficient to meet the stressor criteria for diagnosis of PTSD. This determination is made by a medical professional when determining whether

the criteria have been met for a diagnosis of PTSD.

References: For more information on the minimum information required to request corroboration of a stressor, see

M21-1, Part IV, Subpart ii, 1.D.2.h the role of the U.S. Army and Joint Services Records Research Center

(JSRRC) Coordinator in stressor corroboration, see M21-1, Part IV, Subpart ii, 1.D.3.a, and

processing claims for PTSD based on personal trauma, see- M21-1, Part III, Subpart iv, 4.H.4- M21-1, Part IV, Subpart ii, 1.D.4- the PTSD Personal Assault Information site on the Compensation Service

Intranet, and- 38 CFR 3.304(f)(5) .

kc. Primary Evidence to Corroborate a Claimed In-Service Stressor

Primary evidence is generally considered the most reliable source for corroborating in-service stressors and should be carefully reviewed when corroboration is required. It is typically obtained from the National Archives and Records Administration (NARA) or Department of Defense (DoD) entities, such as service departments, JSRRC, and the Marine Corps Archives and Special Collections (MCASC).

Primary evidence includes

service personnel records and pay records military occupation evidence hazard pay records service treatment records (STRs) military performance reports verification that the Veteran received Combat/Imminent Danger/Hostile

Fire Pay unit and organizational histories daily staff journals operational reports-lessons learned (ORLLs) after action reports (AARs) radio logs, deck logs, and ship histories muster rolls command chronologies and war diaries, and monthly summaries and morning reports.

Notes: Many of the unit documents listed above are available on the Compensation

Service Intranet site, Stressor Verification. A Veteran’s military occupation may be specified on his/her DD Form 214

or in service personnel records. This information may be requested from the Department of Defense Finance

and Accounting Service. Military performance reports may be requested via the Personnel

Information Exchange System (PIES). Combat/Imminent Danger/Hostile Fire Pay may be requested through the

Veterans Information Solution (VIS). While confirmation of receipt of Combat/Imminent Danger/Hostile Fire Pay

through VIS alone does not constitute verification of a combat-related stressor, it may, in combination with other evidence, "tip the scales" in favor of the Veteran's assertion of his/her involvement in combat.

Reference: For more information on Combat/Imminent Danger/Hostile Fire Pay, see the PTSD Rating Job Aid website.

ld. Secondary Sources of Evidence That May Corroborate a Claimed In-Service Stressor

Review the following secondary sources of evidence critically and carefully for information confirming participation in combat or to otherwise corroborate a claimed in-service stressor when corroboration is required

buddy statements contemporaneous letters and diaries newspaper archives, and information from Veterans Benefits Administration (VBA)-sanctioned web

sites, which may be accessed through the PTSD Rating Job Aid website.

Important: It may not be necessary to corroborate the claimed stressor if it is related to the Veteran’s fear of hostile military or terrorist activity or drone

aircraft crew member duties, and consistent with the places, types, and circumstances of the Veteran’s

service.

Note: When sufficient evidence is received to corroborate a claimed stressor, annotate the claims folder by editing the subject line of the relevant document(s) used to concede the PTSD stressor using the following format: [Location of stressor], pg. [number].

References: For more information on reviewing for credible supporting evidence of a stressor, see M21-1, Part

IV, Subpart ii, 1.D.3.b, and corroborating personal trauma stressors, see M21-1, Part IV, Subpart ii,

1.D.5editing document properties, see the Veterans Benefit Management System (VBMS) User Guide , and M21-1, Part III, Subpart ii, 4.G.2.s.

me. Accepting Buddy Statements of a Fellow Veteran as Corroboration of a Claimed In-Service Stressor

Accept a buddy statement from a fellow Veteran as corroboration of a claimed in-service stressor if the statement is consistent with the time, place, and circumstances of the service of both the Veteran and the fellow Veteran making the buddy statement.

If the evidence available calls into question the qualifications of the fellow Veteran to make the statement, ask the person to submit his/her DD Form 214 or other evidence of service with the claimant.

Notes: Upon receipt of a DD Form 214 (or other document containing personally

identifiable information(PII)) from a fellow Veteran in support of a paper-based claim- place the document in a separate envelope in the claims folder, and- annotate on the envelope that the contents must not be

reproduced, or reviewed by the Veteran to whom the claims folder pertains or his/her

representative. In paperless claims processing, individual documents bearing the PII of a

Veteran other than the claimant should be designated with a Veterans Benefit Management System (VBMS) bookmark or SUBJECT value that clearly identifies the restricted nature of the content.

Example 1:

Example 2:

References: For more information on bookmarking an electronic claims folder document, see M21-1, Part III,

Subpart ii, 4.G.2.n, and using a document’s SUBJECT field as a note, see M21-1, Part III, Subpart

ii, 4.G.2.s.

f. Annotating Documents Used to Concede a Stressor

When sufficient evidence is received to concede a claimed stressor,

ensure the evidence is properly uploaded to the electronic claims folder (eFolder), and

edit the subject line of the relevant document(s) used to concede the PTSD stressor using the following format: [Nature of stressor], pg. [number].

Reference: For more information on uploading documents to the eFolder and editing document properties, see the

VBMS User Guide , and M21-1, Part III, Subpart ii, 4.G.2.

2. Development for Medical Evidence, Service Records, and Stressor Information

Introduction This topic contains information on development for evidence of in-service and post-service medical evidence and other service records and development for stressor information, including

location of in-service mental health treatment records developing for service department records of in-service mental health

treatment developing for civilian records of in-service mental health treatment obtaining PTSD treatment records from a Military Treatment Facility

(MTF) when to request hospital reports and clinical records PIES request codes to use when submitting a records request involving

PTSD relevant forms related to personnel records in PTSD cases by branch of

service minimum information required from the Veteran related to an in-service

stressor stressors that cannot be verified when to request additional evidence from the Veteran to establish an in-

service stressor information to request from the Veteran to support an in-service stressor,

and stressor corroboration reviewVBMS paragraphs for stressor development.

Change Date October 17, 2017June 14, 2018

a. Location of In-Service Mental Health Treatment Records

In-service mental health treatment records are not stored with the STRs.

They are maintained with the records of a

a military treating treatment facility (MTF), or a civilian treating facility.

Note: The records are typically destroyed five years after the end of the year in which the case is closed. Follow the procedures at M21-1, Part III, Subpart iii, 2.A to determine when and how to request STRs, including in-service mental health records.

b. Developing for Service Department Records of In-

In order to develop for service department records of in-service mental health treatment administered at an military treatment facility (MTF), refer to guidance on clinical record requests as described in

Service Mental Health Treatment

M21-1, Part III, Subpart iii, 2.D.3.a, and M21-1, Part III, Subpart iii, 2.B.4, and M21-1, Part III, Subpart iii, 1.C.3.

References: For more information on requesting records in the custody of a Federal department or agency, see M21-1 Part I, 1.C.1, and M21-1 Part III, Subpart iii, 2-4.

c. Developing for Civilian Records of In-Service Mental Health Treatment

If a service member obtains treatment "off-base" at a civilian facility, any mental health records created during the course of treatment are not automatically associated with the service member's STRs. It is the responsibility of the patient and civilian provider to transfer records of care to the service department.

Records retained by a civilian provider are not records in the custody of a Federal department or agency. They are not forwarded for long-term storage to the National Personnel Records Center (NPRC) and cannot be obtained through PIES/Defense Personnel Records Image Retrieval System (DPRIS).

To obtain identified civilian treatment records, follow procedures for requesting non-Federal or private records.

References: For more information on requesting private treatment records, see- M21-1, Part I, 1.C.2, and- M21-1, Part III, Subpart iii, 1.C.3D, and

STRs including records of “off-base” civilian treatment, see M21-1 Part III, Subpart iii, 2.A.1.e.

d. Obtaining PTSD Treatment Records From an MTF

Obtain any adequately identified records from an MTF that are relevant to a claim for SC for PTSD. If a service member obtains treatment at a military facility, it will be necessary to request all records associated with that treatment by completion of VA Form 21-8359, Information Regarding a Veteran in Uniformed Services Hospital or Dispensary.

When completing the VA Form 21-8359

Complete the first page (Request by VA-1) of VA Form 21-8359, by- filling in all of the blocks in Part I- placing a check mark in the boxes to the left side of the following items in

Part II: Hospital Report 21-Day Certificate, and Notice of Discharge, and

- dating and signing the form (on behalf of the Veterans Service Center

Manager). Send the first, second (21-Day Certificate-2), and third (Notice of

Discharge-3) pages of VA Form 21-8359 to the appropriate uniformed services hospital on a date that ensures the hospital will receive it on or after the twenty-first day of the Veteran’s hospitalization.

Retain the fourth page (VA Control Copy-4) of VA Form 21-8359 in the claims folder.

Take no further action.

Note: MTFs do not furnish hospital reports until after the Veteran’s discharge from the hospital when a Veteran has been admitted for treatment.

References: For more information on the duty to assist in obtaining relevant records of a Federal department or

agency, see M21-1, Part I, 1.C.1, and policies and procedures for development for mental health records from an

MTF, see M21-1, Part III, Subpart iii, 1.C.8.

ed. When to Request Hospital Reports and Clinical Records

Request hospital reports and clinical records if the Veteran indicates pertinent treatment in a Department of Veterans Affairs (VA) facility, Vet Center, or elsewhere.

Reference: For more information on requesting VA medical or Vet Center records, see M21-1, Part III, Subpart iii, 1.C.2.

fe. PIES Request Codes to Use When Submitting a Records Request Involving PTSD

Service personnel records may be obtained using either PIES or DPRIS based on the date of the Veteran’s discharge, as described in M21-1, Part III, Subpart iii, 2.D.1.a. When a request for records is appropriate in PIES, use the table below to determine which PIES request code to use when attempting to obtain records required to process a claim for SC for PTSD.

If ... And … Then ...the request is related to a claim that is not being processed in VBMS

the stressor is associated with an episode of personal assault or trauma, such as military sexual trauma (MST), or

the Veteran is claiming SC for PTSD as a result of both personal trauma and other types of stressors

use PIES request code O18.

the stressor is not associated with an episode of personal assault or trauma, such as military sexual traumaMST

use PIES request code O19.

the request is related to a claim that is being processed in VBMS

use PIES request code O50.

Notes: Only limited documents from the Veteran’s personnel folder, including

those listed under M21-1, Part IV, Subpart ii, 1.D.2.if, are provided in response to submission of a PIES request under request code O19.

A copy of all documents within the personnel folder are provided in response to a PIES request submitted under request code O18 for claims processed outside of VBMS and O50 for claims processed in VBMS.

If documents not routinely provided by NPRC in response to a request submitted under request code O19 are needed, identify the documents in a customized request, using request code O99.

References: For more information on requesting information and records through PIES or DPRIS, see M21-1, Part III,

Subpart iii, 2.D, and fire-related records, see M21-1, Part III, Subpart iii, 2.E.1.e.

gf. Relevant Forms Related to Personnel Records in PTSD Cases by Branch of Service

The table below identifies the forms that contain information about the Veteran’s unit(s) of assignment, military occupation, and service locations.

Note: These forms are among the documents that will be provided in response to PIES requests submitted under request code O19 or in the service personnel records obtained in DPRIS.

Branch of Service Name(s) of Forms

Army DA Form 2-1, Personnel Qualification Record

Notes: DA Form 2-1- is used for both officers and enlisted personnel,

and- first came into use in January 1973.

Prior to January 1973, DA Form 20, Enlisted Qualification Record and DA Form 66, Officer Qualification Record were used.

Navy enlisted record of Transfer and Receipts, pages- 12- 32, and- 33

enlisted record Administrative Remarks, pages- 4 through 9- 13, and- 34, and

officer record, NAVPERS 1301/51, Officer Data Card, page 35.

Note: DD Form 214 and enlistment contracts are usually included.

Air Force enlisted record, AF Form 7, Airman Military Record, pages 36 through 39

officer record, AF Form 11, Officer Military Record, pages 39 and 40, and

performance reports for both enlisted personnel and officers.

Marine Corps enlistment contracts discharge papers MABMC-11 (Discharge Order), and service records, pages- 3- 5 through 6- 8 through 9- 12 through 13, and- 17.

Coast Guard enlisted record Endorsement on Order Sheet, (DoT Form CG

3312B) officer record Service Records Card DoT Form CG 3301, Enlistment Contract DoT Form CG 3303, Achievement Sheet DoT Form CG 3305, Leave Record, pages 3, 5, 6-7,

and DD Form 214.

jg. When to Request Additional Evidence From the Veteran to Establish an In-Service Stressor

For PTSD claims, a Section 5103 notice is generally not warranted as the evidence requirements are covered under the Disability Service Connection evidence table of the VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits.

Exception: Send a Section 5103 notice if the claimant files a substantially complete application on a non-EZ form.

Request Do not send the Veteran a subsequent development letter

requestingprovide credible supporting evidence to establish that an in-service stressor occurred unless if the evidence of record shows that

PTSD was initially diagnosed in service a confirmed stressor is already of record, or the claimed stressor is related to the Veteran’s- verified combat or former prisoner of war (FPOW) service and is

consistent with the circumstances, conditions, or hardships of such service, or

- fear of hostile military or terrorist activity, or the Veteran served as a drone aircraft crew member, and exposure to such activity is consistent with the places, types, and circumstances of the Veteran’s service.

Important: Send a subsequent development letter prior to deciding the claim, if the Veteran did not submit a completed VA Form 21-0781, Statement in Support of

Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD), VA Form 21-0781a, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault, or equivalent information, and the stressor cannot be established under the above guidelines, or

submitted a completed stressor form or equivalent information, but did not provide sufficient details for the stressor to be corroborated.

References: For more information on sending a subsequent development letter for PTSD claims, see M21-1, Part

IV, Subpart ii, 1.D.2.h and i required information in MST development letters, see M21-1, Part IV,

Subpart ii, 1.D.5.i, and notification requirements for special issues, see M21-1, Part I, 1.B.1.f.

kh. Information to Request From the Veteran to Support an In-Service Stressor

Stressor development is necessary when the evidence submitted with the claim or received through other development (such as service records) does not allow for corroboration of a stressor.

When stressor development is necessary

use the appropriate PTSD development paragraphs in VBMSreferenced in M21-1, Part IV, Subpart ii, 1.D.2.i to request information from the Veteran

enclose VA Form 21-0781 or VA Form 21-0781a to solicit specific details of the in-service stressor, such as the- date of the incident- place of the incident- unit of assignment at the time of the incident- detailed description of the event- medals or citations received as a result of the incident, and- name and other identifying information concerning any other individuals

involved in the event, if appropriate, and

allow the claimant 30 days to submit the requested evidence.Refer to the table below to determine which PTSD development paragraph is

appropriate based on the stressor evidence submitted by the Veteran.If the Veteran claims a stressor related to ...

Then use the VBMS development paragraph named ...

combat, fear, or hostile military or terrorist activities that cannot otherwise be corroborated based on evidence currently of record

PTSD—Need stressor details/med evid combat-related incdnt.

a non-combat incident such as a car accident, hurricane, etc., or

does not mention a source for his stressor and does not provide details

PTSD—Need stressor details/med evid of stressful incdnt.

a military sexual trauma (MST) or similar personal trauma incident such as harassment

PTSD—Need stressor details/med evid personal trauma incdnt.

Important: Do not enclose VA Form 21-0781 or 21-0781a if the Veteran submitted one

with the claim. Do not unnecessarily delay an examination or claim by asking the Veteran

for specific details or send the Veteran VA Form 21-0781 in any case in which- there is credible supporting evidence that demonstrates the claimed in-

service stressor occurred, or such as evidence of- internment as an FPOW fear of hostile military or terrorist activity- receipt of one of the decorations listed in M21-1, Part IV, Subpart ii,

1.D.1.e, or- lay testimony sufficient to independently establish an in-service stressor as

discussed in M21-1, Part IV, Subpart ii, 1.D.1.b.- the Veteran already provided sufficient details to allow for additional

stressor research. Do not routinely transmit or request return of a VA Form 21-0781a,

Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault, absent an indication that the claim involves personal trauma.

Do not send a second development letter requesting stressor information if the Veteran- fails to respond to the request for stressor information within 30 days, or- submits insufficient information in response to the 30 day request.

References: For guidance on obtaining information from the Veteran in claims based on MST or personal trauma and use of the VA Form 21-0781a, see M21-1, Part IV, Subpart ii, 1.D.4.k.more information on stressor verification, see M21-1, Part IV, Subpart ii, 1.D.3.c minimum information required to research an in-service stressor, see M21-1,

Part IV, Subpart ii, 1.D.3.l VBMS paragraphs for stressor development, see M21-1, Part IV, Subpart ii,

1.D.2.i, and

developing claims based on personal trauma, see M21-1, Part IV, Subpart ii, 1.D.5.

i. VBMS Paragraphs for Stressor Development

When it is necessary to develop to the Veteran for additional stressor details, generate and send a subsequent development letter.

Refer to the table below to determine which PTSD development paragraph or language and attachment is appropriate based on the stressor evidence submitted by the Veteran.

Stressor evidence VBMS development paragraph or language

Attachment

Combat, fear, or hostile military or terrorist activities that cannot otherwise be corroborated based on evidence currently of record, and

no VA Form 21-0781 submitted.

PTSD—Need stressor details/med evid combat-related incdnt

VA Form 21-0781

Non-combat incident such as a car accident, hurricane, etc., or

does not mention a source for his stressor and does not provide details, and

no VA Form 21-0781 submitted.

PTSD—Need stressor details/med evid of stressful incdnt

VA Form 21-0781

MST or similar personal trauma incident such as harassment, and

no VA Form 21-0781 or VA Form 21-0781a submitted.

PTSD—Need stressor details/med evid personal trauma incdnt

Important: Follow the procedures in M21-1, Part IV, Subpart ii, 1.D.5 when sending an MST subsequent development letter to the Veteran.

VA Form 21-0781a

Any of the above stressor types, and

VA Form 21-0781 or 21-0781a was submitted, but

the Veteran failed to provide sufficient details for the stressor to be corroborated.

On [date] you provided details regarding the stressful event(s) that caused your post traumatic stress disorder. The information we received does not meet the minimum level of detail needed for VA to seek assistance from the U.S. Army and Joint Services Records Research Center (JSRRC). JSRRC assists VA in verifying veteran's claimed stressful incidents when VA

VA Form 21-4138, Statement in Support of Claim

cannot verify the stressful incident based on records from the service department or when VA cannot obtain the necessary records from the service department.

Important: Inform the Veteran of the specific information that is still needed to allow for corroboration.

Important: Do not send a second development letter requesting stressor information if the Veteran fails to respond to the request for stressor information within 30 days, or submits insufficient information in response to the 30-day request.

Reference: For guidance on obtaining information from the Veteran in claims based on MST or personal trauma, see M21-1, Part IV, Subpart ii, 1.D.5.

3. Concession of an In-Service Stressor

Introduction This topic contains information on concession of an in-service stressor, including

when a Veteran’s lay testimony alone may establish an in-service stressor reviewing for credible supporting evidence of a stressor stressor verification review procedure definitions of- engaging in combat with the enemy, and- fear of hostile military or terrorist activity

individual decorations as evidence of combat participation examples of service in areas of hostile military or terrorist activity establishing a stressor related to- combat- fear of hostile military or terrorist activity, and- drone aircraft crew member duties

use of APO mailbox information to verify Republic of Vietnam Service minimum information required to research an in-service stressor stressors that cannot be verified when to refer a claim to a JSRRC Coordinator, and procedures for routing a PTSD claim for JSRRC review.

Change Date June 14, 2018

ba. When a Veteran’s Lay Testimony Alone May Establish an In-Service Stressor

A Veteran’s lay testimony alone may, under specified circumstances, establish an in-service stressor for purposes of establishing SC for PTSD if

PTSD is diagnosed in service, and the stressor is related to that service, or the stressor is related to the Veteran’s- engagement in combat with the enemy- experience as an former prisoner of war (FPOW) as defined by 38 CFR

3.1(y), or- the stressor is related to fear of hostile military or terrorist activity or

duties as a drone aircraft crew member, if a Department of Veterans Affairs (VA) psychiatrist or psychologist, or contract equivalent, confirms the claimed stressor is adequate to support a diagnosis of PTSD, and the Veteran’s symptoms are related to the claimed stressor.

Notes: For the Veteran’s lay testimony alone to establish the occurrence of a

claimed stressor- the stressor must be consistent with the

circumstances, conditions, or hardships of service for claims based on an in-service PTSD diagnosis or FPOW or combat service, or

places, types, and circumstances of service for claims based on a fear of

hostile military or terrorist activity or duties as a drone aircraft crew member, and

- there must be no clear and convincing evidence to the contrary. For claims decided prior to July 13, 2010, a Veteran’s testimony alone

could not establish the occurrence of a stressor that was related to the Veteran’s fear of hostile military or terrorist activity.

The July 13, 2010, amendment of 38 CFR 3.304(f) is not considered a liberalizing rule under 38 CFR 3.114(a).

References:For more information on evidence requirements for claims based on

- a diagnosis of PTSD in service, see 38 CFR 3.304(f)(1) , and M21-1, Part III, Subpart iv, 4.HO.2.d

- combat service, see 38 CFR 3.304(f)(2) , and VAOPGCPREC 12-1999

- a fear of hostile military or terrorist activity, see 38 CFR 3.304(f)(3)- FPOW service, see 38 CFR 3.304(f)(4), and- when the Veteran’s testimony alone may establish an in-service stressor,

see M21-1, Part III, Subpart iv, 4.H.3.a. For the definitions of- engaging in combat with the enemy, see M21-1, Part IV, Subpart ii,

1.D.13.cd, and- fear of hostile military or terrorist activity, see M21-1, Part IV, Subpart ii,

1.D.13.de, and establishing a stressor related to- combat, see M21-1, Part IV, Subpart ii, 1.D.3.h- fear of hostile military or terrorist activity, see M21-1, Part IV, Subpart ii,

1.D.3.i, and- drone aircraft crew member duties, see M21-1, Part IV, Subpart ii, 1.D.3.j.

b. Reviewing for Credible Supporting Evidence of a Stressor

Review the claim for credible supporting evidence that a claimed in-service stressor occurred when the stressor cannot be conceded based on the criteria in M21-1, Part IV, Subpart ii, 1.D.3.a.

Credible supporting evidence is evidence that

documents the Veteran's participation in the event indicates the Veteran served in the immediate area and at the particular time

in which the stressful event is alleged to have occurred, and supports the description of the event.

Credible supporting evidence of a stressor may be obtained from sources other than service records. When reviewing evidence to corroborate a claimed in-service stressor, claims processors must consider the credibility and probative value of the evidence to determine if the stressor is consistent

with the circumstances of the Veteran’s service.

Examples of claimed stressors that must be corroborated by credible supporting evidence include, but are not limited to

a plane crash a severe weather event a motor vehicle accident witnessing the death, injury, or threat to the physical being of another

person caused by something other than hostile military or terrorist activity, and

actual or threatened death or serious injury, or other threat to one’s physical being, caused by something other than hostile military or terrorist activity.

Notes: Corroboration of every detail is not required. Evidence may be sufficient if it implies a Veteran's personal exposure to the

event. Evaluate the evidence as a whole to determine whether a stressor is

sufficiently corroborated.

Important: While it is incumbent upon each claims processor to review evidence to determine if a claimed in-service stressor can be conceded, stressor concession is ultimately the rating activity's responsibility.

References: For more information on the stressor verification review procedure, see M21-1, Part IV, Subpart ii,

1.D.3.c credible supporting evidence of a stressor, see M21-1, Part III, Subpart iv,

4.O.4.f and g reviewing evidence for corroboration of a stressor, M21-1, Part III, Subpart

iv, 4.O.4.h, and weighing evidence, see M21-1, Part III, Subpart iv, 5.A.

lc. Stressor Corroboration Verification Review Procedure

Follow the steps in the table below to determine if there is credible supporting evidence that a claimed in service stressor occurred determine proper routing of the claim based on the status of stressor corroboration.

Important: Ensure all necessary service records have been requested as noted in M21-1, Part IV, Subpart ii, 1.D.2.e.

Exception: For claims based on personal trauma, follow the procedures in M21-1, Part IV, Subpart ii, 1.D.5.

Step Action1 Review the stressor information submitted by the Veteran, if

any, as well as all other service records, medical evidence, and lay or other evidence to determine if at least the minimum

information required to concede or request verification of a stressor has been received, per M21-1, Part IV, Subpart ii, 1.D.2.h.

Can the claimed stressor be conceded based on the Veteran’s lay testimony alone as described in M21-1, Part IV, Subpart ii, 1.D.3.a? Is sufficient stressor information of record?

If yes, proceed to Step 2.If no, refer the claims folder to the rating activity whenthe Veteran has not responded to stressor development and there

is no stressor information of record, orthe stressor information is insufficient to meet the criteria

described in M21-1, Part IV, Subpart ii, 1.D.2.h. If yes,

- annotate the claims folder as directed in M21-1, Part IV, Subpart ii, 1.D.1.f, and

- proceed to Step 5. If no, proceed to the next step.

2 Obtain all relevant secondary sources of evidence identified by the Veteran.

Can the stressor information be corroborated based on the evidence of record and/or preliminary research of primary and secondary sources of evidenceassociated with the claimed stressor?

If yes,- annotate the claims folder as directed at M21-1, Part IV,

Subpart ii, 1.D.1.l.f, and- proceed to Step 35.

If no, proceed to the next step.refer the claims folder to the JSRRC coordinator, as directed at M21-1, Part IV, Subpart ii, 1.D.3.c.

Reference: For more information on primary and secondary sources of evidence, see M21-1, Part IV, Subpart ii, 1.D.1.c and d, and M21-1, Part III, Subpart iv, 4.O.4.h.

3 Has the Veteran provided the minimum information needed to allow for additional research as described in M21-1, Part IV, Subpart ii, 1.D.3.l?

If yes, refer the claim to the JSRRC Coordinator, as directed at M21-1, Part IV, Subpart ii, 1.D.3.k.

If no,- send a subsequent development letter as directed in M21-1,

Part IV, Subpart ii, 1.D.2.g-i

- allow 30 days for a response, and then- proceed to the next step.

4 Did the Veteran provide the details requested in Step 3?

If yes, refer the claim to the JSRRC Coordinator, as directed at M21-1, Part IV, Subpart ii, 1.D.3.k.

If no, refer the claim to the rating activity.35 Has a compensation examination been completed?

If yes, refer the claims folder to the rating activity. If no, request an examination.

Important: Do not route a claim to the JSRRC Coordinator for review until

development is complete in every respect per the above procedures. A diagnosis of PTSD is not a prerequisite for initiating the stressor

verification process.

cd. Definition: Engaging in Combat With the Enemy

Engaging in combat with the enemy means personal participation in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. It includes presence during such events either as a

combatant, or service member performing duty in support of combatants, such as

providing medical care to the wounded.

Reference: For additional information on determining combat service, see M21-1, Part IV, Subpart ii, 1.D.3.f M21-1, Part III, Subpart iv, 4.H.4.b, and VAOPGCPREC 12-1999.

de. Definition: Fear of Hostile Military or Terrorist Activity

Fear of hostile military or terrorist activity means

the Veteran experienced, witnessed, or was confronted with an event or circumstance that involved- actual or threatened death or serious injury, or- a threat to the physical integrity of the Veteran or others, and

the Veteran’s response to the event or circumstances involved a psychological or psycho-physiological state of fear, helplessness, or horror.

Examples of exposure to hostile military or terrorist activity include presence at events involving

actual or potential improvised explosive devices (IEDs) vehicle-embedded explosive devices incoming artillery, rocket, or mortar fire small arms fire, including suspected sniper fire, or

attacks upon friendly aircraft.

Reference: For more information on fear of hostile military and terrorist activity, see 38 CFR 3.304(f)(3) , and M21-1, Part IV, Subpart ii, 1.D.3.g and i.

ef. Individual Decorations as Evidence of Combat Participation

When a Veteran has received any of the combat decorations listed below, VA will presume that the Veteran engaged in combat with the enemy, unless there is clear and convincing evidence to the contrary

Air Force Achievement Medal with “V” Device Air Force Combat Action Medal Air Force Commendation Medal with “V” Device Air Force Cross Air Medal with “V” Device Army Commendation Medal with “V” Device Bronze Star Medal with “V” Device “C” device, denoting combat conditions, when affixed to other awards for

meritorious service or achievement Combat Action Badge (CAB) Combat Action Ribbon (CAR) (Note: Prior to February 1969, the Navy

Achievement Medal with “V” Device was awarded.) Combat Aircrew Insignia Combat Infantry/Infantryman Badge (CIB) Combat Medical Badge Distinguished Flying Cross Distinguished Service Cross Fleet Marine Force (FMF) Combat Operations Insignia Joint Service Commendation Medal with “V” Device Medal of Honor Navy Commendation Medal with “V” Device Navy Cross Parachutist Badge with Combat Jump Device Purple Heart, and/or Silver Star.

Important: Receipt of one of the decorations cited above is not the only acceptable evidence of engagement in combat.

References: For additional information on determining combat service, see M21-1, Part III, Subpart iv, 4.HO.64.b, and VAOPGCPREC 12-99.

hg. Examples of Service in Areas of Hostile

Evaluation of evidence for service in a location associated with hostile military or terrorist activity must be done on a case-by-case basis. The fear-based regulation is intended to encompass military service not involving

Military or Terrorist Activity

direct combat but where there was always a potential for hostile military or terrorist activity. The list below includes examples of service in areas of hostile military or terrorist activity. The list is not all-inclusive.

Service along the Korean demilitarized zone (DMZ), which separates North from South Korea, has been a location of hostile military activity since the Korean War armistice of 1953, whereas service on U.S. bases in the rest of South Korea generally has not been.

Service aboard a ship in the offshore “blue waters” of Vietnam or service in Thailand for which the Veteran received the Vietnam Service Medal or Vietnam Campaign Medal is sufficient to establish service in a potentially hostile military environment.

Reference: For more information on fear of hostile military or terrorist activity, see 38 CFR 3.304(f)(3) , and M21-1, Part IV, Subpart ii, 1.D.3.e and i.

fh. Action to Take if a Veteran Received aEstablishing a Stressor Related to Combat Decoration but Does Not State the Nature of the Stressor

If Concede a stressor when

a Veteran received one of the combat decorations cited in M21-1, Part IV, Subpart ii, 1.D.13.ef, or

there is other credible supporting evidence that the Veteran engaged in combat as defined in M21-1, Part IV, Subpart ii, 1.D.3.d.

Note: If the Veteran does not expressly state the nature of the stressor, assume the stressor is combat-related if the Veteran received one of the

combat decorations cited in M21-1, Part IV, Subpart ii, 1.D.3.f, and request service personnel records as discussed in M21-1, Part IV, Subpart ii,

1.D.2.e.- does not expressly state the nature of the stressor

assume the stressor is combat-relatedrequest service personnel records as discussed in M21-1, Part IV, Subpart ii,

1.D.2.horder an examination, if necessary to decide the claim, andin the examination requeststate that VA has verified the Veteran’s combat service, andspecify any details regarding the combat stressor contained in the record.

References: For more information on determining combat service, see M21-1, Part III, Subpart iv, 4.O.4.b and c determining if an examination is necessary, see M21-1, Part I, 1.C.3 guidance not to exclude a claim for PTSD from the Fully Developed Claims

(FDC) program due to non-receipt of VA Form 21-0781, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD), when a Veteran is in receipt of a recognized combat decoration, see M21-1, Part III, Subpart i, 3.B.2.a, and

when to proceed with an examination in a PTSD claim, see M21-1, Part IV, Subpart ii, 1.D.6.ascheduling examinations in PTSD cases, see M21-1, PartIII, Subpart iv, 4.H.5.

gi. Establishing a Stressor Related to Fear of Hostile Military or Terrorist Activity and When to Schedule an Examination

Schedule an examination if there is evidence of a PTSD diagnosis or symptoms, and Concede a stressor when the Veteran’s DD Form 214, Certificate of Release or Discharge From Active Duty, or other service records, shows service in an area of potential hostile military or terrorist activity.

Notes: Service personnel records must be requested prior to or concurrently with

any necessary examination being ordered so as to avoid unnecessary delays in claims processing.

The receipt of military awards such as, but not limited to, the Vietnam Service or Campaign Medal, Kuwait Liberation Medal, Iraq Campaign Medal, and Afghanistan Campaign Medal is generally considered evidence of service in an area of potential hostile military or terrorist activity.

The receipt of military awards such as the National Defense Service Medal, Armed Forces Service Medal, and Global War on Terrorism (GWOT) Service Medal generally does not indicate service in locations that involve exposure to hostile military or terrorist activity because these are general medals that do not denote service in a particular area or campaign. If the Veteran served in an area of potential hostile military or terrorist activity, he/she likely would have received a more specific medal for such service.

The GWOT Expeditionary Medal also does not necessarily indicate service in an area that would involve exposure to hostile military or terrorist activity. Consider that award and the other evidence of record to determine if there was service in an area of potential hostile military or terrorist activity before scheduling an examination.

The fear-based stressor criteria are not met based on anticipation of future deployment to a location of hostile military or terrorist

activity, or learning of the death of another person, when such death occurred remote

from the Veteran in a location of hostile military or terrorist activity.

References: For more information on establishing a stressor related to the fear of hostile military or terrorist

activity, see M21-1, Part III, Subpart iv, 4.O.4.d when to proceed with an examination in a PTSD claim, see M21-1, Part IV,

Subpart ii, 1.D.6.a determining that an examination is necessary, see M21-1, Part I, 1.C.3 scheduling examinations in PTSD cases, see M21-1, Part III, Subpart iv,

4.H.5 requesting service personnel records from the National Personnel Records

Center (NPRC) in PTSD claims, see M21-1, Part IV, Subpart ii, 1.D.2.fe, and

obtaining service records, see M21-1, Part III, Subpart iii, 2.B.

ij. Establishing a Stressor Related to Drone Aircraft Crew Member Duties and When to Schedule an Examination

Recent military operations and warfareThe GWOT has seen have involved the expansive use of armed drone aircraft, including, but not limited to, the Predator and Reaper. Schedule an examinationConcede a stressor if there is evidence of a PTSD diagnosis or symptoms, and the Veteran’s DD Form 214 or other service records shows service as an armed drone aircraft crew member.

Note: Service personnel records must be requested prior to or concurrently with any necessary examination being ordered so as to avoid unnecessary delays in claims processing.

References: For more information on when to proceed with an examination in a PTSD claim, see M21-1, Part IV,

Subpart ii, 1.D.6.a requesting service personnel records from NPRC in PTSD claims, see M21-

1, Part IV, Subpart ii, 1.D.2.fe, and obtaining service records, see M21-1, Part III, Subpart iii, 2.B, and establishing SC for PTSD based on drone aircraft duties, see M21-1, Part

III, Subpart iv, 4.O.4.e.

mk. Use of APO Mailbox Information to Verify Republic of Vietnam Service

The listing of Army post office (APO) address numbers for the Asian Pacific Theater during the Vietnam Era contains APO numbers for all major Army and Air Force bases in Asia, including Vietnam, Korea, Thailand, Japan, Taiwan, Okinawa, Guam, and the Philippines. Review the record to include personnel and medical records for an APO number written or stamped in the records. As this is official evidence of the Veteran’s presence at that location, the listing can assist with stressor corroboration in PTSD claimsestablishing service in a location of potential hostile military or terrorist activity.

Note: The APO listing is available on the Compensation Service Intranet website under the Stressor Verification Site. To access the listing, open the General Information folder and click on “General 1942-2002 APO-FPO Files.” Each APO number is shown along with the location it identifies and the previous number that it replaced. When successive locations are identified with the same APO number, the dates of use at each location are specified as well as the close-out date.

hl. Minimum Information Required From the Veteran Related to anto Research an In-Service Stressor

When initial review of the available primary and secondary sources of evidence does not establish an in-service stressor, the next step is to determine if additional research and development is possible. At a minimum in order to undertake the additional research, the Veteran or available records must provide the following:

a stressor that can be documented the location where the incident took place

the approximate date (within a two-month period) of the incident, and the unit of assignment at the time the stressful event occurred, and if the stressor refers to a casualty, the full name and unit designation of the

casualty.Inform the Veteran that

the information is necessary to obtain supportive evidence of each of the stressful events, and

failure to respond or an incomplete response may result in denial of the claim.

Exception: There is no regulatory requirement for credible supporting evidence of a pre-service stressor resulting in delayed onset of PTSD in service. If a Veteran is sound on enlistment and develops delayed or late-onset PTSD in service related to a pre-service stressor, SC may be established under 38 U.S.C. 1110, which contains the general criteria for establishing SC for a chronic disability.

Notes: Specific details of claimed stressful events may also be gathered from such

sources as VA or private medical treatment reports and examination reports. Claims processors may obtain the date and location of well-documented

events, such as the Tet Offensive, from VBA-sanctioned web sites (available through the PTSD Rating Job Aid website) and supply this information on the Veteran’s behalf.

References: For more information on the types of stressors that may be impossible to corroborate, see M21-1, Part

IV, Subpart ii, 1.D.2.i3.i, and onset of PTSD in service due to a pre-service stressor, see M21-1, Part III,

Subpart iv, 4.HO.2.e.

im. Stressors That Cannot Be Verified

Some stressors are clearly impossible to verify and should not be referred to JSRRC. The following list includes examples of types of stressors that should not be referred to JSRRC:

events that almost happened events involving civilians mistreatment of enemy prisoners sniper attacks events occurring while traveling/driving in a convoy, and duty as a door gunner.

Examples: A Veteran claims that she drove over a land mine, but it didn’t explode.

This could never be verified through records research. A Veteran claims that the barber who cut his hair at the local barber shop

was later found to be an enemy sniper. JSRRC would be unable to verify

this event involving a civilian. A Veteran claims he almost shot a child. This is an event that almost

happened and could not be verified by JSRRC. A Veteran claims that civilians were accidentally killed in combat. This

type of event is rarely documented in service records and, consequently, extremely difficult to verify.

Reference: For more information on the types of stressors that may be impossible to corroborate, see the JSRRC Stressor Verification Guide, Section V .

bn. When to Refer a Claim to a JSRRC Coordinator

As directed in M21-1, Part IV, Subpart ii, 1.D.2.l, only route those claims to the JSRRC Coordinator in whichPrior to referring a claim to the JSRRC Coordinator for additional stressor research, the development activity must first determine if a stressor can be conceded with available evidence. Refer the claim to the JSRRC Coordinator for stressor corroboration only when the

required development is completed, but the claimed stressor cannot be conceded based on the stressor verification review procedures in M21-1, Part IV, Subpart ii, 1.D.3.c, and

claims folder contains the minimum information needed to allow for additional research as noted in M21-1, Part IV, Subpart ii, 1.D.3.h.

sufficient stressor information has been submitted by the Veteran or is otherwise present in the claims folder to meet the criteria outlined in M21-1, Part IV, Subpart ii, 1.D.2.h, and

the stressor cannot be conceded and requires additional research.

Important: Do not

route a claim to the JSRRC Coordinator for review until development is complete in every respect except for

corroboration of the in-service stressor, and- a confirmed diagnosis of PTSD, or- schedule a VA examination before receiving corroboration of the claimed

in-service stressor. A diagnosis of PTSD is not a prerequisite for initiating the stressor

verification process.

References: For more information ondeveloping claims for SC for PTSD unrelated to personal trauma or MST, see M21-1, Part IV, Subpart ii, 1.D.1 and 2developing claims for SC for PTSD associated with personal trauma or MST, see M21-1, Part IV, Subpart ii, 1.D.4corroboration of stressors in personal trauma and MST claims, see M21-1, Part IV, Subpart ii, 1.D.4.q, andprocedures for routing a PTSD claim for JSRRC review, see M21-1, Part IV, Subpart ii, 1.D.3.co.

co. Procedures for Routing a PTSD Claim for JSRRC Review

To route a claim to the JSRRC Coordinator, the claims processor conducting routine development of the claim for SC for PTSD unrelated to personal trauma or MST will

ensure all development is complete as directed in M21-1, Part IV, Subpart ii, 1.D.1 and 23.c

establish a VBMS tracked item using the JSRRC COORDINATOR REVIEW option from the COMPMGT drop down menu, and

add the JSRRC Request special issue for routing the request to the JSRRC Coordinator.

References: For more information on establishing tracked items and special issues in VBMS, see the

- VBMS User Guide , and- M21-4, Appendix D, Section I.b, and

National Work Queue (NWQ) procedures for using a special issue for routing the request to the JSRRC Coordinator, see the National Work Queue NWQ Phase 1 Playbook .

34. Requesting Corroboration of an In-Service Stressor

Introduction This topic contains information on requesting corroboration of an in-service stressor, including

duties of the JSRRC Coordinator when to refer a claim to a JSRRC Coordinator procedures for routing a PTSD claim for JSRRC review criteria for submission to JSRRC, MCASC, or NARA procedures for conducting JSRRC Coordinator review where to send a request for corroboration of an in-service stressor unrelated

to personal trauma or MST format of requests for stressor corroboration to JSRRC information to include in requests for stressor corroboration to JSRRC

(formerly the U.S. Armed Services Center for Unit Records Research (CURR))

refraining from submitting duplicate requests to JSRRC circumstances in which JSRRC requests may be expedited sending requests for research of Marine Corps unit records to NARA accessing Korean Conflict and Vietnam Era Marine Corps unit records use of Army post office (APO) mailbox information to verify Republic of

Vietnam service requesting stressor corroboration from Marine Corps records dated after the

Vietnam Era responsibilities of the MCASC information to include in record requests to MCASC related to a claimed in-

service stressor sample e-mail to MCASC for a determination as to the availability of

records required to corroborate a stressor where to send requests for Navy deck logs invalid or incomplete research requests to JSRRC, MCASC, or NARA, and handling requests for more information from JSRRC, MCASC, or NARA.

Change Date October 17, 2017June 14, 2018

a. Duties of the JSRRC Coordinator

The JSRRC Coordinator is the primary point of contact within each regional office (RO) for all procedures related to requests for corroboration of stressors unrelated to MST or personal trauma. Although this title refers to JSRRC, the JSRRC Coordinator also has jurisdiction over requests to MCASC and NARA.

The JSRRC Coordinator or individual acting in the capacity of a JSRRC Coordinator

determines whether or not submission of a request to JSRRC, MCASC, or NARA for stressor verification is appropriate

serves as the MCASC and NARA point of contact for issues related to records requests

personally submits all of the RO’s requests for stressor corroboration notifies JSRRC, MCASC, or NARA when further action on a pending

research request is no longer necessary, such as when evidence is received that verifies the claimed stressor or the claim is withdrawn altogether, and

forwards inquiries from the regional office (RO) regarding JSRRC-related issues to the VA Central OfficeCompensation Service (VACO) JSRRC mailbox at VAVBAWAS/CO/JSRRC.

db. Criteria for Submission to JSRRC, MCASC, or NARA

The following general criteria must be met before the JSRRC Coordinator may submit a request for corroboration of a claimed stressor to JSRRC, MCASC, or NARA:

the required development is completed, but the claimed stressor cannot be conceded based on the stressor verification review procedures in M21-1, Part IV, Subpart ii, 1.D.3.c, and the evidence does not corroborate the Veteran’s claim that he/she engaged in combat, served as an FPOW, was exposed to hostile military or terrorist activity, served as a drone aircraft crew member, or experienced other in-service stressor(s)

the in-service stressor claimed is capable of being documentedclaims folder contains minimum information needed to allow additional research as described in M21-1, Part IV, Subpart ii, 1.D.3.l.

the Veteran’s records contain- evidence of a diagnosis of PTSD, such as outpatient treatment records

showing treatment for PTSD, or- competent lay evidence of persistent or recurrent symptoms of PTSD,

such as the Veteran’s description of symptoms indicative of PTSD, and development is complete in every respect except for- corroboration of the in-service stressor, and- a confirmed diagnosis of PTSD.

Important: When a stressor is not of record, dDo not schedule a VA examination before

receiving corroboration of the claimed in-service stressor. A diagnosis of PTSD is not a prerequisite for initiating the stressor

verification process.

ec. Procedures for Conducting JSRRC Coordinator Review

The table below describes the procedure for conducting JSRRC Coordinator review.

Step Action1 Review the primary and secondary sources of evidence of record to

determine if there is credible supporting evidence that the claimed

stressor can beoccurred corroborated.

Can the stressor be corroborated conceded without submitting a request to JSRRC, MSACS, or NARA?

If yes,- annotate the claims folder as directed at M21-1, Part IV, Subpart

ii, 1.D.1.lf, and- proceed to Step 5.

If no, proceed to Step 2.

Reference: For more information on credible supporting evidence see M21-1, Part III, Subpart iv, 4.O.4.f-h.

2 Submit a request for corroboration of the stressor to the proper location, per M21-1, Part IV, Subpart ii, 1.D.34.fd. , and

Pproceed to Step 3.3 Establish a VBMS tracked item for the request for corroboration

utilizing with a 30-day suspense timedate. Use the table below to determine the appropriate tracked item to use based on the type of request being submitted.

Mark the JSRRC COORDINATOR REVIEW tracked item as RECEIVED and remove the JSRRC Request special issue indicator, which will allow the claim to be recalled to the NWQ.

Note: At this point, the JSRRC Coordinator’s duties are complete for the request phase. When a response to the request is received, proceed to Step 4.

Reference: For more information on establishing tracked items, see M21-1, Part III, Subpart iii, 1.F.3, and the VBMS User Guide.

4 When a response to a request for corroboration of a claimed stressor is received from JSRRC, MCASC, or NARA

upload a copy of the response to the claims folder, and

Location Request is Submitted to

Tracked Item for Use

JSRRC CONFIRM PTSD STRESSOR, TO JSRRC located in the 3RDPARTYRQST drop down menu

MCASC CONFIRMED PTSD STRESSOR, TO MC HISTORICAL CTR located in the 3RDPARTYRQST drop down menu

NARA Utilize a custom tracked item and enter CONFIRM PTSD STRESSOR, TO NARA in the ITEM REQUESTED field.

close the corresponding tracked item for the records request (established in Step 3).

Did the request result in additional credible supporting evidence Does the information received clearly allow for corroboration of the claimed stressor occurred?

If yes,- document the claims folder as directed at M21-1, Part IV, Subpart

ii, 1.D.1.lf, and- proceed to Step 5.

If no, and the stressor clearly cannot be corroborated, refer the claim to the rating activity., or

the information received does not clearly indicate whether a stressor may or may not be corroborated, proceed to Step 5

Important: The determination that a claimed in-service stressor cannot be corroborated is to be made based on the objective evidence of record and not the JSRRC Coordinator’s own personal feelings about the believability of the stressor.

5 After a stressor has been corroborated or evidence has been received that may allow RVSR corroboration, rReview the evidence of record to determine whether a compensation examination has been completed.

Has the examination been completed?

If yes, refer the claim to the rating activity. If no, request the examination.

Note: If the response to the request for corroboration does not clearly indicate whether a stressor may be conceded, Tthe determination as to whether a stressor is conceded is ultimately the responsibility of the rating activity. However, at this stage a request for examination will be made given the potentialif there is any favorable evidence that the stressor occurredmay be conceded at the time of RVSR review.

Important: Guidance prescribed in this block is not routinely applicable in cases involving stressors related to personal trauma and/or MST, as is emphasized in M21-1, Part IV, Subpart ii, 1.D.45.qk.

References: For more information on JSRRC Coordinator’s duties, see M21-1, Part IV, Subpart ii, 1.D.34.a, and general information required to submit requests for verification to JSRRC,

MCASC, or NARA, see M21-1, Part IV, Subpart ii, 1.D.34.db.

fd. Where to Send a Request for Corroboration of an In-Service Stressor Unrelated to Personal Trauma or MST

Use the table below to determine where to send a request for corroboration of an in-service stressor unrelated to personal trauma or MST.

If the stressor occurred during service in the …

Send the request to … References

Army Navy Air Force, or Coast Guard

JSRRC (address code 55) via DPRIS under request code

O40 - first (or only) stressor O41 - second stressor (if more

than one is claimed), orO42 - third stressor (if more than

two are claimed).

For more information on submitting a request to JSRRC, see

the DPRIS User Guide the JSSRC Stressor Verification

Guide M21-1, Part IV, Subpart ii,

1.D.4.e and f, and M21-1, Part III, Subpart iii,

2.I.4.Marine Corps, during the Vietnam Era or earlier

Address:National Archives and Records AdministrationAttention: Modern Military Records8601 Adelphi RoadCollege Park, MD 20740-6001

Exceptions: Do not submit a request for stressor corroboration to this address if the claimed stressor can be corroborated through

review of Marine Corps unit records on the Stressor Verification page

occurred during assignment aboard a Navy ship, or

occurred after Vietnam Era service.

Note: Most unit records covering the Korean Conflict and Vietnam Era are available on the Stressor Verification page.

For more information on

the Stressor Verification page, see M21-1, Part IV, Subpart ii, 1.D.4.j, and

submitting a request to NARA, see M21-1, Part IV, Subpart ii, 1.D.4.i.

Marine Corps, after the Vietnam Era

Send an e-mail to Nancy K. Whitfield, Archives Technician, MCASC, at the following address:

Nancy.Whitfield@usmcu.edu

Telephone number:(703) 432-4517

Reference: For more information on what information to include in the e-mail to MCASC for verifying claimed in-service stressors, see M21-1, Part IV, Subpart ii, 1.D.3.p.

Exceptions: Do not submit a request for stressor corroboration to this e-mail address if the claimed stressor can be corroborated through

review of Marine Corps unit records on the Stressor Verification page

occurred during assignment aboard a Navy ship, or

occurred during Vietnam Era service or earlier.

For more information on submitting a request to MCASC, see M21-1, Part IV, Subpart ii, 1.D.4.k and l.

Marine Corps, during assignment aboard a Navy ship

Address:U.S. Army and Joint Services Records Research Center7701 Telegraph RoadKingman Building, Room 2C08Alexandria, VA 22315-3852

For more information on requesting Naval records, see M21-1, Part IV, Subpart ii, 1.D.4.m.

ge. Format of Requests for Stressor Corroboration to JSRRC

When submitting a request for stressor corroboration to JSRRC, submit all requests using the DPRIS web application. If, due to an exceptional circumstance, the need arises to submit a written (paper) request, send correspondence to the PIES mailbox at VAVBAWAS/CO/PIES advising of the reason for the exception.

Important: JSRRC and VA have an agreement that JSRRC will research deck logs up to 60 days and, under certain circumstances, an additional 60 days, if needed. If additional deck logs are needed beyond the 120 days, VSRs should request additional deck logs from NARA’s College Park location.

References: For more information on

submitting requests through DPRIS, see M21-1, Part III, Subpart iii, 2.I.4, and

how to contact NARA’s College Park location or to submit a JSRRC request, see M21-1, Part IV, Subpart ii, 1.D.34.fd.

hf. Information to Include in Requests for Stressor Corroboration to JSRRC (Formerly CURR)

Military records are organized by units. Unit records are further organized by date. When submitting a request for stressor corroboration to JSRRC (formerly CURR), provide

a point of contact adequate identifying information, to include the Veteran’s full name and

Social Security number (SSN) a description of the claimed stressor(s). List only one stressor in the PTSD

Stressor block per 040, 041, and 042. Do not submit requests with three or four stressors listed in the same block.

the most specific date(s), at minimum the month and year, during which the stressful event occurred (JSRRC will research records dated 30 days before the date provided and 30 days after).

the Veteran’s complete tour dates related to the unit of assignment when the incident occurred

the designation of the Veteran’s unit of assignment at the time of the stressful event down to the lowest possible level, and

the geographic location where the stressful event took place. In the UNIT LOCATION block, provide more concise locations such as Fallujah, Iraq, instead of Iraq, or Seoul, Korea, instead of just Korea.

Additional information identified by JSRRC as helpful in conducting research includes

the medals or citations received by the Veteran, and the names of other soldiers or sailors involved in the stressful incident.

Important: For Army requests, provide the full unit designation to the company level,

such as HHC, 1st Brigade, 2d Armored Division (instead of 2d Armored Division only), and Company C, 1st Battalion, 14th Infantry, 1st Brigade Combat Team, 4th Infantry Division.

For Navy requests, provide the full unit designation and hull numbers for ships, such as USS Franklin D. Roosevelt (CVA-42) instead of USS Roosevelt only.

For Air Force requests, at a minimum, provide squadron and group designations, such as 366th Field Maintenance Squadron, 366th Combat Support Group instead of 366th Tactical Fighter Wing only. Providing just the wing is insufficient because there are numerous units under a wing and various unit locations.

Notes: The telephone number for VA’s Liaison Officer at JSRRC is (703) 428-

6870. When inputting electronic research requests for JSRRC, if it is not possible

to read the DA Form 20 or equivalent document listing to include unit of assignment, mail or fax the document to the VA Liaison Officer for assistance.

References: For more information on personnel documents containing the Veteran’s unit(s) of assignment and

service locations, see M21-1, Part IV, Subpart ii, 1.D.2.gf, and submitting a JSRRC request, see

- M21-1, Part IV, Subpart ii, 1.D.4.d, and- the JSSRC Stressor Verification Guide.

ig. Refraining From Submitting Duplicate Requests to JSRRC

If you have already input a request and have not received a response, do not input a new request to JSRRC as a follow-up, as this will delay the case if it is not finalized yet. Instead, for status of research requests already submitted to JSRRC, an inquiry may be sent to the following mailbox: VAVBAWAS/CO/JSRRC.

jh. Circumstances in Which JSRRC Requests May Be Expedited

JSRRC is able to expedite requests only under the following extraordinary circumstances

terminal illness, or Congressional inquiry.

Note: It is JSRRC’s policy to research and complete all cases within 45 to 60 days.

ki. Sending Requests for Research of Marine Corps Unit Records to NARA

Send Mail a request for research of Marine Corps unit records to NARA at the address listed in M21-1, Part IV, Subpart ii, 1.D.4.d when the

corroboration of a stressor is requiredclaim meets the criteria for submission described in M21-1, Part IV, Subpart ii, 1.D.4.b, and

the necessary unit records cover are from the Vietnam Era or earlier.

Exception: Unit records covering the Korean Conflict or the Vietnam Era may be accessed on the Stressor Verification page as described in M21-1, Part IV, Subpart ii, 1.D.3.l.

Use the table below to request stressor corroboration from NARA.The following information must be included in each request to NARA for records needed to document a claimed stressor:

the Veteran’s last name designation of the Veteran’s unit of assignment at the time of the stressful

event, down to the lowest possible level

the most specific date(s), at minimum the month and year, during which the stressful event occurred

geographical location where stressful event took place description of the stressful event, and the name and e-mail address of the VA point of contact.

Important: Before submitting a request to NARA, ROs must research the claimed stressor by accessing the unit records covering the Korean Conflict or the Vietnam Era on the Stressor Verification page as described in M21-1, Part IV, Subpart ii, 1.D.4.j.

Step Action1 Access the inquiry form at NARA’s website address.2 Select “Records created by the United States military” from the

drop-down list of question topics.3 In the box provided

identify yourself as a VBA employee, and indicate the specific information you are seeking, as well as the

Veteran’s- name- rank- unit of assignment at the time of the stressful event, and- inclusive dates of service.

4 Furnish your contact information in the spaces provided.

lj. Accessing Korean Conflict and Vietnam Era Marine Corps Unit Records

Marine Corps unit records covering the Korean Conflict and Vietnam Era are available to VA personnel on the Stressor Verification page.

Perform a thorough search on the Stressor Verification page to obtain information needed to corroborate the claimed stressor(s) of a Korean Conflict or Vietnam Era Veteran.

Note: NARA maintains custodianship of the records on the Stressor Verification page and is the ultimate authority on the content and organization of the records.

n. Requesting Stressor Corroboration From Marine Corps Records Dated After the Vietnam Era

Requests for stressor corroboration from Marine Corps for unit records dated after the Vietnam Era must be e-mailed directly to MCASC.

References: For more information on MCASC’s e-mail address, see M21-1, Part IV, Subpart ii, 1.D.3.f, and what to include in an e-mail to MCASC for stressor verification, see M21-1,

Part IV, Subpart ii, 1.D.3.p.

o. Responsibilities of the MCASC

MCASC is primarily responsible for

identifying post-Vietnam Era record(s) required to document the stressors, or

providing confirmation that the claimed stressor(s) cannot be corroborated using records in its custody.

Important: An RO cannot deny a claim for PTSD based solely on the absence of a verified stressor until MCASC or NARA has confirmed the RO’s negative findings.

pk. Information to Include in Record Requests to MCASC Related to a Claimed In-Service Stressor

The following information must be included in each e-mail request to MCASC for records needed to document a claimed stressor:

the Veteran’s last name designation of the Veteran’s unit of assignment at the time of the stressful

event down to the lowest possible level the most specific date(s), at minimum the month and year, during which the

stressful event occurred geographical location where stressful event took place description of the stressful event, and the name and e-mail address of the VA Point of Contact.

Notes: Do not include in the request any medical information or statement(s) from

the Veteran. MCASC only researches unit command chronology. Therefore, personal

identification information, such as SSN, service number, date of birth, and dates of service should not be included in the request.

Submit a request to MCASC only after exhausting all efforts to document the claimed stressor(s) through other means, including the Stressor Verification page and/or official military web sites.

Include a copy of the e-mail request in the Veteran’s claims folder.

References: For more information on For MCASC’s e-mail address, see M21-1, Part IV, Subpart ii, 1.D.34.fd.,

and For a sample of an e-mail request to MCASC for stressor verification, see

M21-1, Part IV, Subpart ii, 1.D.34.ql.

ql. Sample E-mail to MCASC for a Determination as to the Availability of Records Required to

Below is a sample of the text to include in the e-mail to MCASC for a determination as to the availability of records required to corroborate a stressor that occurred during service in the Marine Corps after the Vietnam Era.

To: Marine Corps Archives and Special Collections

Corroborate a Stressor

From: XYZ Regional Office

Subject: Request for Research of Records for In-Service Stressor(s)

This is a request for research of records in your possession for the purpose of verifying an in-service stressor. The following information is provided to assist your research:

Smith 3d Battalion, 12th Marines, Bravo Company, Unit XYZ, Camp

Foster, Okinawa, Japan January 2009 Norther Training Area, Okinawa, Japan Collision of two helicopters that killed 10 people during a training

exercise in the Northern Training Area of Okinawa. John Doe, Veterans Service Representative

E-mail address: John.Doe@va.gov.

rm. Where to Send Requests for Navy Deck Logs

Use the table below to determine the address to use when requesting Navy deck logs.

If the Navy deck logs … Then send the request to …are dated 1940 or earlier Old Military and Civil Records

National Archives and Records Administration700 Pennsylvania Ave., NWWashington, DC 20408

are dated between 1941 and 30 years prior to the current date

Modern Military BranchNational Archives and Records Administration8601 Adelphi Rd.College Park, MD 20740

are less than 30 years old Department of the NavyNaval Historical Center805 Kidder Breese, SEWashington Navy YardWashington, DC 20374-5060

Reference: For more information on Navy deck logs and how to obtain them, see http://www.history.navy.mil/research/archives/deck-logs.html.

sn. Invalid or Incomplete Research Requests to JSRRC,

JSRRC, MCASC, or NARA will return to the appropriate RO any research request identified as invalid or incomplete, with an explanation of the deficiency(ies) identified. JSRRC, MCASC, or NARA then closes out the request; it must be resubmitted as a new request to receive further

MCASC, or NARA

consideration.

Note: JSRRC, MCASC, and NARA process research requests on a first-come, first-served basis. Incomplete requests that are later resubmitted losetheir original “place in line.” For this reason, it is very important to providecorrect and complete information to JSRRC, MCASC, and NARA at the timeof the initial submission.

to. Handling Requests for More Information From JSRRC, MCASC, or NARA

Occasionally, JSRRC, MCASC, or NARA requires additional information in order to conduct its research. When this occurs, the RO must take immediate action to comply with the request.

Notes: The JSRRC Coordinator may contact the Veteran by telephone to obtain the

additional information needed to document the in-service stressor. The substance of the telephone call must be documented on a VA Form 27-0820, Report of General Information.

Failure by the Veteran to respond substantively to the request for information is grounds for denial of the claim based on the absence of a verifiable stressor.

Reference: For more information on stressor corroboration and the additional evidence that may be required to conduct research, see the JSRRC Stressor Verification Guide.

45. Developing Claims for SC for PTSD Based on Personal Trauma

Introduction This topic contains information on developing claims for SC for PTSD based on personal trauma, including

general information on personal trauma evidence required to establishdeveloping claims of SC based on in-service

personal trauma assigning claim attributes to personal trauma claims process for obtaining information from the Veteran in claims based on in-

service personal trauma procedure for reviewing for credible evidence of a personal trauma stressor DoD’s reporting procedures following MST incidents action VA takes upon receipt of a claim based on MST language to include in the section 5103 notice if thesubsequent development

letter for a restricted MST report is restricted language to include in the section 5103 notice if the MST report is

unrestricted developing to DoD in claims based on MST sample development letter to DoD in claims based on MST sample Response to Request for DD Form 2910 or Other Similar Form Modern Awards Processing-Development (MAP-D) or VBMS required

information in MST claims development lettersletters to use to obtain information from the Veteran in claims based on personal trauma

process for obtaining service records in claims based on personal trauma problems associated with development in claims based on personal trauma alternative sources for information in claims based on personal trauma process for obtaining police reports in claims based on personal trauma, and contact information for DoD MST units by branch of service personal trauma and or MST stressors that cannot be corroboratedand

JSRRC., and requesting examinations for PTSD claims based on MST.

Change Date October 17, 2017June 14, 2018

a. General Information on Personal Trauma

Personal trauma for the purpose of VA disability compensation claims based on PTSD refers broadly to stressor events involving harm perpetrated by a person who is not considered part of an enemy force.

Examples: Assault, battery, robbery, mugging, stalking, harassment.

Military sexual trauma (MST) is a subset of personal trauma and refers to sexual harassment, sexual assault, or rape that occurs in a military setting.

Reference: For more information on processing claims for PTSD based on personal trauma, see M21-1, Part III, Subpart iv, 4.HO.43 the PTSD Personal Assault Information site on the Compensation Service

Intranet, and 38 CFR 3.304(f)(5) .

b. Evidence Required to EstablishDeveloping Claims of SC Based on In-Service Personal Trauma

When a Veteran claims To establish SC for PTSD based on in-service personal trauma, undertake required development of the claim for there must be credible evidence to support the Veteran’s assertion that the stressful event occurred.

Because a personal trauma is an extremely personal and sensitive issue

many incidents of personal trauma are not officially reported, and the victims of this type of in-service trauma may find it difficult to produce

evidence to support the occurrence of the stressor.

Important:This does not mean that the evidence actually proves that the incident occurred, but that there is at least an approximate balance of positive and negative evidence that the event did occur. Identifying possible sources of evidence to support the claim may require

asking the Veteran for information concerning the traumatic incident. Make this request as compassionately as possible in order to avoid causing further trauma.

Although personal trauma is most often thought of as involving female Veterans, male Veterans may also be involved. Be sure requests for evidence/ information reflect the appropriate gender of the Veteran.

Note: The development activity must work closely with the rating activity when developing personal trauma cases.Veterans whose stressor occurred during inactive duty for training (INACDUTRA) are eligible for SC in the same manner as those whose stressor occurred during active duty or active duty for training. VA Office of General Counsel concluded in VAOPGCPREC 8-2001 that “PTSD resulting from sexual assault may be considered a disability resulting from an injury.”

References: For more information on applying the benefit-of-the-doubt rule, see

- M21-1, Part III, Subpart iv, 2.B.3.k- M21-1, Part III, Subpart iv, 2.B.4.f, and- M21-1, Part III, Subpart iv, 5.A.1.j

negative evidence, see- Forshey v. Principi, 284 F.3d 1335 (Fed. Cir. 2002) (en banc), and- Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000), and

guidance that the absence of a service record documenting an unreported sexual assault or failure to report an in-service sexual assault to military authorities may not be considered evidence that the sexual assault did not

occurabsence of military documentation of a sexual assault, see- M21-1, Part III, Subpart iv, 4.HO.43.c, and- AZ, AY v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013).

c. Assigning Claim Attributes to Personal Trauma Claims

To facilitate tracking and proper routing of claims, claims processors must assign the appropriate claim attributes to personal trauma claims.

Determine the nature of a Veteran’s personal trauma claim and using the table below, ensure one of the following special issues is assigned to the relevant contention(s).

If the claim is for ... Then assign the ...any condition, mental or physical (including PTSD), resulting from MST

MST special issue indicator.

PTSD resulting from a non-sexual personal trauma

PTSD – Personal Trauma special issue indicator.

any condition, mental or physical (other than PTSD), resulting from a non-sexual personal trauma

Non-PTSD Personal Trauma special issue indicator.

Reference: For more information on special issues in VBMS, see the VBMS User Guide , and M21-4, Appendix D.

c. Process for Obtaining Information From the Veteran in Claims Based on In-Service Personal Trauma

Identifying possible sources of evidence to support the claim may require asking the Veteran for information concerning the traumatic incident. Make this request as compassionately as possible in order to avoid causing further trauma.

Although personal trauma is most often thought of as involving female Veterans, male Veterans may also be involved. Be sure requests for evidence/ information reflect the appropriate gender of the Veteran.

d. Procedure for Reviewing For Credible Evidence of a Personal Trauma Stressor

The Secretary has undertaken a special obligation to assist a claimant in producing corroborating evidence of an in-service stressor in personal trauma claims per Patton v. West, 12 Vet. App. 272 (1999). In view of this special obligation it is critical to

make all required efforts to obtain evidence of personal trauma, and consider all available evidence bearing on the question of whether the

trauma occurred.

Follow the steps in the table below to determine if there is credible supporting evidence of a personal trauma stressor.

Step Action Reference

1 Ensure all STRs and the entire personnel folder have been obtained.

M21-1, Part IV, Subpart ii, 1.D.2

2 If the claim is based on MST, contact the Veteran.

M21-1, Part IV, Subpart ii, 1.D.5.f

3 Was VA Form 21-0781a or equivalent submitted?

If yes, proceed to next step. If no,

- send a subsequent development letter- wait 30 days, and- proceed to the next step.

Important: If the claim is based on MST, include in the letter the appropriate DoD report notification

language shown in M21-1, Part IV, Subpart ii, 1.D.5.g and h, and

MST coordinator contact information shown in M21-1, Part IV, Subpart ii, 1.D.5.i.

M21-1, Part IV, Subpart ii, 1, D.2.g-i

4 Review primary sources of evidence for supporting documentation of the traumatic event.

Is there supporting credible evidence the claimed stressor occurred?

If yes,- annotate the relevant document(s) in

accordance with M21-1, Part IV, Subpart ii, 1.D.1.f, and

- complete all other required development, including an examination.

If no, proceed to the next step.

M21-1, Part IV, Subpart ii, 1.D.1.c, and

M21-1, Part IV, Subpart ii, 1.D.6

5 Did the Veteran provide a sufficiently detailed account of the personal trauma stressor on VA Form 21-0781a or its equivalent to allow for additional research of the stressor?

If yes, proceed to the next step. If no,

- send a subsequent development letter asking the Veteran to provide the missing details

- wait 30 days, and- proceed to the next step.

M21-1, Part IV, Subpart ii, 1, D.2.g-i

Important: If the claim is based on MST, include in the letter the appropriate DoD report notification

language shown in M21-1, Part IV, Subpart ii, 1.D.5.g and h, and

MST coordinator contact information shown in M21-1, Part IV, Subpart ii, 1.D.5.i.

6 Obtain any alternative sources of evidence identified by the Veteran.

Do alternative sources of evidence contain credible supporting evidence that the claimed stressor occurred?

If yes,- annotate in accordance with M21-1, Part

IV, Subpart ii, 1.D.1.f, and- complete all other required

development, including an examination. If no, proceed to next step.

M21-1, Part III, Subpart iv, 4.O.3.c

7 Review records for evidence of behavioral changes around the time of, and after, the incident(s), which may constitute a marker of a personal trauma PTSD stressor.

Is there evidence that constitutes a potential marker?

If yes,- annotate in accordance with M21-1, Part

IV, Subpart ii, 1.D.1.f, and- complete all other required

development, including an exam. If no, refer the claim to the rating activity.

M21-1, Part III, Subpart iv, 4.O.3.d

de. DoD’s Reporting Procedures Following MST Incidents

DoD offers two reporting options for MST, restricted and unrestricted. Restricted reporting allows a service member to file a report confidentially without initiating the investigative process.

Following an MST incident, a service member may elect one of these reporting options by completing DD Form 2910, Victim Reporting Preference Statement.

The service member may also elect an optional sexual assault forensic examination (SAFE), which is performed by a health care provider and is documented on DD Form 2911, Forensic Medical Report: Sexual Assault Examination.

Notes: DoD may have used other forms prior to the issuance of DD Form 2910.

For example, the Department of the Navy used the form NAVPERS 1752/1, Sexual Assault Incident Data Collection Report.

In restricted reporting cases, DoD stores the evidence, including results from the SAFE, for one year following the date of the victim’s report of sexual assault. If the victim does not claim the evidence or elect an unrestricted report within one year, DoD destroys it.

Reference: For more information on requesting an MST report from DoD, see M21-1, Part IV, Subpart ii, 1.D.5.g.

ef. Action VA Takes Upon Receipt of Claim Based on MST

The table below shows the action VA takes upon receipt of a claim based on MST.

Step Action1 The RO’s MST Outreach Coordinator contacts the Veteran via

telephone to ask if he/she completed DD Form 2910, DD Form 2911, or a similar form following the incident.

Was telephone contact successful?

If yes, proceed to Step 2. If no,

- document the unsuccessful attempt as a permanent VBMS note, and

- proceed to Step 5.

Note: If the MST Outreach Coordinator is unable to contact the Veteran by telephone on the first attempt, a second attempt is not necessary. Continue to develop for the evidence by letter using the restricted report paragraphs as shown in M21-1, Part IV, Subpart ii, 1.D.4.f.

2 Did the Veteran state he/she completed one of the forms?

If yes, go proceed to Step 3. If no,- advise Veteran evidence from alternative sources or

behavioral changes may constitute credible supporting evidence of MST, and

- proceed to Step 4. follow the normal procedures for developing claims based on personal trauma shown in this topic.

3 Ask the Veteran for the following information:

the name and location of the military base where the report was filed

copies of the DD Form 2910, DD Form 2911, or other evidence, and

whether the report was restricted or unrestricted.Notes:Inform the Veteran that he/she will receive a letter documenting this request for information.If the Veteran indicated that the report is unrestricted, develop for the DoD records immediately by sending the development letter shown in M21-1, Part IV, Subpart ii, 1.D.4.i.

4 Inform the Veteran that he/she may receive a letter documenting this request for information

Ddocument the telephone contact on VA Form 27-0820, and proceed to the next step.

Reference: For more information on documenting telephone contacts, see M21-1, Part III, Subpart iii, 1.B.1.d.

5 Send the claimant the section 5103 notice, to include normal personal trauma development, such as

development for VA Form 21-0781a, and the additional paragraph shown in M21-1, Part IV, Subpart ii, 1.D.4.f (restricted report), or M21-1, Part IV, Subpart ii, 1.D.4.g (unrestricted report).

Note: DD Form 2911 may be used in lieu of VA Form 21-0781a, as both forms contain the same information.

Reference: For more information on using letters to obtain information in personal trauma claims, see M21-1, Part IV, Subpart ii, 1.D.4.k.

5 Follow the procedures M21-1, Part IV, Subpart ii, 1.D.5.d to obtain and review all relevant credible supporting evidence.

fg. Language to Include in the Section 5103 NoticeSubsequent Development Letter if for a Restricted MST Report Is Restricted

Include the following language in the section 5103 noticesubsequent development letter if

the Veteran indicated he/she completed a restricted MST report, or is restricted

contact with the claimant in M21-1, Part IV, Subpart ii, 1.D.5.f is unsuccessful and M21-1, Part IV, Subpart ii, 1.D.5.d requires sending a subsequent development letter to the Veteran:

If you have completed DD Form 2910, Victim Report Preference Statement, or similar form, following the personal assault, please provide us with a copy. If you don’t have the form, you may obtain a

copy of the form by contacting the Sexual Assault Prevention and Response Office (SAPRO) at the military base where you filed your report.

If you would like us to obtain the form on your behalf, please complete and return the enclosed VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA). Be sure to reference DD Form 2910, or similar form, on VA Form 21-4142.

Additionally, if you had a sexual assault forensic examination (SAFE) performed following the personal assault, please send us any copies of the examination that you have. If you would like us to obtain them for you, please indicate this on the VA Form 21-4142. If you are submitting copies of the SAFE, you do not need to complete VA Form 21-0781a, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault.

Important: The letter must include the language noted in M21-1, Part IV, Subpart ii, 1.D.5.i.

g. Language to Include in the Section 5103 Notice if MST Report Is Unrestricted

Include the following language in the section 5103 notice if the MST report is unrestricted:

We have requested the following records from the Department of Defense:

DD Form 2910, Victim Report Preference Statement, or similar form, and/or

sexual assault forensic examination (SAFE).

If you have these records in your possession, please provide us with copies. If you don’t have the records, you may obtain copies of them by contacting the Sexual Assault Prevention and Response Office (SAPRO) at the military base where you filed your report.

h. Developing to DoD in Claims Based on MST

Initiate development to DoD immediately

when the Veteran indicates the MST report was unrestricted, or upon receipt of VA Form 21-4142, Authorization and Consent to Release

Information to the Department of Veterans Affairs (VA).

Follow the steps in the table below when requesting an MST report from DoD.Send the development letter shown in M21-1, Part IV, Subpart ii, 1.D.4.i, to the Sexual Assault Prevention and Response Office (SAPRO) at the base on which the assault is reported to have occurred.

If no response is received within 30 days, send a follow-up letter to the appropriate base. Establish a 30-day control, notify the Veteran of the delay in obtaining the records, and ask the Veteran to submit any restricted or unrestricted records that he/she has in his/her possession.

If DoD indicates it cannot locate the documents, prepare a memorandum of unavailability per M21-1, Part III, Subpart iii, 2.I.6.c.

Reference: For contact information for MST units in each branch of service, see M21-1, Part IV, Subpart ii, 1.D.4.p.

Step Action1 Use the following link to search for the MST units at each branch

of service:

https://www.safehelpline.org/

Notes: Utilize the search function located at the top of the webpage and

input the city or military installation to find the contact information for reporting authorities. The results provide unit and phone number.

Telephone contact to the unit will be necessary to obtain addresses or fax information to send requests for information.

2 Send the MST DoD Letter from the Letter Creator to the Sexual Assault Prevention and Response Office (SAPRO) at the base on which the assault is reported to have occurred.

Important: If the Veteran reports the report is restricted, attach a completed VA Form 21-4142.

3 Send the Veteran notice of the records request using the following language:

We have requested the following records from the Department of Defense:

DD Form 2910, Victim Report Preference Statement, or similar form, and/or

sexual assault forensic examination (SAFE).

If you have these records in your possession, please provide us with copies. If you don’t have the records, you may obtain copies of them by contacting the Sexual Assault Prevention and Response Office (SAPRO) at the military base where you filed your report.

Important: The letter must include the language noted in M21-1, Part IV, Subpart ii, 1.D.5.i.

4 Did VA receive a response from DoD within 30 days?

If yes, proceed to the next step. If no,

- send a follow-up letter to the appropriate base- establish a 30-day control, and- notify the Veteran of the delay in obtaining the records, and

ask the Veteran to submit any restricted or unrestricted records that he/she has in his/her possession.

5 Did DoD provide the requested report?

If yes,- annotate the claims folder as directed in M21-1, Part IV,

Subpart ii, 1.D.1.f, and- proceed with all other required development, including

requesting a VA examination. If no, continue to review the claim for credible supporting

evidence in accordance with the procedures M21-1, Part IV, Subpart ii, 1.D.5.d.

i. Sample Development Letter to DoD in Claims Based on MST

Below is a sample development letter requesting evidence from DoD in claims based on MST.

Reference: For a sample Response to Request for DD Form 2910 or Other Similar Form, see M21-1, Part IV, Subpart ii, 1.D.4.j.

Refer To:[File Number][RO Unit Number]

[Name][Address] [Veteran’s Name]

Dear [name]:

[Veteran’s name] has applied for disability benefits from VA. The Veteran states that he/she reported a sexual assault at your facility.

Please furnish copies of the following forms:

DD Form 2910, Victim Report Preference Statement, or similar form, and DD Form 2911, Forensic Medical Report: Sexual Assault Examination, or similar form.

We have enclosed VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), signed by the Veteran permitting you to release this information to VA.

Please send these records within 30 days. Be sure to attach a copy of this letter with your response. If you do not have the records, please advise us of that fact. For your convenience, we have included a response sheet at the end of this letter. If you have any questions, you

may call us at 1-800-827-1000. If you call, please have this letter available.

Sincerely yours,

Veterans Service Center Manager

Enclosures:Response to Request for DD Form 2910 or Other Similar FormVA Form 21-4142, Authorization for Release of Information

j. Sample Response to Request for DD Form 2910 or Other Similar Form

Below is a sample Response to Request for DD Form 2910 or Other Similar Form.

Note: Enclose this form with the sample development letter shown in M21-1, Part IV, Subpart ii, 1.D.4.i.

Response to Request for DD Form 2910 or Other Similar Form

[ ] We have enclosed the following forms:

[ ] DD Form 2910

[ ] DD Form 2911

[ ] Other Similar Form: ______________________________

[ ] Other Evidence: _____________________________

[ ] The Veteran filed a report; however, the documents were destroyed. The following information is provided to you:

Date Veteran Filed Report: ________________________

Date Report was Destroyed: _______________________

Type of Report: Restricted Unrestricted

[ ] We have no record that the Veteran filed a report.

Signature: _____________________________ Date: _______________

Name: ____________________________ Title: ___________________

ki. MAP-D or VBMS Letters

When writing a letter to obtain information from the Veteran regarding a

to Use to Obtain Information From the Veteran in Claims Based on Personal Trauma Required Information in MST Claims Development Letters

PTSD claim based on personal traumaMST, use Modern Awards Processing-Development (MAP-D) or VBMS and select the appropriate personal trauma special issue on the CONTENTIONS screen

MST (claims for any conditions, mental or physical (including PTSD), resulting from MST)

PTSD – Personal Trauma (claims for PTSD resulting from a non-sexual personal trauma), or

Non-PTSD Personal Trauma (claims for any condition, mental or physical (other than PTSD), resulting from a non-sexual personal trauma).

Enclose VA Form 21-0781a to solicit details of the claim, and ensure the development letter includes the following contact information if the Veteran has questions about the claim, the RO’s request for information, and a contact at the Veterans Health Administration (VHA) for questions concerning health care or counseling:

If you have any questions concerning your claim or our request for information, please call us at 1-800-827-1000, or visit the following web site to locate the Military Sexual Trauma (MST) outreach coordinator for your area: http://www.benefits.va.gov/benefits/mstcoordinators.asp.

If you have questions concerning health care or counseling, you should call [NAME], the Military Sexual Trauma (MST) outreach coordinator at the [CITY] VA Medical Center at [PHONE NUMBER].

Important: Locate the applicable VHA MST Coordinator’s information using the MST

Resource SharePoint Page at https://vaww.portal.va.gov/sites/mst_community/section_pages/People-Finder/Find-MST-Coordinators.aspx.

Letters used by ROs to solicit details concerning a combat stressful incident are inappropriate for PTSD claims based on personal trauma.

l. Process for Obtaining Service Records in Claims Based on Personal Trauma

Review the claim and all attached documents. Request STRs and the entire personnel folder from the appropriate records custodian, if necessary.

Note: VSRs must work closely with RVSRs when developing personal trauma cases.

m. Problems Associated With Development in Claims Based

Because a personal trauma is an extremely personal and sensitive issue

many incidents of personal trauma are not officially reported, and the victims of this type of in-service trauma may find it difficult to produce

evidence to support the occurrence of the stressor.

on Personal Trauma It is often necessary to seek alternative evidence that may demonstrate the

presence of markers. The term marker refers to evidentiary signs, events, or circumstances indicating a possibility that the claimed stressor occurred, such as reports, lay statements, or behavioral changes that may be associated with the approximate timeframe of the claimed stressor.

References: For more information on alternative sources for information, see M21-1, Part IV, Subpart ii, 1.D.4.n,

and behavioral changes in claims based on personal trauma, see M21-1, Part III,

Subpart iv, 4.H.4.d and f.

n. Alternative Sources for Information in Claims Based on Personal Trauma

Service records not normally requested may be needed to develop claims for SC for PTSD based on personal trauma, including MST. Responses to a request for information may identify alternative sources for information, such as

a rape crisis center or center for domestic abuse a counseling facility or health clinic family members or roommates a faculty member civilian police reports medical reports from civilian physicians or caregivers who treated the

Veteran immediately following the incident or sometime later a chaplain or clergy fellow service members, and personal diaries or journals.

Reference: For information on the duty-to-assist in seeking recordspertaining to an individual other than the claimant, see M21-1, Part I, 1.C.2.d.

oj. Process for Obtaining Police Reports in Claims Based on Personal Trauma

In certain cases, the Veteran may identify police reports as a relevant alternative source of evidence. If the report is not already part of the available military or other records, oObtain reports, as appropriate, from

military police shore patrol a provost marshal’s office, or other military or civilian law enforcement offices.

Note: Requests may be submitted via phone, fax, e-mail, or written correspondence, as long as the request is properly documented in the claims folder.

p. Contact Use the following link to search for the MST units at each branch of service:

Information for DoD MST Units by Branch of Service

https://www.safehelpline.org/

Utilize the search function located at the top of the web page and input the city or military installation to find the contact information for reporting authorities. The results provide unit and phone number. Telephone contact to the unit will be necessary to obtain addresses or fax information to send requests for information.

qk. Personal Trauma and or MST Stressors That Cannot Be Corroboratedand JSRRC

Provided all applicable developmental efforts described in this topic have been undertaken, the JSRRC Coordinator need not routinely be involved in the development of personal trauma or MST claims. However, when the circumstances of the described event are of a nature that would otherwise warrant JSRRC research, the claim should be referred to the JSRRC Coordinator for review of the evidence and possible request for verification of the stressor, per M21-1, Part IV, Subpart ii, 1.D.34.d b and ec.

References: For more information on when to request corroboration of an in-service stressorrefer a claim to a

JSRRC Coordinator, see M21-1, Part IV, Subpart ii, 1.D.3.bn, and the nature of research conducted by JSRRC, see the JSRRC Stressor

Verification Guide.

6. Examinations in Claims for SC for PTSD

Introduction This topic contains information about handling examinations in claims for SC for PTSD, including

when to proceed with an examination in a PTSD claim, and requesting- initial PTSD examinations other than personal trauma, and- examinations for PTSD claims based on personal trauma.

Change Date June 14, 2018

a. When to Proceed With an Examination in a PTSD Claim

In PTSD claims, request an examination if

there is credible supporting evidence that the claimed stressor occurred evidence (to include lay statements) indicates the Veteran currently suffers

from symptoms consistent with a diagnosis of PTSD, and medical evidence adequate for rating purposes is not already of record.

Notes: Do not request an examination until development for credible supporting

evidence of the claimed stressor is complete as outlined in either M21-1, Part IV, Subpart ii, 1.D.3 and 4, or 5.

Forward the claims folder to the examining facility and request its review as part of the examination process any time the issue is SC for PTSD.

In PTSD claims alleging personal trauma based on MST, a VA examination should be scheduled and a medical opinion requested when there is evidence of a “marker” found in the records.

References: For more information on requesting examinations, see M21-1, Part III, Subpart iv, 3.A, and assisting with medical evidence requests, see M21-1, Part I, 1.C.

b. Requesting Initial PTSD Examinations Other Than Personal Trauma

When evidence of exposure to stressors related to combat, experience as an FPOW, fear of hostile military or terrorist activity, or drone aircraft crew member duties is established by a Veteran’s individual decoration(s) or other military records, include a statement to that effect in the Remarks section of the examination request. This evidence allows VA (including the examiner) to accept the Veteran’s own description of the specific events without further corroboration.

Important: Evidence of experience as an FPOW, exposure to combat, fear of hostile military or terrorist activity, or drone aircraft crew member duties in itself, does not satisfy the diagnostic criteria for PTSD.

Note: When requesting a PTSD examination, specify that, if possible, the Veteran’s treating mental health professional should not perform the examination.

Reference: For more information on evidence of stressors related to combat, experience as an FPOW, or a fear of hostile military or terrorist activity, see M21-1, Part III, Subpart iv, 4.O.4, and M21-1, Part IV, Subpart ii, 1.D.1 and 3.

rc. Requesting Examinations for PTSD Claims Based on MSTPersonal Trauma

In compliance with 38 CFR 3.159(c)(4), an compensation and pension examination will always be needed when a thorough review shows

a current medical diagnosis of PTSD or the Veteran’s lay statements describing PTSD symptoms

credible supporting evidence of the personal trauma incident or circumstantial evidence of a marker in the in-service or post-service records

indication that the PTSD symptoms may be associated with the claimed MST stressor (established by applying a low threshold and liberal approach satisfied by virtue of a current diagnosis or symptoms and the presence of a marker), and

medical evidence adequate for rating purposes is not already of recordinsufficient evidence to make an informed decision on the claim without examination.

In these cases where the only evidence of the personal trauma stressor are behavioral changes that may be markers of the claimed trauma, an compensation and pension examination is almost always needed because the marker itself has does not established the occurrence of the stressor, but and the opinion of the qualified examiner can provide credible and probative evidence to make that determination. The examination is needed specifically to determine

whether a medical opinion can provide evidence for occurrence of the claimed in-service MST personal trauma stressor based on the marker and the Veteran’s lay statement, and

whether that claimed stressor is related to current PTSD symptoms.

Important: In order to ensure the examination request language is adequate, use the Exam Request Builder (ERB) or Simplified ERB (ERB-S) tool, as appropriate, and select either the PTSD MST or PTSD personal trauma (non-MST) medical opinion template based on the nature of the claimed stressor.Although the examiner’s opinion is not determinative of the outcome of the claim, it will be accepted as significant probative evidence when evaluating SC for the diagnosed mental disorder.

References: For more information on requesting examinations, see M21-1, Part III, Subpart iv, 3.A evidence that may constitute markers of trauma, see M21-1, Part III,

Subpart iv, 4.O.3.d, and medical opinions to interpret evidence of behavioral changes see

- M21-1, Part III, Subpart iv, 4.O.3.e, and- Patton v. West, 12. Vet.App. 272 (1999).- Utilize the language below to request examination for PTSD associated

with MST markers. Until the Exam Request Builder (ERB) is updated, remove the text generated by that tool and replace it with the text below.

This examination is being conducted to assist with determining whether the Veteran experienced an in- service personal assault stressor related to military sexual trauma (MST) that has resulted in a current PTSD diagnosis. Please review the claims file and state in your report that it was reviewed. In your review of the claims file, please pay special attention to signs, events, or circumstances that may represent markers for the MST stressor described by the Veteran. Your review is not limited to the evidence identified on this request form, or tabbed in the claims folder. If additional testing is required, please obtain it prior to rendering your opinion.

Based upon your review of the evidence, please provide a medical opinion as to whether the MST stressor event described by the Veteran is at least as likely as not (50 percent or greater probability) supported by and consistent with the in-service marker evidence. Please provide a rationale for the opinion and list the marker evidence used to arrive at your decision.

In addition:[1.] IF YOUR EXAMINATION DETERMINES THE VETERAN

HAS A CURRENT DIAGNOSIS OF PTSD, please provide an opinion as to whether the current PTSD diagnosis is at least as likely as not (50 percent or greater probability) caused by or a result of the in-service MST-related marker(s), and provide a rationale. Please note that only PTSD can be service connected based on circumstantial marker evidence (38 CFR 3.304(f) (5)).

[2.] IF YOUR EXAMINATION DETERMINES THAT, IN ADDITION TO PTSD, THE VETERAN HAS ADDITIONAL MENTAL DISORDERS, please state whether the additional mental disorders are at least as likely as not (50 percent or greater probability) secondary to the PTSD, and provide a rationale. For each mental disorder diagnosed, identify and clearly list which symptoms are attributed to each diagnosis. If one or more symptoms overlap and cannot be separated without speculation, please state so and provide a rationale (38 CFR 3.310).

[3.] IF YOUR EXAMINATION DETERMINES THE VETERAN DOES NOT HAVE PTSD, BUT HAS A DIFFERENT MENTAL DISORDER(S), please review the service treatment records

(STRs) and service personnel records for in-service direct evidence. Direct evidence is clear, undisputable proof of an event, injury, or disease. Such evidence includes, but is not limited to, mental health treatment, mental health symptoms, or a mental health diagnosis. If direct evidence exists in the STRs or service personnel records, please provide an opinion as to whether the mental disorder(s) diagnosed on examination is at least as likely as not (50 percent or greater probability) caused by or a result of the direct evidence noted in service. Please provide a rationale for the opinion and list the evidence used to arrive at your decision. (38 CFR 3.303).

Rationale must be provided in the appropriate section.

References: For more information on requesting and interpreting examiner’s opinions in PTSD claims based on

MST, see Patton v. West, 12. Vet.App. 272 (1999) handling medical opinions linking a non-PTSD diagnosis to a claimed

PTSD stressor, see M21-1, Part III, Subpart iv, 4.H.6.j, and using the ERB, see the ERB User Guide.