Overview
In This Section |
This section contains the following topics:
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1. General Information on Developing Claims for SC for PTSD
Introduction |
This topic contains general information on developing claims for SC for PTSD, including
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Change Date |
June 14, 2018
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IV.ii.1.D.1.a.
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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
References: For more information on
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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.
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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
Notes:
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:
Important: It may not be necessary to corroborate the claimed stressor if it is
References: For more information on
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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:
Example 1: Example 2: References: For more information on
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IV.ii.1.D.1.f. Annotating Documents Used to Concede a Stressor |
When sufficient evidence is received to concede a claimed stressor,
Reference: For more information on uploading documents to the eFolder and editing document properties, see the
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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
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Change Date |
March 14, 2019
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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
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.
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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
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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
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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.
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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.
Notes:
References: For more information on
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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
Important: Send a subsequent development letter prior to deciding the claim, if the Veteran
References: For more information on
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IV.ii.1.D.2.h. Information to Request From the Veteran to Support an In-Service Stressor |
When stressor development is necessary,
Important:
References: For more information on
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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.
Important: Do not send a second development letter requesting stressor information if the Veteran
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.
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Introduction
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This topic contains information on concession of an in-service stressor, including
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Change Date
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June 14, 2018
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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
Notes:
References: For more information on
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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
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,
Notes:
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
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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.
Important:
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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
Reference: For additional information on determining combat service, see
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IV.ii.1.D.3.e. Definition: Fear of Hostile Military or Terrorist Activity |
Fear of hostile military or terrorist activity means
Examples of exposure to hostile military or terrorist activity include presence at events involving
Reference: For more information on fear of hostile military and terrorist activity, see
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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:
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
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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.
Reference: For more information on fear of hostile military or terrorist activity, see
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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
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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:
References: For more information on
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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
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IV.ii.1.D.3.k.
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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.
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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:
Notes:
References: For more information on the
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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:
Examples:
Reference: For more information on the types of stressors that may be impossible to corroborate, see the JSRRC Stressor Verification Guide, Section V.
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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.
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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
References: For more information on
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4. Requesting Corroboration of an In-Service Stressor
Introduction |
This topic contains information on requesting corroboration of an in-service stressor, including
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Change Date |
June 14, 2018
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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
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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:
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IV.ii.1.D.4.c. Procedures for Conducting JSRRC Coordinator Review |
The table below describes the procedure for conducting JSRRC Coordinator 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 inM21-1, Part IV, Subpart ii, 1.D.5.k.
References: For more information on
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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.
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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
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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
Additional information identified by JSRRC as helpful in conducting research includes
Important:
Notes:
References: For more information on
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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.
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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:
Note: It is JSRRC’s policy to research and complete all cases within 45 to 60 days.
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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:
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.
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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.
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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:
Notes:
References: For more information on
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IV.ii.1.D.4.l.
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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:
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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.
Reference: For more information on Navy deck logs and how to obtain them, seehttp://www.history.navy.mil/research/archives/deck-logs.html.
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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:
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
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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
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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,
Important:
Note: The development activity must work closely with the rating activity when developing personal trauma cases.
References: For more information on
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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).
Reference: For more information on special issues in VBMS, see the
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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
Follow the steps in the table below to determine if there is credible supporting evidence of a personal trauma stressor.
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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.
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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.
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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
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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.
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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.
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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
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.
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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
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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
Important: To ensure accurate claims processing, the following checklists/worksheet are recommended for completion and uploading to the claims folder:
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Introduction
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This topic contains information about handling examinations in claims for SC for PTSD, including
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Change Date
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June 14, 2018
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IV.ii.1.D.6.a. When to Proceed With an Examination in a PTSD Claim |
In PTSD claims, request an examination if
Notes:
References: For more information on
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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
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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
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
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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1-16-19_Key-Changes_M21-1IV_ii_1_SecD-1.docx | May 21, 2019 | 138 KB |
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Change-May-21-2015-Transmittal-Sheet-M21-1IV_ii_1_SecD_TS.docx | May 21, 2019 | 38 KB |
Change-April-15-2015-Transmittal-Sheet-M21-1IV_ii_1_SecD_TS.docx | May 21, 2019 | 44 KB |
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