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M21-1, Part IV, Subpart ii, Chapter 1, Section D – Claims for Service Connection (SC) for Post-Traumatic Stress Disorder (PTSD)

Overview


In This Section

This section contains the following topics:
Topic
Topic Name
1
2
3
4
5
6

1.  General Information on Developing Claims for SC for PTSD


Introduction

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

Change Date

 June 14, 2018

IV.ii.1.D.1.a.
Developing Claims of SC for PTSD Due to In-Service Stressors

When a Veteran claims service connection (SC) for posttraumatic stress disorder (PTSD) associated with an in-service stressor, 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

IV.ii.1.D.1.b.  Responsibility for StressorVerification

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

IV.ii.1.D.1.c.  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, the 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
  • 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, Certificate of Release or Discharge From Active Duty, or in service personnel records.
  • This information may be requested from the 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.


IV.ii.1.D.1.d.  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 VBA-sanctioned websites, 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.

References:  For more information on


IV.ii.1.D.1.e.  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:

Image of working notes regarding PII

Example 2:

Image of subject value.

 
References:  For more information on

IV.ii.1.D.1.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

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

Change Date

March 14, 2019

IV.ii.1.D.2.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
  • military treatment facility (MTF), or
  • civilian treating facility.
Note:  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.

IV.ii.1.D.2.b.Developing for Service Department Records of In-Service Mental Health Treatment

In order to develop for service department records of in-service mental health treatment administered at an MTF, refer to guidance on clinical record requests as described in
Reference:  For more information on requesting records in the custody of a Federal department or agency, see

IV.ii.1.D.2.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

IV.ii.1.D.2.d.  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.

IV.ii.1.D.2.e.  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 MST
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.f, 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

IV.ii.1.D.2.f.  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 2-1Personnel 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 20EnlistedQualification Record, and DA Form 66Officer 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 7Airman Military Record, pages 36 through 39
  • officer record, AF Form 11Officer 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 3305Leave Record, pages 3, 5, 6-7, and
  • DD Form 214.

IV.ii.1.D.2.g.  When to Request Additional Evidence From the Veteran to Establish an In-Service Stressor

It is unnecessary to issue Section 5103 notice when a Veteran files a claim for SC for PTSD on a form that provides, or otherwise indicates he/she received, the notice, such as VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits.
Do not send the Veteran a subsequent development letter requesting credible supporting evidence to establish that an in-service stressor occurred 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
References:  For more information on

IV.ii.1.D.2.h.  Information to Request From the Veteran to Support an In-Service Stressor

When stressor development is necessary,
  • use the appropriate PTSD development paragraphs referenced 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.
Important:
  • Do not enclose VA Form 21-0781 or VA Form 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 that the claimed in-service stressor occurred, or
    • 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 absent an indication that the claim involves personal trauma.
References:  For more information on

IV.ii.1.D.2.i.  VBMS Paragraphs for Stressor Development

When it is necessary to request additional stressor details from the Veteran, 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 21-0781submitted.
PTSD—Need stressor details/med evid combat-related incdnt
  • Non-combat incident such as a car accident, or hurricane, or
  • does not mention a source for his/her stressor and does not provide details, and
  • no VA Form 21-0781submitted.
PTSD—Need stressor details/med evid of stressful incdnt
PTSD—Need stressor details/med evid personal trauma incdnt
Important:  Include the language in M21-1, Part IV, Subpart ii, 1.D.5.i when sending an MST subsequent development letter to the Veteran.
  • Any of the above stressor types, and
  • VA Form 21-0781 or VA Form 21-0781a was submitted, but
  • the Veteran failed to provide sufficient details for the stressor to be corroborated.
PTSD—Follow Up for Stressor Details
Important:
  • Inform the Veteran of the specific information that is still needed to allow for corroboration.
  • Include the language in M21-1, Part IV, Subpart ii, 1.D.5.iwhen sending an MST subsequent development letter to the Veteran.
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

Change Date
 June 14, 2018

IV.ii.1.D.3.a.  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 FPOW as defined by 38 CFR 3.1(y), or
    • fear of hostile military or terrorist activity or duties as a drone aircraft crew member, if a VA psychiatrist or psychologist, or contract equivalent, confirms the
      • claimed stressor is adequate to support a diagnosis of PTSD, and
      • 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.
References:  For more information on

IV.ii.1.D.3.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 inM21-1, 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

IV.ii.1.D.3.c. StressorVerification Review Procedure

Follow the steps in the table below to determine if there is credible supporting evidence that a claimed in-service stressor occurred.
Important:  Ensure all necessary service records have been requested as noted inM21-1, 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
Action
1
Review the stressor information submitted by the Veteran, if any, as well as all other service records, medical evidence, and lay or other evidence.

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?

2
Obtain all relevant secondary sources of evidence identified by the Veteran.
Can the stressor be corroborated based on the evidence of record and/or preliminary research of primary and secondary sources of evidence?

Reference:  For more information on primary and secondary sources of evidence, see

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?
4
Did the Veteran provide the details requested in Step 3?
5
Has a compensation examination been completed?
  • If yes, refer the claim 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.

IV.ii.1.D.3.d.  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

IV.ii.1.D.3.e.  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

IV.ii.1.D.3.f.  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) (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.
Reference:  For additional information on determining combat service, see

IV.ii.1.D.3.g. Examples of Service in Areas of Hostile Military or Terrorist Activity

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 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 Korea 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

IV.ii.1.D.3.h.  Establishing a Stressor Related to Combat

Concede a stressor when
Note:  If the Veteran does not expressly state the nature of the stressor,
References:  For more information on

IV.ii.1.D.3.i.  Establishing a Stressor Related to Fear of Hostile Military or Terrorist Activity

Concede a stressor when the Veteran’s DD Form 214 or other service records show 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

IV.ii.1.D.3.j.  Establishing a Stressor Related to Drone Aircraft Crew Member Duties

Recent military operations and warfare have involved the expansive use of armed drone aircraft, including, but not limited to, the Predator and Reaper.  Concede a stressor if 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

IV.ii.1.D.3.k.  
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 establishing 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.

IV.ii.1.D.3.l.  Minimum Information Required to 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
  • 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.
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 websites (available through the PTSD Rating Job Aid website) and supply this information on the Veteran’s behalf.

References:  For more information on the


IV.ii.1.D.3.m.  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.

IV.ii.1.D.3.n.  When to Refer a Claim to a JSRRC Coordinator

Prior 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
Reference:  For more information on procedures for routing a PTSD claim for JSRRC review, see M21-1, Part IV, Subpart ii, 1.D.3.o.

IV.ii.1.D.3.o.  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.3.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

4.  Requesting Corroboration of an In-Service Stressor


Introduction

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

Change Date

 June 14, 2018

IV.ii.1.D.4.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 RO regarding JSRRC-related issues to the Compensation Service JSRRC mailbox at VAVBAWAS/CO/JSRRC.

IV.ii.1.D.4.b. 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:
Important:
  • Do 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.

IV.ii.1.D.4.c.  Procedures for Conducting JSRRC Coordinator Review 

The table below describes the procedure for conducting JSRRC Coordinator review.
Step
Action
1
Review the primary and secondary sources of evidence to determine if there is credible supporting evidence that the claimed stressor occurred.
Can the stressor be conceded without submitting a request to JSRRC, MSACS, or NARA?
Reference:  For more information on credible supporting evidence see M21-1, Part III, Subpart iv, 4.O.4.f-h.
2
3
Establish a VBMS tracked item for the request for corroboration with a 30-day suspense date.  Use the table below to determine the appropriate tracked item to use based on the type of request being submitted.
Location Request is Submitted to
Tracked Item for Use
JSRRC
CONFIRM PTSD STRESSOR, TO JSRRClocated 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 enterCONFIRM PTSD STRESSOR, TO NARA in the ITEM REQUESTED field.

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
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
  • close the corresponding tracked item for the records request (established in Step 3).
Did the request result in additional credible supporting evidence the claimed stressor occurred?
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
Review 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:  The 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 if there is any favorable evidence that the stressor occurred.
 
Important:  Guidance prescribed in this block is not routinely applicable in cases involving stressors related to personal trauma and/or MST, as is emphasized inM21-1, Part IV, Subpart ii, 1.D.5.k.
References:  For more information on

IV.ii.1.D.4.d.  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), or
  • O42 – third stressor (if more than two are claimed).
For more information on submitting a request to JSRRC, see
Marine Corps, during the Vietnam Era or earlier
Address:
National Archives and Records Administration
Attention:  Modern Military Records
8601 Adelphi Road
College 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 theStressor Verificationpage
  • 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 Verificationpage.
For more information on
Marine Corps, after the Vietnam Era
Send an e-mail to Nancy K. Whitfield, Archives Technician, MCASC, at the following address:
Telephone number:
(703) 432-4517
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 theStressor Verificationpage
  • 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 Center
7701 Telegraph Road
Kingman Building, Room 2C08
Alexandria, VA  22315-3852
For more information on requesting Naval records, seeM21-1, Part IV, Subpart ii, 1.D.4.m.

IV.ii.1.D.4.e.  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.
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, request additional deck logs from NARA’s College Park location.
References:  For more information on

IV.ii.1.D.4.f.  Information to Include in Requests for Stressor Corroboration to JSRRC

Military records are organized by units.  Unit records are further organized by date.  When submitting a request for stressor corroboration to JSRRC, 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 thePTSD 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

IV.ii.1.D.4.g.  Refraining From Submitting Duplicate Requests to JSRRC

Do not input a new request to JSRRC as a means of following up on a pending request, as this will delay the request 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.

IV.ii.1.D.4.h.  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.

IV.ii.1.D.4.i.  Sending Requests for Research of Marine Corps Unit Records to NARA

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
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 the 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.

IV.ii.1.D.4.j.  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.

IV.ii.1.D.4.k.  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 the 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, on the Stressor Verification page and/or official military websites.
  • Include a copy of the e-mail request in the Veteran’s claims folder.
References:  For more information on

IV.ii.1.D.4.l.
E-mail to MCASC for a Determination as to the Availability of Records Required to Corroborate a Stressor

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
  
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
  • Northern 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.

IV.ii.1.D.4.m.  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 Administration
700 Pennsylvania Ave., NW
Washington, DC 20408
are dated between 1941 and 30 years prior to the current date
Modern Military Branch
National Archives and Records Administration
8601 Adelphi Rd.
College Park, MD 20740
are less than 30 years old
Department of the Navy
Naval Historical Center
805 Kidder Breese, SE
Washington Navy Yard
Washington, DC 20374-5060
 
Reference:  For more information on Navy deck logs and how to obtain them, seehttp://www.history.navy.mil/research/archives/deck-logs.html.

IV.ii.1.D.4.n.  Invalid or Incomplete Research Requests to JSRRC, MCASC, or NARA

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

IV.ii.1.D.4.o.  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 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.


5.  Developing Claims for Service Connection for PTSD Based on Personal Trauma


Introduction

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

Change Date

January 16, 2019

IV.ii.1.D.5.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

IV.ii.1.D.5.b.  Developing Claims of SC Based on In-Service Personal Trauma

When a Veteran claims SC for PTSD based on in-service personal trauma, undertake required development of the claim for 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:
  • 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.
References:  For more information on

IV.ii.1.D.5.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

IV.ii.1.D.5.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 perPatton 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.
2
Ensure MST coordinator actions are taken, if applicable.
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, generate the appropriate DoD MST report development language by following the relevant procedures in M21-1, Part IV, Subpart ii, 1.D.5.g and h.
4
Review primary sources of evidence for supporting documentation of the traumatic event.
Is there supporting credible evidence the claimed stressor occurred?
  • If yes,
  • If no, proceed to the next step.
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.
Important:  If the claim is based on MST, generate the appropriate DoD MST report development language by following the relevant procedures in M21-1, Part IV, Subpart ii, 1.D.5.g and h.
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,
  • If no, proceed to next step.
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,
  • If no, refer the claim to the rating activity.

IV.ii.1.D.5.e.  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.
  
Note:  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.
Reference:  For more information on requesting an MST report from DoD, seeM21-1, Part IV, Subpart ii, 1.D.5.g.

IV.ii.1.D.5.f.  MST Outreach Coordinator Actions

The table below shows the action VA takes upon receipt of a claim based on MST.
Step
Action
1
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.
2
Did the Veteran state he/she completed one of the forms?
  • If yes, proceed to Step 3.
  • If no,
    • advise the Veteran that evidence from alternative sources or evidence of behavioral changes may constitute credible supporting evidence of MST, and
    • proceed to Step 4.
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.
4
  • Inform the Veteran that he/she may receive a letter documenting this request for information
  • document 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.e.
5
Follow the remaining procedures in M21-1, Part IV, Subpart ii, 1.D.5.d to obtain and review all relevant credible supporting evidence.

IV.ii.1.D.5.g.  Subsequent Development Letter for a Restricted MST Report

Send a subsequent development letter using the MST – Restricted Report VBMS development paragraph if

IV.ii.1.D.5.h.  Developing to DoD in Claims Based on MST

Initiate development to DoD
Follow the steps in the table below when requesting an MST report from DoD.
Step
Action
1
Use the following link to search for the MST units at each branch of service:
Notes:
  • Utilize the search function located on 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 MST Unrestricted Report VBMS development paragraph.
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
    • 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?

IV.ii.1.D.5.i.  Required Information in MST Claims Development Letters

When writing a letter to obtain information from the Veteran regarding a PTSD claim based on MST, ensure the development letter includes the following information:
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 website 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 the Military Sexual Trauma (MST) outreach coordinator at your local VA Medical Center.
Important:  Letters used by ROs to solicit details concerning a combat-related stressful incident are inappropriate for PTSD claims based on personal trauma.

IV.ii.1.D.5.j.  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, obtain 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.

IV.ii.1.D.5.k.Personal Trauma or MST Stressors and 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.4.b and c.
References:  For more information on

IV.ii.1.D.5.l.  MST Claim Processing Requirements
All development actions on claims involving MST must only be taken by an individual who has
  • completed the required MST Training Performance Support System module(s), and
  • been designated by an RO as an MST claims processor.
Important:  To ensure accurate claims processing, the following checklists/worksheet are recommended for completion and uploading to the claims folder:

6.  Examinations in Claims for SC for PTSD


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

Change Date
 June 14, 2018

IV.ii.1.D.6.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

IV.ii.1.D.6.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, a fear of hostile military or terrorist activity, or drone aircraft crew member duties, see

IV.ii.1.D.6.c. Requesting Examinations for PTSD Claims Based on Personal Trauma

In compliance with 38 CFR 3.159(c)(4), an 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 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 record.
In cases where the only evidence of the personal trauma stressor are behavioral changes that may be markers of the claimed trauma, an examination is almost always needed because the marker itself does not establish the occurrence of the stressor, but 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 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.
References:  For more information on
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