M21-1, Part IV, Subpart ii, Chapter 1, Section I – Developing Claims for Service Connection (SC) Based on Other Exposure Types

In This Section

Introduction

• action to take when
  • only a positive tuberculin reaction is claimed, and
  • a positive tuberculin reaction and other disabilities are claimed, and
• reporting responsibilities of the Department of Veterans Affairs (VA) outpatient clinics and VA medical centers (VAMCs).

Change Date

IV.ii.1.I.1.a.  Action to Take When Only a Positive Tuberculin Reaction Is Claimed

IV.ii.1.I.1.b.   Action to Take When a Positive Tuberculin Reaction and Other Disabilities Are Claimed

• complete any appropriate development required for the other disabilities, and
• refer the claim to the rating activity for rating of all the claimed disabilities.

IV.ii.1.I.1.c.  Reporting Responsibilities of VA Outpatient Clinics and VAMCs

Introduction

• definition of a chronic disease
• establishing whether a disease is chronic
• considering
  • SC for a chronic or tropical disease, and
  • presumptive SC
• locations of lists of chronic and tropical diseases, and
• action to take if a chronic or tropical disease was
  • treated in service, or
  • not treated in service.

Change Date

IV.ii.1.I.2.a.  Definition:  Chronic Disease

• of prolonged duration, producing incapacitating symptoms of varying degree
• that may undergo remission, and
• that is seldom entirely cured with all residuals of damage being completely eradicated.

IV.ii.1.I.2.b.  Establishing Whether a Disease Is Chronic

IV.ii.1.I.2.c.  Considering SC for a Chronic or Tropical Disease

• SC based on manifestation of the claimed disease during service, and
• SC based on a presumption that the disease, which was first manifested following discharge from service, is nevertheless related to service.

IV.ii.1.I.2.d.  Considering Presumptive SC

• the possibility of entitlement to presumptive SC exists when the Veteran alleges inception within the limiting periods contained in
  • 38 U.S.C. 1112, or
  • 38 U.S.C. 1133, when appropriate
• the Veteran does not need to establish that the disease in question was definitely diagnosed within the presumptive period, and
• the evidence should show that manifestations of the condition, disabling to the degree of at least 10 percent, became apparent prior to the expiration of the presumptive period shown in 38 CFR 3.307.

IV.ii.1.I.2.e.  Locations of Lists of Chronic and Tropical Diseases

• 38 U.S.C. 1101(3) and 38 CFR 3.309(a) are chronic diseases, and
• 38 U.S.C. 1101(4) and 38 CFR 3.309(b) are tropical diseases.

IV.ii.1.I.2.f.  Action to Take if a Chronic or Tropical Disease Was Treated in Service

IV.ii.1.I.2.g.  Action to Take if a Chronic or Tropical Disease Was Not Treated in Service

• 38 U.S.C. 1112
• 38 U.S.C. 1133, or
• 38 U.S.C. 1137.

Introduction

• entitlement to SC for conditions based on exposure to asbestos
• development action to take when no disability related to asbestos exposure is claimed
• asbestos claims development procedures
• use of Navy Military Occupational Specialty (MOS) to determine probability of in-service asbestos exposure
• consideration of all evidence in the claims folder in determining in-service asbestos exposure, and
• requesting a respiratory examination and opinion for claims based on asbestos exposure.

Change Date

IV.ii.1.I.3.a.  Entitlement to SC for Conditions Based on Exposure to Asbestos

IV.ii.1.I.3.b.  Development Action to Take When No Disability Related to Asbestos Exposure Is Claimed

• 38 CFR 3.159(a)(3), and
• M21-1, Part I, 1.B.1.b.

IV.ii.1.I.3.c.  Asbestos Claims Development Procedures

• military personnel records
• specific exposure information from the claimant, and
• medical evidence of the specific diagnosis.

IV.ii.1.I.3.d.  Use of Navy MOS to Determine Probability of In-Service Asbestos Exposure

IV.ii.1.I.3.e.  Consideration of All Evidence in the Claims Folder in Determining In-Service Asbestos Exposure

• an assessment of the credibility of the evidence, and
• whether the evidence establishes that the exposure occurred.

• occupational exposure as explained in M21-1, Part IV, Subpart ii, 2.C.2.d and e
• exposure information that the Veteran provides in response to the asbestos development letter, to include lay testimony
• service personnel records
• service treatment records (STRs)
• buddy statements, and
• all other evidence located in the claims folder or identified by the Veteran relevant to the determination of asbestos exposure.

• The term credibility refers to believable evidence that tends to support the Veteran’s assertion based on consideration of plausibility, consistency with other evidence in the case, and source.
• Once asbestos exposure has been demonstrated by the evidence of record and the evidence contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of disability, accept the Veteran’s lay testimony as sufficient evidence of current symptoms or disease that could potentially be related to asbestos exposure for purposes of requesting an examination and medical opinion.

IV.ii.1.I.3.f.  Requesting a RespiratoryExamination and Opinion for Claims Based on Asbestos Exposure

• follow the guidance in M21-1, Part III, Subpart iv, 3.A.8.d to identify all relevant records the examiner should review in making a medical opinion, and
• ensure that the examination request states all relevant information as to asbestos exposure to include, but not limited to,
  • the Veteran’s MOS(s) and probability of asbestos exposure or the event or other occupational experience on which exposure is based, and
  • all pre- and post-service exposure history.

Introduction

• definition of AIDS
• causative agent of AIDS
• tests available to verify AIDS
• obtaining medical records showing treatment of AIDS, and
• when to send the claim to the rating activity.

Change Date

IV.ii.1.I.4.a.  Definition:  AIDS

IV.ii.1.I.4.b.  Causative Agent of AIDS

IV.ii.1.I.4.c.  Tests Available to Verify AIDS

• the screening enzyme-linked immunosorbent assay (ELISA) test, and
• the confirmatory Western Blot test.

IV.ii.1.I.4.d. Obtaining Medical Records Showing Treatment of AIDS

• STRs if they are not in the claims folder, and
• records of treatment from a VAMC or VA outpatient clinic, if the Veteran indicates that he/she received treatment at one of these facilities.

• reports treatment by a private hospital or physician, but
• does not furnish the treatment records.

IV.ii.1.I.4.e.  When to Send the Claim to the Rating Activity

• M21-1, Part I, 1.A.4.f
• M21-1, Part I, 1.B.1.b, and
• 38 CFR 3.159(a)(3).

Introduction

• definition of Special Operations
• developing claims related to Special Operations incidents
• exhibit of a Special Operations Forces Incident document, and
• responses from the U.S. Special Operations Command (USSOCOM).

Change Date

IV.ii.1.I.5.a.  Definition:  Special Operations

• typically composed of relatively small groups of highly-trained, armed personnel, and
• often transported by helicopter, small boats, or submarines, or parachute from aircraft for stealthy infiltration by land.

• U.S. Army’s Special Forces, commonly called the “Green Berets.”
• U.S. Navy sea, air, and land teams (SEALs).

IV.ii.1.I.5.b.  Developing Claims Related to Special Operations Incidents

IV.ii.1.I.5.c.  Exhibit:  Special Operations Forces Incident Document

IV.ii.1.I.5.d.  Responses From USSOCOM

Introduction

• locations of specific environmental hazards identified by Department of Defense (DoD)
• environmental hazard EP control and tracking
• action to take when the Veteran claims environmental hazards exposure but does not claim a disability
• guidelines for developing environmental hazard claims
• establishing exposure to environmental hazards
• verifying service at the Qarmat Ali Water Treatment Plant
• using alternate evidence or lay statements to establish exposure to environmental hazards, and
• what to include in VA examination and/or medical opinion requests in environmental hazard claims.

Change Date

IV.ii.1.I.6.a.  Locations of Specific Environmental Hazards Identified by DoD

IV.ii.1.I.6.b.  Environmental Hazard EP Control and Tracking

• establish a standard end product (EP), such as EP 110, 010, or 020, and
• if the claim is based on service in Southwest Asia, enter theEnvironmental Hazard in Gulf War special issue indicator for the related contention(s).

IV.ii.1.I.6.c.  Action to Take When the Veteran Claims Environmental Hazards Exposure but Does Not Claim a Disability

IV.ii.1.I.6.d.  Guidelines for Developing Environmental Hazard Claims

• the circumstances under which it is necessary to issue Section 5103 notice, see
  • M21-1, Part I, 1.B, and
  • M21-1, Part III, Subpart ii, 2.D.1.f
• requesting evidence from
  • the claimant, see M21-1, Part III, Subpart iii, 1.B, and
  • other sources, see M21-1, Part III, Subpart iii, 1.C and D
• developing for STRs and other service records, see M21-1, Part III, Subpart iii, 2.B, and
• verifying military service, see M21-1, Part III, Subpart ii, 6.B.2.

IV.ii.1.I.6.e.  Establishing Exposure to Environmental Hazards

• M21-1, Part IV, Subpart ii, 1.I.6.g, and
• M21-1, Part IV, Subpart ii, 2.C.5.l and m.

IV.ii.1.I.6.f.  Verifying Service at the Qarmat Ali Water Treatment Plant

IV.ii.1.I.6.g.  Using Alternate Evidence or Lay Statements to Establish Exposure to Environmental Hazards

• considering evidence in claims for disability compensation, see
  • 38 U.S.C. 1154(a), and
  • 38 CFR 3.303(a), and
• a list of what alternate evidence includes, see M21-1, Part IV, Subpart ii, 2.C.5.l.

IV.ii.1.I.6.h.  What to Include in VA Examination and/or Medical Opinion Requests in Environmental Hazard Claims

• Advise the examiner of the nature of the claimed environmental hazard and the location and timeframe of exposure.
• Remember that more than one environmental hazard may apply when Veterans are alleging exposure to a specific event.  Therefore, each fact sheet related to service in Iraq, as provided in Exhibits 1 through 4 (M21-1, Part IV, Subpart ii, 1.I.10–13) should be provided to the VA examiner.  This is necessary for Iraq Veterans since the Veteran served in Iraq and could have been exposed to burn pit emissions and the same high levels of particulate matter (PM) as others in the Southwest Asia theater of operations.
• Forward the claims folder to the examiner and ask him/her to
  • review the medical and other evidence in the claims folder, including the fact sheet or other documents for Camp Lejeune or other exposure claims, and
  • provide an opinion, and rationale for the opinion, as to the likelihood that the Veteran’s claimed disability is related to the hazardous environmental exposure.

• In all claims where service in the Southwest Asia theater of operations is established, review M21-1, Part IV, Subpart ii, 2.C.5.c to determine if the provisions of 38 CFR 3.317 must be applied.
• Do not request an examination or medical opinion until exposure has been established.

• establishing exposure to a claimed environmental hazard, see M21-1, Part IV, Subpart ii, 2.C.5.l and m, and
• developing claims based on Southwest Asia service, see M21-1, Part IV, Subpart ii, 1.E.

Introduction

Change Date

IV.ii.1.I.7.a.Presumption of SC Based on Exposure to Contaminated Water at Camp Lejeune

• service at Camp Lejeune, see 38 CFR 3.307(a)(7)(iii)
• rating claims based on Camp Lejeune service, see M21-1, Part IV, Subpart ii, 2.C.6, and
• service in the Reserve or National Guard, see M21-1, Part III, Subpart ii, 6.A.

IV.ii.1.I.7.b.  Definition:  Camp Lejeune Issue

• any disability specifically claimed as due to exposure to contaminants at Camp Lejeune, or
• one of the conditions listed at either 38 CFR 3.309(f) or 38 CFR 17.400, regardless of whether service at Camp Lejeune during the contamination period is
  • expressly claimed by the claimant, or
  • it is otherwise established by the evidence of record.

IV.ii.1.I.7.c.  Processing Jurisdiction of Camp Lejeune Claims 

• Veterans residing in foreign territories
• original pre-discharge claims
• restricted access claims, and
• other specific special mission claims, as needed.

IV.ii.1.I.7.d.  ROJ Processing of Camp Lejeune Claims  

• the Veteran did not serve at Camp Lejeune between August 1, 1953, and December 31, 1987
• the claim is for a disability recognized under 38 CFR 3.309(f) and
  • the Veteran had at least 30 days of service at Camp Lejeune during the contamination period, or
  • the evidence does not establish a diagnosis of the claimed condition
• no disability is specifically claimed as a result of exposure, such as claims stating “Camp Lejeune” or “exposure at Camp Lejeune”
• Veteran status needs to be established, such as through a character-of-discharge (COD) determination, or
• the only claim is for a disability of a dependent, including birth defects.  VA has no statutory authority to compensate a Veteran’s dependents exposed to Camp Lejeune water contamination.  Follow the procedures inM21-1, Part III, Subpart v, 2.A to administratively decide these claims.

• action to take when no disability is claimed, see M21-1, Part IV, Subpart ii, I.7.k
• clarifying claims, see M21-1, Part III, Subpart iii, 1.B.1.c, and
• COD decisions, see M21-1, Part III, Subpart v, 1.B.

IV.ii.1.I.7.e.  Initial Actions to Take on Camp Lejeune Claims

IV.ii.1.I.7.f.  ROJ’s Actions to Verify Service at Camp Lejeune

• verify the Veteran had at least one day of service at Camp Lejeune between August 1, 1953, and December 31, 1987, and
• review all available service records to determine the number of days the Veteran served at Camp Lejeune during the contamination period.

• When calculating the 30-day service requirement, consider the number of cumulative days a Veteran served at Camp Lejeune.  The 30 days of Camp Lejeune service do not have to be consecutive.
• Regardless of the disability claimed, ROJs must retain jurisdiction of all claims where there is no qualifying service at Camp Lejeune during the contamination period.
• If STRs document an official visit, such as for medical treatment, within the defined borders of Camp Lejeune, the days associated with the visit count as service at Camp Lejeune, even if personnel records indicate the Veteran had a different official duty station.

Step	Action
1	Do service records establish at least one day of service at Camp Lejeune between August 1, 1953, and December 31, 1987? If yes, proceed to the next step. If no, ensure the service records development procedures in M21-1, Part IV, Subpart ii, 1.I.7.g were followed send the claimant the subsequent development letter detailed in M21-1, Part IV, Subpart ii, 1.I.7.j provide 30 days for a response, and proceed to Step 4.
2	In the Veteran’s VBMS eFolder, edit the subject line of the relevant document(s) used to verify service at Camp Lejeune. Example: Reference:  For more information on editing document properties, see the VBMS User Guide.
3	Calculate the cumulative number of days the Veteran served at Camp Lejeune between August 1, 1953, and December 31, 1987.
4	Did the claimant provide additional evidence sufficient to establish at least one day of service at Camp Lejeune between August 1, 1953, and December 31, 1987? If yes, return to Step 2. If no, undertake normal claims processing without routing the claim for centralized processing.

IV.ii.1.I.7.g.  Obtaining Records of Camp Lejeune Service

• verify that the Veteran’s service at Camp Lejeune occurred during the period of water contamination, August 1, 1953, to December 31, 1987
• establish the number of days of Camp Lejeune service during this time frame, and
• annotate the service records that verify service at Camp Lejeune.

IV.ii.1.I.7.h.  Actions Taken by Centralized Processing RO on Camp Lejeune Claims

• Camp Lejeune claims jurisdiction, see M21-1, Part IV, Subpart ii, 1.I.7.c
• Camp Lejeune legacy appeals jurisdiction, see M21-1, Part IV, Subpart ii, 1.I.7.e, and
• inextricably intertwined Camp Lejeune legacy appeals, see M21-1, Part IV, Subpart ii, 1.I.7.l.

IV.ii.1.I.7.i. Determining the Need for Medical SME Review

• claims for compensation for a
  • 38 CFR 3.309(f) disability with less than 30 days of Camp Lejeune service, or
  • chronic disability recognized for healthcare purposes under 38 CFR 17.400 with at least one day of verified service at Camp Lejeune during the contamination period, and
• any disability claim with
  • at least one day of verified service at Camp Lejeune during the contamination period, and
  • evidence sufficient to warrant an examination under 38 CFR 3.159.

IV.ii.1.I.7.j. Developing to the Claimant in Camp Lejeune Claims

• provides the information the development letter solicits, or
• is otherwise sufficient to decide the claim.

• notification requirements for special issues, see M21-1, Part I, 1.B.1.f, and
• processing claims in VBMS, see the VBMS User Guide.

IV.ii.1.I.7.k. Action to Take When the Veteran Claims Exposure to Contaminants but Does Not Claim a Disability

IV.ii.1.I.7.l.  Inextricably Intertwined Non-Camp Lejeune Legacy Appeals

• legacy appeal EP to the Louisville RO, and
• Veterans Appeals Control and Locator System (VACOLS) record to RO70.

• annotate the decision in VACOLS and VBMS
• remove any special issue indicators, and
• return the legacy appeal to the originating ROJ.

• inextricably intertwined legacy appeals, see
  • M21-1, Part I, 5.A.1.g, and
  • M21-1, Part I, 5.E.3.c and d
• VACOLS, see the VACOLS User Guide, and
• transferring EPs, see M21-1, Part III, Subpart ii, 5.G.1.a.

Introduction

• background on the SHAD Project
• identifying a SHAD Claim
• EP control of SHAD claims
• requesting access to the U.S. DoD and VA Chemical Biological Warfare Exposure System (Chem-Bio) Database
• verification of participation and SHAD Manager notification
• action to take upon receipt of final negative response from DOD regarding SHAD participation, and
• procedure when receiving confirmation of SHAD participation.

Change Date

IV.ii.1.I.8.b.Identifying a SHAD Claim

• The SHAD Project was part of a larger effort called Project 112, with tests being both ship- and land-based.  For VA purposes, all claims resulting from participation in ship-based or land-based chemical or biological testing under these projects are considered SHAD claims.
• A claim in which the Veteran clearly served outside of the dates SHAD was conducted would not be considered a SHAD claim but could be considered a chemical-biological exposure claim that must be clarified with the claimant.

IV.ii.1.I.8.c.  EP Control of SHAD Claims

IV.ii.1.I.8.d.  Requesting Access to the U.S. DoD and VA Chem-Bio Database

IV.ii.1.I.8.e.Verification of Participation  and SHAD Manager Notification

IV.ii.1.I.8.f. Action to Take Upon Receipt of Final Negative Response From DoD Regarding SHAD Participation

IV.ii.1.I.8.g.Procedure When Receiving Confirmation of SHAD Participation

• a request for a medical opinion regarding any relationship between the claimant’s current disability and exposure to agents, simulants, tracers, and decontaminants used in the test(s) the Veteran was involved in, and
• a copy of all applicable DoD fact sheets for the test(s) the Veteran participated in.

• If the name of the test(s) is/are known, in the comment section of the examination request include a list of the agents, simulants, tracers, and decontaminants listed in the DoD fact sheet.
• Many claimants were involved in multiple tests.  Medical examiners need information about all tests in which the Veteran was involved.
• SC should be considered on direct and presumptive bases, where applicable.

Introduction

• definition of CBRNE claims
• action to take when the Veteran claims participation in CBRNE testing but does not claim a disability
• EP control procedures for claims based on CBRNE testing
• sending notification of entitlement to medical treatment at a VAMC for individuals claiming exposure as a test participant 
• CBRNE POCs and Chem-Bio Database Access
• procedure for verifying participation in CBRNE testing
• referring the claim to Compensation Service to verify participation in CBRNE testing
• where to schedule an examination for claims based on CBRNE testing, and
• information to include in examination or medical opinion requests for claims based on CBRNE testing.

Change Date

IV.ii.1.I.9.a.  Definition:  CBRNE Claims

• Edgewood Arsenal between 1955 and 1975
• Fort (Ft.) Detrick, and
• Dugway Proving Ground.

IV.ii.1.I.9.b.  Action to Take When the Veteran Claims Participation in CBRNE Testing but Does Not Claim a Disability

IV.ii.1.I.9.d. Sending Notification of Entitlement to Medical Treatment at a VAMC for Individuals Claiming Exposure as a Test Participant

IV.ii.1.I.9.e.     CBRNE POCs and Chem-Bio Database Access

IV.ii.1.I.9.f.  Procedure for Verifying Participation in CBRNE Testing

IV.ii.1.I.9.g. Referring the Claim to Compensation Service to Verify Participation in CBRNE Testing

IV.ii.1.I.9.h.  Where to Schedule an Examination for Claims Based on CBRNE Testing

IV.ii.1.I.9.i.  Information to Include in Examination or Medical Opinion Requests for Claims Based on CBRNE Testing

Change Date

IV.ii.1.I.10.a.  Fact Sheet: Burn Pits in Iraq, Afghanistan, and the Horn of Africa

Change Date

IV.ii.1.I.11.a.  Fact Sheet:Particulate Matter Throughout Iraq, Afghanistan, and Djibouti

Change Date

IV.ii.1.I.13.a.  Fact Sheet: Qarmat Ali Water Treatment Plant

Change Date

IV.ii.1.I.14.a.  Fact Sheet: Naval Air Facility in Atsugi, Japan