information to clinicians for referring combat veterans from past and future conflicts, with

difficult-to-diagnose, debilitating illnesses to the Department of Veterans Affairs (VA) War

Related Illness and Injury Study Centers (WRIISC).

WRIISCs, eligibility, and procedural requirements.

contents of this Handbook. Questions may be referred to 202-273-8463.

the last working day of July 2009.

S/ Arthur S. Hamerschlag for

Jonathan B. Perlin, MD, PhD, MSHA, FACP

Acting Under Secretary for Health

DISTRIBUTION: CO: E-mailed 7/16/04

FLD: VISN, MA, DO, OC, OCRO, and 200 – E-mailed 7/16/04

1. Purpose ....... 1

2. Background 1

3. Authority .... 1

4. Mission ...... 2

5. Eligibility and Referral Procedures .......................................................................................... 2

6. References . 3

APPENDIXES

A Criteria Used to Determine Eligibility as Combat Veterans ................................................ A-1

B VA Form 10-0417, Pre-screen Application for Referral to WRIISC ................................... B-1

C Patient Assessment Information for Possible Referral to WRIISC ....................................... C-1

This Veterans Health Administration (VHA) Handbook provides information to clinicians for

referring combat veterans from past and future conflicts, with difficult-to-diagnose, debilitating

illnesses to the Department of Veterans Affairs (VA)’s War Related Illness and Injury Study

Centers (WRIISC).

a. Public Law 105-368 directed VA to contract with the National Academy of Sciences

(NAS) to develop a plan for establishing national centers for the study of war-related illnesses

and post-deployment issues.

b. On November 5, 1999, NAS recommended that VA establish centers for the study of warrelated

illnesses similar in structure to VA’s Geriatric Research Education, and Clinical Centers.

NAS came to the conclusion that applying a proven model of care, research, and education to the

issue of deployment health "should contribute greatly to the advancement of knowledge in this

area."

c. On May 10, 2001, the Secretary of Veterans Affairs announced the establishment of two

War-Related Illness and Injury Study Centers (WRIISCs) at VA medical centers in Washington,

DC, and East Orange, NJ. Additional Centers may be added in the future. For further

information on WRIISCs, please refer to the following website:

d. These centers collaborate with the Department of Defense (DOD) personnel and other

health care professionals engaged in similar post-deployment health issues for active duty service

members and veterans.

e. In addition to specialty clinical care for combat veterans with difficult-to-diagnose

disabling illnesses, the two WRIISCs are charged with developing new research for new

treatments for such patients; education for patients and VA health care providers who work with

these patients; and risk communication on war-related illnesses for patients and their families.

The mission of WRIISCs is to provide health-related services to veterans who served in a

theater of combat operations, or in combat support, during a past, current, or future conflict, and

who, subsequent to such service, have suffered, are suffering, or suffer from difficult-to-diagnose

disabling illnesses. Such services include: clinical care, risk communication, education,

research addressing potential environmental exposures and experiences, and adverse health

outcomes.

No special treatment authority applies to care provided through the WRIISCs. Care is to be

provided to enrolled combat veterans under VA’s general treatment authority. This means that

veterans in a co-payment required status, either for medical care or for medications, may be

subject to co-payment unless a separate eligibility factor exempts them from such co-payment

requirements.

a. As part of the WRIISC evaluation process, veterans must first have a thorough

examination by their VA primary care clinician. The WRIISC serves as a second opinion for

veterans with war-related concerns. Eligibility criteria are:

(1) Veterans must have served in an area of combat. To determine whether a veteran has

served in combat for purposes of the WRIISC Program, VA relies upon the same citations and

criteria used to determine a veteran’s eligibility for readjustment counseling at VA Vet Centers

as authorized by Title 38 United States Code (U.S.C.) Section 1712A (see App.A); and the

criteria set forth in current VHA policy.

(2) Veterans must have an undiagnosed or difficult to diagnose illness and/or disabling

unexplained symptoms.

(3) Veterans must be medically and psychiatrically stable for participation and evaluation at

the WRIISC since these are fairly intense 4 to 5 day programs. Also, the WRIISC staff must

b. The referring facility assumes the responsibility for arranging and paying for travel to the

WRIISC. Each WRIISC, in turn, assumes the responsibility of arranging and paying for the

return travel of the veteran.

d. An electronic WRIISC Computerized Patient Record System (CPRS) template must be

completed by the primary care provider. A national template was developed for WRIISC and

distributed in patch TIU*1.0*159. The title is WRIISC ASSESSMENT.

e. VA Form 10-0417, Pre-screening Application for WRIISC Referral, must be completed

and sent to the Office of Environmental Agents (131), either by fax (202) 273-9080, or e-mail.

a. Information Bulletin 10-165.

b. Slide presentation "War-Related Illness and Injury Study Centers (WRIISCs)" at website:

1. To determine veterans’ eligibility as a combat veteran, the Department of Veterans Affairs

(VA) relies on the same citation and criterion used to determine eligibility for readjustment

counseling at VA Vet Centers, as authorized by Title 38 United States Code (U.S.C.), Section

1712A, and current VHA policy. According to present VHA policy, a positive determination in

any of the following criteria indicates eligibility as a combat veteran:

a. Any veteran who served in a theater of combat operations during World War II and is

eligible for one or more of the following three campaign medals:

(1) The European-African-Middle Eastern Campaign Medal; it was awarded for theater

military service to include combat operations during the period December 7, 1941, through

November 8, 1945.

(2) The Asiatic-Pacific Campaign Medal; it was awarded for theater military service to

include combat operations during the period December 7, 1941, through March 2, 1946.

(3) The American Campaign Medal; it was awarded for theater military service to include

combat operations during the period December 7, 1941, through March 2, 1946.

b. Any veteran who served in the theater of combat operations in Korea during the Korean

War, and is eligible for the Korean Service Medal; it was awarded for theater military service to

include combat operations during the period June 27, 1950, through July 27, 1954.

c. Any veteran who served in the theater of combat operations in Vietnam during the

Vietnam era (July 3, 1965 through May 7, 1975) and who received the Vietnam Service Medal

for such service or Armed Forces Expeditionary Medal for specific operations in 1975.

d. Any veteran who served in the Lebanon theater of operations (August 25, 1982, through

February 26, 1984) and who received the Armed Forces Expeditionary Medal for such service.

e. Any veteran who served in the Grenada theater of operations (October 23, 1983, through

November 21, 1983) and who received an Armed Forces Expeditionary Medal for such service.

f. Any veteran who served in the Panama theater of operations (December 20, 1989, through

January 31, 1990) and who received an Armed Forces Expeditionary Medal for such service.

g. Any veteran who served in the theater of combat operations in the Gulf War (August 2,

1990, and continuing until ended by Presidential proclamation or law), and who received a

Southwest Asian Campaign Medal for such service.

h. Any veteran who served in the Somalia theater of operations (September 17, 1992, and

ending by Presidential proclamation or law) and who received an Armed Forces Expeditionary

Medal for such service.

2. Veterans who served in the peace-keeping operations in the former Republic of Yugoslavia,

including Bosnia and Kosovo, who were awarded an Armed Forces Expeditionary Medal for one

or more of the following three operations: Operation Joint Endeavor; Operation Point Guard, or

Operation Joint Forge. Services for combat veterans under this policy are authorized by the

Secretary of Veterans Affairs in the VA Memorandum "Eligibility for Veteran Returnees from

the Former Republic of Yugoslavia," dated April 26, 2000.

3. Requests for medical services that do not meet these eligibility requirements may still qualify

for such services if the veteran’s DD-214, Discharge Papers, shows an award of the Armed

Forces Expeditionary Medal for service in some other conflict or period of armed hostility not

included in the preceding list. Service members, Reservists, and members of the National Guard

who were activated to a combat mission who subsequently separate from active duty should

each receive a DD-214, which may indicate receipt of such an award.

4. National Guard and Reserve personnel who were activated and served in a theater of combat

or in combat against a hostile force may also be eligible. National Guard and Reserve personnel

are eligible for VA health care if they were ordered to active duty by a Federal declaration and

released or discharged from active duty under other than dishonorable conditions. In addition,

National Guard or Reserve personnel must have served either 24 months of continuous active

duty, or the full period for which they were called or ordered to active duty, whichever is shorter.

5. For further information relating to determining combat status of veterans who served in

combat during a period of war after the Gulf War, or against a hostile force during a period of

hostilities after November 11, 1998, refer to current VHA policy.

PRE-SCREEN APPLICATION FOR WRIISC REFERRAL

Please fax the completed form to the Senior Environmental Health Coordinator at (202) 273-9080.

Questions may be directed to Veterans Affairs Central Office (VACO) (202-273-8463) or WRIISC administrative contacts in Washington, DC (800-

722-8340) and East Orange, NJ (800-248-8005).

VAMC ADDRESS

VETERAN NAME VETERAN HOME ADDRESS

SOCIAL SECURITY NUMBER TELEPHONE NUMBER FAX NUMBER

PRIMARY CARE CLINICIAN NAME TELEPHONE NUMBER FAX NUMBER

NOTE: Refer to Appendix A for the following questions.

COMBAT VETERAN? SERVICE DATES

IF YES, WHICH COMBAT?

DOES VETERAN HAVE UNDIAGNOSED, DEBILITATING SYMPTOMS/ILLINESSES?

IF YES, PLEASE PROVIDE A BRIEF SUMMARY OF THE SYMPTOMS/ILLNESSES:

ADMINISTRATIVE SUPPORT STAFF NAME TELEPHONE NUMBER FAX NUMBER

VA FORM

a. Name,

b. Social Security Number (SSN),

c. Date of Birth (DOB),

d. Address,

e. Phone number,

f. Race,

g. Sex,

h. Marital status,

i. Referring physician,

j. Address of referring physician, and

k. Phone number of referring physician.

a. Military service in combat area. Yes or No

b. Dates of deployable military service.

c. Military occupational specialty.

d. Military unit in which veteran served.

e. Prisoner of War (POW) status. Yes or No

a. Allergies.

b. Active medications.

c. Problem list.

d. Social history (include occupational history, tobacco and alcohol use, substance abuse, social

living situation).

(6) Had vaccines or other preventative measures:

a. General;

b. Skin;

c. Head, ears, eyes, nose, and/or throat;

d. Respiratory;

e. Cardiovascular;

f. Gastrointestinal;

g. Genitourinary;

h. Musculoskeletal;

i. Hematological;

j. Peripheral vascular; and

k. Neurological.

a. Is veteran experiencing symptoms of active suicidal ideation? Yes or No

b. Is veteran acutely mentally ill? Yes or No

c. Comments

a. Vitals;

b. Weight;

c. Height;

d. General appearance;

e. Skin;

f. Head, ears, eyes, nose, and throat;

g. Lungs;

h. Cardiovascular;

i. Abdomen;

j. Genitalia;

k. Rectal;

l. Extremities;

m. Neurologic; and

n. Psychiatric.

a. Complete Blood Count (CBC);

b. Multiple Chemistry Screening Tests (Chem 7);

c. Liver function tests (Lfts);

d. Thyroid Stimulating Hormone (Tsh);

e. Venereal disease Research laboratory (Vdrl), i.e., Syphilis test;

f. Occult blood,

g. Vitamin B (B-12);

h. Human Immunodeficiency Virus (HIV);

i. Hepatitis panel;

j. Erythrocyte sedimentation rate (Esr); and

k. Urinalysis.

a. Recent X-rays,

b. Magnetic Resonance Imaging (MRI),

c. Computed Tomography (CT) scan,

d. Electrocardiogram (EKG),

e. Electronmyogram (EMG), and

f. Sleep studies.