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VA HANDBOOK 1303.2 GULF WAR REGISTRY (2005)

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Department of Veterans Affairs VHA HANDBOOK 1303.2
Veterans Health Administration Transmittal Sheet
Washington, DC 20420 March 7, 2005
GULF WAR (INCLUDING OPERATION IRAQI FREEDOM) REGISTRY (GWR)
PROGRAM- (FORMERLY PERSIAN GULF REGISTRY (GWR) PROGRAM)
1. REASON FOR ISSUE. This Veterans Health Administration (VHA) Handbook is revised
to provide updated procedures for the established Gulf War Registry (GWR) Program at all
Department of Veterans Affairs (VA) health care facilities for concerned participants of
“Operation Desert Shield and Desert Storm,” and “Operation Iraqi Freedom (OIF).” NOTE:
This Handbook addresses only the Registry and its implementation; it does not address
treatment or enrollment issues for Gulf War or other combat veterans.
2. SUMMARY OF CONTENTS. This Handbook clarifies eligibility for veterans who served
in the Gulf War (GW), initiates new electronic reporting of GWR examination data via website
http://vaww.registries.aac.va.gov, discontinues reporting GWR examinations (Report Control
Number (RCN)-10-0860), implements name change of GWR Physicians and Coordinators to
Environmental Health (EH) Clinicians and (EH) Coordinators, and confirms the discontinuation
of the GW Referral Centers with provision of alternative methods of referrals of combat veterans
with undiagnosed, disabling illnesses to War Related Illness and Injury Study Centers
(WRIISC).
3. RELATED ISSUES AND WEBSITES. VHA Handbooks 1301.1, and
www.va.gov/environagents/ ; and http://vaww.registries.aac.va.gov .
4. RESPONSIBLE OFFICE. The Office of Environmental Agents (131) is responsible for the
contents of this Handbook. Questions may be referred to 202-273-8463.
5. RECISSIONS. M-10, Part III, Chapters 1, 2, and 3 are rescinded.
6. RE-CERTIFICATION. This VHA Handbook is scheduled for re-certification on or before
the last working day of March 2010.
S/Jonathan B. Perlin, MD, PhD, MSHA, FACP
Acting Under Secretary for Health
DISTRIBUTION: CO: E-mailed 3/8/2005
FLD: VISN, MA, DO, OC, OCRO, and 200 – E-mailed 3/8/2005
March 7, 2005 VHA HANDBOOK 1303.2
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CONTENTS
GULF WAR (INCLUDING OPERATION IRAQI FREEDOM) REGISTRY (GWR)
PROGRAM
PARAGRAPH PAGE
1. Purpose ...... 1
2. Background ............................................................................................................................... 1
3. Registry Evaluation ................................................................................................................... 4
4. Responsibilities ......................................................................................................................... 4
5. Gulf War Registry (GWR) Examination .................................................................................. 6
a. Purpose ... 6
b. Eligibility Criteria .................................................................................................................. 6
c. Program Management ............................................................................................................ 8
d. Responsibilities ...................................................................................................................... 8
e. Establishing, Updating, Retaining and Disposition of Health Records ............................... 12
f. Incarcerated Veterans ........................................................................................................... 12
g. Veterans with other than Honorable Discharges ................................................................... 13
h. Active Duty Military Personnel ........................................................................................... 13
i. Updating EH Clinician and/or EH Coordinator Appointments ............................................ 14
6. Gulf War Uniform Case Assessment Protocol (UCAP) ......................................................... 14
a. Background .......................................................................................................................... 14
b. Authority .............................................................................................................................. 14
c. Scope .... 15
d. Responsibilities .................................................................................................................... 15
7. Media and Other External Contacts........................................................................................... 5
VHA HANDBOOK 1303.2 March 7, 2005
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CONTENTS Continued…
PARAGRAPH PAGE
APPENDIXES
A Definitions and Acronyms ................................................................................................... A-1
B Protocol for Conducting the Physical Examination and Ordering Diagnostic Studies ......... B-1
C Instructions for Completing VA Form 10-9009a, Gulf War Registry
Code Sheet, Phase I ............................................................................................................ C-1
D Example of Gulf War Registry Follow-up Letter (Medical Problem Indicated) ................. D-1
E Example of Gulf War Registry Follow-up Letter (No Medical Problem Indicated) ............ E-1
F Uniform Case Assessment Protocol (UCAP) ........................................................................ F-1
G Instructions for Completing Gulf War Uniform Case Assessment
Protocol (UCAP) Phase II, Part III ................................................................................... G-1
March 7, 2005 VHA HANDBOOK 1303.2
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GULF WAR (INCLUDING OPERATION IRAQI FREEDOM)
REGISTRY (GWR) PROGRAM
NOTE: This Handbook addresses only the Registry and its implementation; it does not address
treatment or enrollment issues for Gulf War or other combat veterans.
1. PURPOSE
This Veterans Health Administration (VHA) Handbook provides procedures to maintain a
Gulf War (including Operation Iraqi Freedom (OIF)) Registry (GWR) Program at all
Department of Veterans Affairs (VA) health care facilities for concerned participants of
“Operation Desert Shield and Desert Storm, and OIF.” NOTE: For purposes of this Handbook,
veterans who served in the Persian Gulf theatre of war are referred to as Gulf War (GW)
veterans.
2. BACKGROUND
a. In response to Iraq’s invasion of Kuwait on August 2, 1990, the United States (U.S.)
began deploying troops to the Arabian Gulf 5 days later in Operation Desert Shield. A total of
forty coalition countries eventually deployed military forces to the Gulf region, including troops
from the U.S., the United Kingdom, France, and Canada. On January 17, 1991, the air war
against Iraq began (Operation Desert Storm), which was followed by a 4-day ground war starting
on February 24, 1991.
b. By the end of active hostilities on February 28, 1991, the U.S. had deployed 697,000
troops to the theater of operations. The British deployed approximately 53,000 military
personnel, the French 25,000, and the Canadians 4,500. In contrast to previous conflicts, a larger
proportion of U.S. troops was from the Reserves and/or National Guard (17 percent) and were
women (7 percent). Along with a rapid buildup of Coalition combat forces, an extensive medical
care infrastructure and preventive medicine effort was established in the theater of operations.
For further details and updates refer to website www.va.gov/gulfwar/ .
c. By the end of the GW, VA medical care personnel became concerned about potential
health problems of U.S. service members exposed to oil well fire smoke. Consequently, VA
developed a proposal to create a clinical registry of GW veterans to evaluate the health problems
they were experiencing and to provide better health care for returning troops. This proposal led
to the establishment of the VA Persian Gulf War Health Examination Registry, authorized in
November 1992 by the “Persian Gulf War Veterans Health Status Act” (Public Law 102-585).
d. The GW examination registry was established after the first Gulf War to identify possible
diseases resulting from U.S. military personnel service in certain areas of Southwest Asia (see
par. 7.b). These diseases were endemic to the area or may have been due to hazardous
exposures, including heavy metals. Furthermore, air pollutants, i.e., carbon monoxide sulfur
oxides, hydrocarbons, particulate matter, and nitrogen oxides, singly or in combination, could
have caused chronic health problems.
(1) Due to the un-ignited petroleum and/or smoke from the sabotage of Kuwaiti oil wells,
the following health problems are to be considered in veterans of the first Gulf War:
VHA HANDBOOK 1303.2 March 7, 2005
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(a) Chronic bronchitis,
(b) Chronic obstructive pulmonary disease,
(c) Pulmonary emphysema,
(d) Bronchial asthmas, and
(e) Lung cancer.
(2) GW veterans reported a wide variety of symptoms and exposures as a consequence of
GW service. These include, but are not limited to exposure to:
(a) For veterans of the first Gulf War, oil, smoke, and other petrochemical agents; and
(b) For veterans of all Gulf Wars including OIF, Leishmaniasis (spread by sand flies).
e. OIF. The U.S. began deploying troops to the Gulf region in late 2002. As of May 19,
2004, among 139,778 veterans of OIF who have separated from active military duty, 15 percent
(21,021) have sought health care from VA. OIF veterans are presenting to VA with a wide range
of both medical and psychological conditions similar to those found in other young military
populations. To date, no unusual illnesses have been found among OIF veterans.
f. With the exception of health problems relating to exposure to oil fires, the type of
symptoms and exposures listed above may be reported by veterans of OIF. Refer to website
www.va.gov/gulfwar/ for health risks details.
g. During the examination process, these exposures and health conditions are identified and
documented in the veterans’ health or administrative record as appropriate.
h. The registry containing medical and other data on exposed veterans signals VA’s
commitment to address questions concerning possible future effects of air pollutant exposure,
other environmental agents, and serve as the basis for future medical surveillance.
3. REGISTRY EVALUATION
Veterans claiming health conditions related to exposure to toxic substance or environmental
hazard must be evaluated clinically by means of a physical examination and appropriate
diagnostic studies (see App. B). Where findings reveal a condition that may require treatment,
refer the veteran to the Enrollment Coordinator in the Business Office to determine if the veteran
is eligible for treatment.
March 7, 2005 VHA HANDBOOK 1303.2
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4. RESPONSIBILITIES
a. The GWR is modeled after the Agent Orange and Ionizing Radiation Registries. All VA
facility staff must be alerted of the GWR through appropriate internal communications, e.g.,
medical center memoranda and posters providing names, locations, and office telephone
numbers of the Environmental Health (EH) Clinician and EH Coordinator.
(1) The GWR is the responsibility of VA Central Office Environmental Agents Service
(EAS), in coordination with:
(a) EH Clinicians;
(b) EH Coordinators; and
(c) The VA Austin Automation Center (AAC), Austin, TX.
(2) The GWR consists of medical examinations and other data of concerned GW
participants. The GWR is the most effective means of identifying such concerned veterans.
b. The EAS has the responsibility to develop, coordinate, and monitor VHA activities
relating to the GW issue. NOTE: All policy and clinical questions relating to the identity of
possible diseases that may result from service of U.S. military personnel in certain areas of
Southwest Asia should be referred to EAS.
c. The EH Clinician and EH Coordinator at each VA facility has the responsibility for
coordinating the medical and administrative aspects of the registry. They and other medical
center staff, play a key role, beginning with the initial contact in:
(1) Providing registry participants with comprehensive health screening examinations at no
cost.
(2) Advising veterans of examination results; and
(3) Reporting examination findings to the AAC via website:
http://vaww.registries.aac.va.gov .
d. There is a time lapse between the date of examination and the processing of examination
results. Accordingly, analyses used in speeches or presentations needs to be qualified to avoid
misleading or misinforming the audience.
5. GULF WAR REGISTRY (GWR) EXAMINATION
a. Purpose. This paragraph sets forth clinical and administrative policies related to the
maintenance of VHA’s GWR Program for physical examination of concerned veterans. NOTE:
VHA HANDBOOK 1303.2 March 7, 2005
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Active duty military personnel who served in Southwest Asia are eligible to participate in the
GWR Program.
b. Eligibility Criteria. VA must provide a GWR examination to veterans who request the
examination and who served on active military duty in Southwest Asia during the GW which
began in 1990, and continues to the present {per 38 U.S.C. § 101(33)} including OIF. NOTE 1:
The Business Office (163) should be consulted to determine whether each veteran applying for
this examination meets pertinent eligibility requirements.
(1) This includes service in one or more of the following areas:
(a) Iraq,
(b) Kuwait,
(c) Saudi Arabia,
(d) The neutral zone (between Iraq and Saudi Arabia),
(e) Bahrain,
(f) Qatar,
(g) The United Arab Emirates,
(h) Oman,
(i) Gulf of Aden,
(j) Gulf of Oman, and
(k) Waters of the:
1. Persian Gulf,
2. Arabian Sea; and
3. Red Sea.
NOTE: Veterans who served in Afghanistan (Operation Enduring Freedom) are not eligible for
GWR examinations. Information on Afghanistan or other combat areas can be accessed on
website http://vaww.vhaco.va.gov/vhahq/publicat.htm.
(2) Eligible GW and/or OIF veterans applying for treatment in a VA medical center and/or
outpatient clinic need to be encouraged to undergo an initial (i.e., “first-time”) GWR
March 7, 2005 VHA HANDBOOK 1303.2
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examination. NOTE: The protocol for conducting the physical examination and ordering
diagnostic studies is contained in Appendix B.
(3) Veterans need to be advised that the registry examination or treatment does not
constitute a formal claim for compensation.
(a) Although the results of a GWR examination may be used to support a compensation
claim, the examination will not in and of itself be considered such a claim.
NOTE: If a compensation examination is performed for a GW veteran and the veteran requests
inclusion in the GWR, it is not necessary to schedule an additional registry examination as long
as the information is sufficient to adequately complete the registry examination questions
included in website http://vaww.registries.aac.va.gov .
(b) Veterans who wish to submit a claim for conditions possibly related to GW service need
to do so via the normal claims process through a Veterans Service Representative (VSR) at the
nearest VA medical center or regional office. For further assistance, the veteran may call one of
the following toll-free numbers:
1. Veterans Health Benefits Service Center 1-877-222-VETS (8387), or
2. VA Helpline 1-800-749-8387.
c. Program Management. For current information and program activities, EH Clinicians,
EH Coordinators, and Business Office employees need to receive and familiarize themselves
with quarterly mail-outs, the EAS website www.va.gov/environagents/ and
www.va.gov/gulfwar/, and various materials distributed by VA Central Office. In addition, all
program officials need to attend the periodic EAS conference calls from VA Central Office.
d. Responsibilities. The EH Clinician, or designee, EH Coordinator, and Business Office
staff play a significant role in determining the perceptions veterans have concerning the quality
of VA health care services and of their individual treatment by VA health care providers.
(1) EH Clinician Responsibilities
(a) The EH Clinician, or designee, is responsible for clinical management of the veteran on
the registry and will serve as their primary health care provider unless another has been assigned.
The EH Clinician serves in an advisory capacity for the administrative management of the
program, discusses with the patient the results of the examination(s) and as appropriate providing
follow-up visits and/or possible referrals to other tertiary medical centers or War Related Illness
and Injury Study Centers (WRIISCs).
NOTE: Some veterans who return from combat missions may experience persistent,
unexplained, disabling symptoms. VA’s WRIISCs are VA’s response to this important health
issue. VA primary care providers examining eligible combat veterans with undiagnosed
illnesses can request a veteran’s evaluation at one of the Centers. Refer to VHA Handbook
VHA HANDBOOK 1303.2 March 7, 2005
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1303.5 and website http://www.va.gov/environagents for WRIISC referral protocol and
brochures and view the VHA video entitled “War and Health: Treating War-Related Illnesses at
VA’s WRIISCs,”which describes the clinical, risk communication, education and research
programs of the WRIISCs. This video also illustrates the type of patient for whom referral may
be indicated.
(b) Major essential responsibilities of the EH Clinician include:
1. Counseling the veteran as to the purpose of the physical registry examination;
2. Providing focused initial registry examination and continuum of care if assigned
responsibility as the primary care clinician to those symptomatic veterans experiencing multiple
symptoms after their GW experience;
3. Conducting and documenting the physical registry examination in the veterans’ health or
administrative record, as appropriate.
4. Providing a complete medical history including:
a. Family;
b. Occupation;
c. Social, including tobacco, alcohol, and drug use;
d. Civilian exposure to possible toxic agents;
e. Psychosocial condition; and
f. Review of systems.
5. Completing all elements of the registry examination, then reviewing and reporting the
code sheets to the AAC via website http://vaww.registries.aac.va.gov no later than 10 working
days after initial examination.
6. Personally discussing with each veteran the findings of the physical registry examination
and completed diagnostic studies. The interview must be conducted in such a way as to
encourage the veteran to discuss any health concerns, as well as concerns expressed by family
members. NOTE: When a follow-up examination is recommended by the EH Clinician, the EH
Clinician serves as the primary care provider to the veteran, unless another primary care
clinician has been assigned.
7. Personally discussing each veteran’s need for a follow-up examination either
recommended by EH Clinician or requested by the veteran.
8. Documenting these discussions and/or findings in each veteran’s health record.
March 7, 2005 VHA HANDBOOK 1303.2
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9. Encouraging the veteran to contact a VA medical center to document additional diagnoses
in an appropriately titled progress note in the veterans’ health record if the veteran is
subsequently diagnosed with a significant health problem by a non-VA physician. This new
diagnosis must be submitted over the non-VA physician’s signature and on official letterhead
and subsequently transmitted to AAC via website http://vaww.registries.aac.va.gov for inclusion
in the registry database.
10. Preparing and signing a follow-up letter to each veteran explaining the results of the
examination and associated laboratory tests. NOTE: Sample follow-up letters are provided in
Appendixes D and E.
a. These letters are to be mailed to the veteran within 2 weeks of the initial examination
appointment. For any examination where there is a new diagnosis, another letter is to be mailed
within 2 weeks. The only exception to this timeframe is when a consultation at a specialty clinic
is requested as part of the initial examination process. This exception suspends, but does not
remove the requirement for the follow-up letter. The follow-up letter is to be sent no later than 2
weeks after the consultation.
b. A copy of this dated and signed letter must be filed and/or scanned into the veteran’s
health record.
c. It is essential that this letter be written in language that can be easily understood by the
veteran. Inappropriate wording could unduly alarm or confuse the veteran. NOTE: A great
deal of sensitivity and care must be exercised in the preparation of this correspondence.
d. The letter must explain that:
(1) If the veteran who was examined has no detectable medical problems, the follow-up
letter needs to so indicate and suggest that the veteran contact the nearest VA health care facility
if health problems appear later.
(2) If it is determined upon examination that the veteran does have medical problems, it is
not necessary to specify the problems in the letter.
(a) The veteran needs to be advised in the letter that the recent examination indicated a
health condition or problem which may require further examination and/or treatment.
(b) If the veteran is eligible for VA medical treatment, the letter needs to so advise and
recommend that the veteran seek follow-up medical care at the VA medical facility.
(c) If the veteran is not eligible for treatment, the letter needs to so advise and recommend
that the veteran seek appropriate medical care elsewhere.
(3) The examination does not automatically initiate a claim for VA benefits. For
information relating to claims, refer the GW veterans to a VSR at the nearest VA medical center
or regional office.
VHA HANDBOOK 1303.2 March 7, 2005
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(4) The results of the examination must be maintained by VA and will be available for
future use as needed.
(5) If the veteran changes place of residence, the veteran needs to provide the new address to
the EH Coordinator and report the new address to the AAC as a Type E entry via website
http://vaww.registries.aac.va.gov .
(2) EH Coordinator Responsibilities
(a) The EH Coordinator is responsible for the administrative management of the program,
including:
1. Completing Registry Code Sheets (see App. C),
2. Scheduling of appointments,
3. Monitoring timeframe compliance, and
4. Reviewing records for accuracy and completeness.
(b) The EH Coordinator is specifically responsible for:
1. Scheduling. Facilities need to make every effort to give each veteran a GWR examination
within 30 days of the request date. If numerous consultations are required, whenever possible,
all of these should be scheduled on the same day, so that the veteran will not be unduly
inconvenienced. When it is not possible to provide all consultations on the same day, the EH
Coordinator, or the scheduler, needs to work with the veteran to minimize the number of
disruptions in the veteran’s life. If a medical center fails to meet the time standard of 30
calendar days from date of request, the medical center Director must explore all alternatives; i.e.,
referrals to other VA facilities, additional staff hours to perform these examinations; and the
possibility of the use of fee-basis sources or contracting out some or all examinations with
volume health care providers, to bring the medical center in line with the time standard. If, after
these alternative measures have been explored and the time standard still cannot be met, an
exemption needs to be requested by contacting EAS, VA Central Office (202) 273-8463 or
(202) 273-8465.
2. Disseminating Information. It is important that each GW veteran be fully advised of the
GWR examination. Facility staff are encouraged to fully communicate all aspects of the GWR
examination by any appropriate means. The following alternatives might be considered:
a. Upon distribution by VA EAS, provide each GW veteran, reporting to the outpatient area,
with the following: NOTE: Information Bulletin (IB) 10-41 and IB 10-42 are also available in
Spanish.
(1) “Gulf War Review,” newsletter;
March 7, 2005 VHA HANDBOOK 1303.2
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(2) IB10-41, “VA Gulf War Veterans’ Illnesses, Questions and Answers,” which describes
the purpose of the examination and its limitations;
(3) IB 10-42, “Gulf War Research – A Report to Veterans,” which is for veterans
specifically interested in research; and
(4) If appropriate, IB 10-166, “Operation Iraqi Freedom/Enduring Freedom Review.”
NOTE: These publications are accessible on website: www.va.gov/gulfwar/. Any questions
and/or answers can be further clarified by the examining physician prior to and during the
course of the physical examination.
b. EH Coordinators provide each veteran with a brief oral explanation of the purposes of the
GWR and the examination process and respond to any questions the veteran might have. This
can be accomplished during the EH Coordinator’s initial contact with the veteran.
3. Data Entry Completion
a. The EH Coordinator, or designee, must complete the demographic sections of the Gulf
War registry code sheet and ensure that all information is entered into the AAC database via
website http://vaww.registries.aac.va.gov before the veteran is referred to the clinician for the
examination.
b. The EH Clinician completes the Symptoms and Exams Section of the Gulf War registry
code sheet. These data may be entered by the clinician or EH Coordinator. NOTE: It is
preferable that the clinician enter the data to ensure accuracy and timeliness.
c. In the event that a veteran requests a GWR examination, but does not wish to be included
in the registry database, a registry examination needs to be performed. In the “Remarks”
indicate the current date and note that the veteran chose not to participate in the registry. This
Gulf War code sheet needs to be filed in the veteran’s administrative or health record, as
appropriate. Do not transmit this code sheet to the AAC.
e. Establishing, Updating, Retaining and Disposition of Health Records
(1) The EH Coordinator must establish a health record on each registry participant if one
does not already exist. VA Form 10-9009B, Gulf War Identification Sticker, must be affixed to
the front of the paper health record, if appropriate, or posting “Gulf War Registry Examination,”
in CPRS.
(2) These GWR records are subject to the same retention and disposition policies as other
medical record files, i.e., Records Control Schedule (RCS) 10-1. The GWR examination
information (registry code sheet, progress notes, laboratory reports and other pertinent
examination documentation) must be made part of the perpetual medical record following the
same retention requirements specified for VA Agent Orange and Ionizing Radiation
examinations.
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f. Incarcerated Veterans
(1) GWR examinations may be provided to incarcerated veterans. The examination may be
provided either in the prison or jail, or in the VA facility.
(2) If an incarcerated veteran is accepted for an GWR examination, VA may conduct such
an examination in a VA facility, but only after the veteran has been released by an official under
circumstances where there is no obligation placed on VA to exercise custodial restraint, or to
ensure the return of the veteran to custody upon completion of the examinations. VA is
encouraged to work with said penal institution to avoid potential disruptions at the VA medical
center upon reporting for the examination (example, the wearing of prison uniforms and
restraints are to be discouraged).
NOTE: The clinic Director, or designee, must notify the civil authorities when the GWR
examination is completed.
(3) A bill is not issued to the penal institution for the GWR examination of an incarcerated
veteran conducted at a VA facility.
(4) For purposes of entry into the GWR, VA medical facilities can provide assistance to
penal authorities or institutions agreeable to conducting examinations to veterans. NOTE. VA
will not reimburse the penal authorities when they conduct these GWR examinations.
(a) Copies of this Handbook 1303.2, GW registry examination code sheets, etc., must be
provided to penal institutions upon request.
(b) Penal authorities must be advised at the time of such requests, that the results of the
examinations provided at their institutions are to be returned to the VA facility of jurisdiction for
inclusion, on the veteran’s behalf, in VA's GWR.
(c) A recommendation can be made to the penal institution to retain a copy of the
examination documents submitted to VA. NOTE: Such documents need to be maintained by
penal authorities and provided to the individual upon release from the penal institution.
g. Veterans With Other Than Honorable Discharges. The requirements of M-1, Part I,
Chapter 4, apply to veterans with less than honorable discharges applying for GWR
examinations.
h. Active Duty Military Personnel. When active duty members of the uniformed services
apply to VA facilities for a GWR examination, the Department of Defense (DOD) must
authorize and provide the appropriate DOD Form 2161, Referral for Civilian Care, or equivalent
form, requesting this examination, or DOD must provide services under an existing DOD-VA
sharing agreement. The requirements of M-1, Part I, Chapter 15, regarding the authorization and
billing from the appropriate branch of service apply. NOTE: VA facilities need to reference the
current directive providing the interagency billing rates.
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(1) Procedures for processing the examination are the same as those for a veteran
participating in this program.
(2) A military facility may perform the GWR examination according to VA instructions or
the corresponding military instructions. NOTE: DOD has established a Hotline, telephone
number 1-800-796-9699, to direct active duty personnel to military hospitals for medical
examinations and provide other related information. An additional telephone number has been
established as the veteran’s Direct Hotline (1-800-472-6719) for GW veterans to call with their
recollection of "incidents" that might be related to health problems.
(3) Military facilities may obtain the pertinent VA administrative issue and appropriate
forms from the nearest VA site. The VA Medical Center, 50 Irving Street, N.W., Washington,
DC 20422, Attn: Environmental Health Coordinator (136), is the processing center for all
active duty members of uniformed services stationed overseas. Military facilities must complete
GWR examination worksheets with exception of the facility number, suffix (if applicable) and
county and state. This information will be completed by the VA EH Coordinator.
(4) Military facilities must provide completed copies of the code sheets, physical
examination, laboratory tests, etc., to the nearest VA medical center or outpatient clinic. The EH
Coordinator must:
(a) Complete the GWR data code sheets to include facility number (and suffix, if
applicable), and county and state codes.
(b) Transmit the code sheet data to the AAC via website: http://vaww.registries.aac.va.gov .
(c) Establish a health record, if one does not already exist, and maintain in the paper
administrative health record or scanned and attached to an appropriately titled CPRS Progress
Note; and
(d) If requested, and only with a written authorization (release of information) from an
active duty member or other legal authority as outlined in VHA Handbook 1605.1, VA may
supply a copy of these medical records to the military facility.
i. Updating EH Clinician and EH Coordinator Appointments. Separate listings of EH
Clinician and EH Coordinators are maintained within EAS.
(1) In an effort to keep these listings current, facilities are required to notify the EAS of any
changes in the status of appointments of the EH Clinician and/or the EH Coordinator at their
respective facilities.
(2) As changes in designation occur, submit in writing the name, title, mail routing symbol,
and telephone numbers including area code, to the Environmental Health Coordinator (131),
EAS, VA Central Office, 810 Vermont Avenue, N.W., Washington, DC 20420 (Facsimile
Number 202-273-9080). NOTE: In order to provide current GW information to concerned VA
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Registry Staff, it is important that any changes in designation of EH Clinicians and EH
Coordinators at VA facilities be provided to VA Central Office (131) as they occur.
6. GULF WAR UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)
a. Background
(1) Many of the almost 690,000 personnel who served in the GW have reported health
problems since their return to the United States. While most of the health problems of these
veterans have been diagnosed as conditions that are readily definable, some veterans have
unexplained illnesses that developed after their Gulf War service. These GW veterans seen by
VA EH Clinicians have complex, multifaceted health problems that provide difficult diagnostic
challenges. Veterans are understandably frustrated that definitive answers regarding the cause(s)
of their problems are not immediately forthcoming.
(2) VA and DOD working cooperatively developed a Uniform Case Assessment Protocol
(UCAP) for the evaluation of these GW veterans who after a thorough routine medical
evaluation are determined to have unexplained illnesses (see App. F). NOTE: This UCAP grew
out of the medical experience in diagnostic evaluation of GW veterans seen at VA Referral
Centers. (These Centers were discontinued and replaced with War Related Illness and Injury
Study Centers expanding their mission to offer similar comprehensive clinical care to combat
veterans of all eras, as described in VHA Handbook 1303.5.) The protocol was then further
refined and adapted for use by both VA and DOD facilities. DOD’s similar protocol is identified
as Comprehensive Clinical Evaluation Program (CCEP).
(3) The UCAP includes a group of supplemental baseline laboratory tests and consultations
which needs to be provided to every veteran with debilitating unexplained illness. It gives
guidelines for the minimum diagnostic work-up for the most frequent complaints experienced by
GW or OIF veterans with unexplained illnesses. This protocol utilizes validated and readily
available diagnostic tests to thoroughly evaluate each of the common symptoms reported by GW
and OIF veterans.
(4) The concept behind the protocol was to identify previously unrecognized major
diagnostic entities which could provide an explanation for the symptoms commonly reported in
GW veterans with unexplained illnesses. NOTE: It should be emphasized that the protocol is
not designed to be all-encompassing; therefore, it needs to be carried out with a high degree of
clinical judgment. All significant symptoms and abnormalities not specifically outlined in the
protocol must be fully evaluated according to the medical judgment of the EH or Primary Care
clinicians directing the work-up. The information gathered by this process is to be entered into a
computerized database at http://vaww.registries.aac.va.gov .
b. Authority. The UCAP for GW veterans with unexplained illnesses was administratively
established by the Under Secretary for Health to assist in addressing the unique health concerns
of the GW veterans. On November 2, 1994, Public Law (Pub. L.) 103-446 amended Title 38
United States Code (U.S.C.) 1117 implementing the uniform and comprehensive medical
evaluation protocol for the GW veterans.
March 7, 2005 VHA HANDBOOK 1303.2
13
c. Scope. All VA health care facilities must examine the available services for GW and OIF
veterans to ensure that quality outreach, diagnostic, and treatment services are furnished as
intended. If these services cannot be provided by the local VA facility, a mechanism must be
developed to provide these services by contract, sharing agreements, or referral to other VA
facilities.
d. Responsibilities
(1) EH Clinicians. The responsibility of the EH Clinician is to:
(a) Conduct the Registry examination (Phase I), which is the first step toward diagnosis of
the health problems of a GW or OIF veteran; and
(b) If a diagnosis is not readily apparent after conducting routine medical evaluations, to
initiate the UCAP, (Phase II) using the protocol provided in Appendix G.
(2) EH Coordinators. The EH Coordinator is responsible for:
(a) Following the reporting instructions as included in Appendix G.
(b) Providing accurate coding of both symptoms and diagnoses, and when questions arise
about these items consult with EH Clinician, or designee.
(c) Completing and transmitting the UCAP to the AAC website at:
http://vaww.registries.aac.va.gov
7. MEDIA AND OTHER EXTERNAL CONTACTS
a. Media Contacts. Reports of Contact from various media sources (e.g., radio, television,
newspapers, etc.) concerning GWR Program activities are to be referred by phone to the facility
Public Affairs Officer. Interviews are not to be given unless approved by the medical center
Public Affairs Officer who may appropriately coordinate response with the regional VA public
affairs representative.
b. Contacts to Advise Centers of “Special Cures” for Gulf War-Related Illnesses.
Medical centers can expect, on occasion, to be contacted by private sector physicians,
researchers, and the general public with information regarding “quick cures” for GW-
related illnesses. Such individuals need to be advised that:
(1) There are medically accepted mechanisms to introduce new clinical treatments;
(2) All new treatments suggested must be reviewed by a formally-designated Human
Subjects Review Committee;
(3) It is important to have independent confirmation of treatment efficacy;
VHA HANDBOOK 1303.2 March 7, 2005
14
(4) Provisions exist to permit the originator of new therapies to retain professional credit and
be appropriately compensated; and/or
(5) The individual might want to consider presenting the “new approach” at a VA or medical
school Grand Rounds or Staff Review Committee meeting.
(6) In general, VA cannot fund experimental treatments of veterans at non-VA facilities.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX A
A-1
DEFINITIONS AND ACRONYMS
1. AAC - The Office of Financial Management, Austin Automation Center (AAC) in Austin,
TX. It is the location of the computerized registry for code sheet data collection and database
entry.
2. ANA - Anti-Nuclear Antibody.
3. BAER - Brainstem Auditory Evoked Response.
4. CAPS-PTSD - Clinical Administered-Post Traumatic Stress Disorder.
5. CARC - Chemical Agent Resistant Compound paint.
6. CBC - Complete Blood Count.
7. CHR - Consolidated Health Record. A file containing medical records relating to patient
identity, diagnosis, prognosis or treatment at Department of Veterans Affairs (VA) facility.
8. CPK - Creatine Phosphokinase.
9. CPRS - Computerized Patient Record System.
10. CT - Computed Tomography.
11. D.O. - Doctor of Osteopathy.
12. DOD - Department of Defense.
13. DOD Form 2161, “Referral for Civilian Care.”
14. DSM-III-R - Diagnostic and Statistical Manual of Mental Disorders, Third Edition,
Revised.
15. DU - Depleted Uranium.
16. EAS - Environmental Agents Service - EAS (131), VA Central Office, has the responsibility
to coordinate and monitor all VHA activities, research and otherwise, relating to the Gulf War
issue.
17. ECG - Electrocardiogram.
18. EEG - Electroencephalogram.
19. EGD - Esophagastroduodenoscopy.
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX A
A-2
20. Environmental Health (EH) Clinician - The EH Clinician is a physician that is responsible
for the clinical management of the Gulf War (GW) Program at each VA medical facility.
21. EH Coordinator - The EH Coordinator is a non-clinician staff member responsible for the
administrative management of the program at each VA facility.
22. EMG - Electromyogram.
23. ENG - Electronystamogram.
24. Examinations
a. Initial. The first physical examination which is completed, transmitted and entered in the
GW registry database, located at the AAC, via website http://vaww.registries.aac.va.gov .
b. Follow-up. Examination performed subsequent to the initial (first) examination and
entered in GW registry website http://vaww.registries.aac.va.gov .
25. Facility - Any VA entity that provides GW Registry examinations to GW veterans.
26. GI - Gastrointestinal.
27. GW - Gulf War.
28. GWR - Gulf War Registry - is a computerized index of veteran participants, is managed
centrally by the EAS in VA Central Office. The coded findings of GWR Program physical
examinations and related diagnostic results are entered into a database by the VA facility staff
via website http://vaww.registries.aac.va.gov.
29. GYN - Gynecology.
30. Hct - Hematocrit.
31. Hgb - Hemoglobin.
32. HIV - Human Immunodeficiency Virus.
33. IB-10-41 - VA Information Bulletin (IB) entitled “Gulf War Veterans’ Illnesses, Questions
and Answers.”
34. IB 10-42 - “Gulf War Research – A Report to Veterans.”
35. IB 10-166 - “Operation Iraqi Freedom/Enduring Freedom Review.”
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX A
A-3
36. ICD-9-CM - The current issue of the International Classification of Diseases, 9th Edition,
Clinical Modification provides standardized classification of diseases.
37. IgG - Immunoglobulin G.
38. KIA - Killed in Action.
39. KTO - Kuwait Theater of Operations.
40. LDH - Lactic Acid Dehydrogenase.
41. LP - Lumbar Puncture.
42. MIA - Missing in Action.
43. MOS - Military Occupational Specialty.
44. M.D. - Doctor of Medicine.
45. MRI - Magnetic Resonance Imaging.
46. MSLT - Multiple Sleep Latency Test.
47. NCV - Nerve Conduction Velocity.
48. OIF - Operation Iraqi Freedom.
49. O&P - Ova and Parasites.
50. P.A. - Physician’s Assistant.
51. PFT - Pulmonary Function Test.
52. Plt - Platelet.
53. PPD - Purified Protein Derivative.
54. PTF - Patient Treatment File.
55. PTSD - Post-traumatic Stress Disorder.
56. Persian Gulf Area of Service. For eligibility purposes, active military duty in Southwest
Asia during the Gulf War would include service in one or more of the following areas: Iraq,
Kuwait, Saudi Arabia, the neutral zone (between Iraq and Saudi Arabia), Bahrain, Qatar, the
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX A
A-4
United Arab Emirates, Oman, waters of the Persian Gulf, Red Sea, Arabia Sea, and Gulfs of
Aden and Oman.
57. (Persian) Gulf War Period of Service. Public Law 102-25 established a (Persian) Gulf
War period of service that affects persons serving on active duty as of August 2, 1990. The
wartime period of service continues until terminated by Presidential proclamation or by law.
58. Records Control Schedule (RCS) 10-1. Provides instructions for record retention and
disposition.
59. RHP - Reproductive Health Problems.
60. SCID - Structured Clinical Interview for DSM-III.
61. SCUDS - The common name for Soviet designed surface to surface missiles.
62. SED - Skin Erythema Dose.
63. SGPT(ALT) - Serum Glutamic Pyruvate Transaminase.
64. SGOT (AST) - Serum Glutamic Oxaloacetic Transaminase.
65. SMA (6/12) - SMA is a Manufacturer’s Trademark for a Chemistry Analyzer.
66. SSN - Social Security Number.
67. T4 - Thyroxine Total Serum.
68. TB - Tuberculosis.
69. TSH - Thyroid Stimulating Hormone.
70. UCAP - Uniform Case Assessment Protocol.
71. UGI - Upper Gastrointestinal.
72. VA - Department of Veterans Affairs.
73. VBR - Veterans Benefits Representative.
74. VDRL - Venereal Disease Research Laboratory.
75. VHA - Veterans Health Administration.
76. VA Form 10-9009B - Identification Sticker entitled “Persian Gulf.”
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX A
A-5
77. WBC - White Blood Cells.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX B
B-1
PROTOCOL FOR CONDUCTING THE PHYSICAL EXAMINATION
AND ORDERING DIAGNOSTIC STUDIES
1. It is essential that a complete medical history, physical examination and interview be
performed and documented on appropriate forms. The required forms that must be fully
completed are: VA Form 10-9009a (July 1995), Gulf War Registry Code Sheet; dated follow-up
letters which must be maintained in the paper administrative health record or scanned and
attached to an appropriately titled CPRS Progress Note; and all medical records of the registry
examination, i.e., Standard Form (SF) 88, Report of Medical Examination, and SF 509, Progress
Notes (for follow-up) which must be maintained within CPRS.
NOTE: This should be accomplished by or under the direct supervision of the Environmental
Health (EH) Clinician. Examination data will be recorded in the veteran’s medical record as
routinely as done for any other medical examination.
The complete medical history needs to address the following:
(a) Family history;
(b) Occupational history;
(c) Social history including tobacco, alcohol, drug use;
(d) Civilian exposure(s) history to possible toxic agents;
(e) Psychosocial history; and
(f) Review of systems.
2. The person actually performing the physical examination will be identified by name,
signature and title (i.e., Doctor of Osteopathy, Doctor of Medicine, Physician’s Assistant, etc.).
3. When a GWR examination is done as part of a compensation and pension examination, the
physical examination will be done by/or under the direct supervision of the EH Clinician or
designee.
4. The physician should be aware of the variety of exposures endemic to the GW area. These
are listed in Appendix C. There has been a wide distribution of major categories of diagnosis
reported by VA EH Clinicians; however, no significant variation in occurrence of major
categories of medical problems has been identified. We are listing below (for informational
purposes) some of the health problems and/or diseases that should be considered:
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX B
B-2
NOTE: Recommended coding (refer to International Classification of Diseases, Current
Edition)
Complaints Symptom Code Diagnosis Diagnostic Code
(If confirmed)
(1) Other Symptoms involving:
Nervous and Musculoskeletal
Systems for Pain in the joint 78199 Arthralgia 71940-71949
(2) Malaise and Fatigue 78079 Chronic Fatigue Syndrome 78071
Fibromyalgia 7291
(3) Insomnia with sleep apnea 78051 Sleep Apnea 99001
or 78053
DIAGNOSIS
(1) Amebiasis
(2) Apnea, sleep
(3) Arthralgia
(4) Asthma
(5) Brill’s Zinsser disease (recrudescent typhus)
(6) Bronchiectasis
(7) Bronchopneumonia, organism unspecified
(8) Brucellosis
(9) Chronic obstructive pulmonary disease, not elsewhere classified
(10) Chronic bronchitis
(11) Chronic Fatigue Syndrome
(12) Chronic Laryngotracheitis
(13) Chronic respiratory conditions due to fumes and vapors
(14) Emphysema
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX B
B-3
(15) Fibromyalgia
(16) Giardiasis
(17) Leishmaniasis
(18) Malaria
(19) Other and unspecified diseases of upper respiratory tract
(20) Pneumoconiosis due to other silica or silicates
(21) Pneumoconiosis, unspecified
(22) Unspecified chronic respiratory disease
(23) Respiratory conditions due to unspecified external agent
(24) Sandfly fever (phlebatomus fever)
(25) Schistosomiasis (bilharziasis)
(26) Toxoplasmosis
(27) Typhoid fever, also carrier - V02.1
(28) Tuberculosis, specify variant(s)
(29) Viral hepatitis
(30) Memory loss
(31) Polyneuropathy
(32) Skin rash
(33) Adjustment disorder, including Post Traumatic Stress
Disorder (PTSD)
(34) Alcohol dependence syndrome
(35) Drug dependence
5. In gathering these data, it is important to determine and record, the:
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX B
B-4
a. Time of onset of the symptoms or conditions,
b. Intensity,
c. Degree of physical incapacitation, and
d. Details of any treatment received.
6. Each veteran will be given the following baseline laboratory studies (Phase I Registry
Examination):
a. Complete Blood Count (CBC);
b. Blood and serum screening tests (SMA-6, SMA-12 or equivalent) including glucose,
electrolytes or equivalent blood chemistries and enzyme studies; and
c. Urinalysis.
7. Appropriate additional diagnostic studies should be performed and consultations obtained as
indicated by the patient’s symptoms and the physical and laboratory findings.
NOTE: If individuals have unexplained illnesses, after a Phase I registry examination is
performed, a Phase II examination is conducted according to the judgment of the EH Clinician
or Primary Care Clinician (see par. 9 and App. G, for instructions).
a. Other diagnostic studies, such as pulmonary function test, sperm counts, should be
performed if medically indicated.
b. Laboratory tests results should be filed in the CHR and/or CPRS.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX C
C-1
INSTRUCTIONS FOR COMPLETING VA FORM 10-9009a
GULF WAR REGISTRY CODE SHEET, PHASE 1
1. General Instructions for completing Department of Veterans Affairs (VA)
Form 10-9009 (July 1995).
a. Electronic entry of Gulf War Registry (GWR) code sheet data should be completed and
transmitted to the Austin Automation Center (AAC), Austin, TX database via website
http://vaww.registries.aac.va.gov. Instructions for accessing this website are included on the
home page. The home page includes a User’s Guide, Frequently Asked Questions, Validation
Reports, and Logon functions. Edits are automatically accomplished at the time of entry. The
completed registry code sheet must be maintained in the paper administrative health record or
scanned and attached to an appropriately titled Computerized Patient Record System (CPRS)
progress note.
NOTE: As of September 30, 2003, the AAC no longer accepts hard copies of code sheets mailed
to their offices in Austin, TX.
b. Follow instructions carefully to ensure that all data fields are accurately completed.
(1) Part I of the code sheet may be completed in the presence of the veteran.
(2) Parts II and III of the code sheet should be completed at the time of the examination by
the Environmental Health (EH) or Primary Care Clinician and coded by appropriate staff, either
the EH Coordinator and Coding Clerk. NOTE: Careful attention should be paid to assigning
the correct code for both complaints (symptoms) and diagnosis. International Classification of
Diseases, Clinical Modification, 9th Edition (ICD-9-CM) code 78999, for uncodable complaints
(symptoms), should be assigned only after all coding possibilities have been thoroughly
explored. The indiscriminate use of ICD-9-CM code 78999 may result in skewed or misleading
statistics.
2. Instructions for Completing Part I (Initial Examination)
a. Item 1. Facility Number and Suffix. Facility Number and Suffix. Enter facility code
as listed on website http://vaww.aac.va.gov/npcd/facility_quick_reference.asp or
http://vaww.aac.va.gov/npcd/new/Stations.php .
b. Item 2. Last Name of Veteran. Enter veteran’s current last name. Do not use
apostrophe and/or hyphen in the name. If the last name is followed with JR, SR, I, II, III, do not
use commas, etc.
c. Item 3. First Name of Veteran. Enter veteran’s first name.
d. Item 4. Middle Name of Veteran. Enter veteran’s middle name or initial.
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX C
C-2
e. Item 5. Type of Examination. The following are transaction types that appear at the
registry logon:
A - Initial Examination. The veteran’s first Gulf War (GW) examination. If an initial
examination code sheet has already been entered for the veteran, “A” is not available.
B – Deletes an entire initial examination that was originally submitted through the manual
batch process. Do not use this to delete an initial examination that was entered via the website.
If the transaction was entered using the registries website, simply edit the original transaction.
This will automatically create a Type “B” that deletes the original and adds the corrected
transaction to the master file.
C - Follow-up Examination. The veteran’s second and subsequent GWR examination.
Entering data for the first follow-up examination is required. Data from subsequent follow-up
code sheets will not be entered or transmitted to the AAC unless a diagnostic code differs from
previously submitted code sheets.
NOTE: Consultations relating to the initial or first-time examination are not considered followup
examinations for the purpose of this registry.
D - Deletes an entire follow-up examination that was originally submitted through the
manual batch process. Do not use this to delete a follow-up examination that was entered via the
website. If the transaction was entered using the registries website, simply edit the original
transaction.
E - Transmits a change in demographics, i.e., name, address, or date of birth. Enter “E,” and
complete items with name, Social Security Number (SSN), date of birth, and address. No other
items need to be completed.
I - To include those veterans whose names are not on the GWR but would like their name
and address included on a mailing list for the “Gulf War Review” newsletter.
P - To include diagnoses submitted by a private physician, on the physician’s letterhead
paper, and signed by that physician, certifying the accuracy of the diagnoses.
X - Identifies and verifies that a registry participant is deceased. Complete items with the
name, SSN, and date of birth. No other items need to be completed.
f. Item 6. SSN. The SSN that is entered at Registry Search via
http://vaww.registries.aac.va.gov , appears in these spaces.
g. Item 7. Date of Birth. Enter numerical equivalent for the month, day, and four-digit
year (e.g., 01/19/1960).
h. Item 8. Permanent address. Enter veteran’s permanent street address.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX C
C-3
8a = Enter veteran’s city or town.
8b = Enter County and State.
8c = Enter zip code of permanent residence (National Zip Code Directory).
8d = Optional (Extended Zip Code).
8e = The user does not enter the County and State Code, as they are entered automatically.
i. Item 9. Race or Ethnicity. Enter from the pull-down menu.
j. Item 10. Marital Status. Enter one of the following codes from the pull-
down menu:
1 = Married
2 = Divorced
3 = Separated
4 = Widowed
5 = Single, Never Married
k. Item 11. Sex. Enter one of the following codes from the pull-down menu:
M = Male
F= Female
l. Item 12. Current Status. Enter one of the following codes from the pull-down menu:
1 = Inpatient
2 = Outpatient
3 = Incarcerated
4 = Active Duty (Outpatient)
5 = Active Duty (Inpatient)
m. Item 13. Branch of Service. If veteran was in more than one branch of service, enter the
latest GW service. Enter one of the following codes:
1 = Army (including Reserves and National Guard)
2 = Air Force (including Reserves and National Guard)
3 = Navy (including Reserves)
4 = Marine Corps
5 = Coast Guard
6 = Other (e.g., Public Health Service, National Oceanic and Atmospheric Administration)
n. Item 14, 14A, and 14B. Military Service in Persian Gulf.
(1) Enter one of the following codes from the pull-down menu:
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX C
C-4
Y = Yes (If yes, list the dates of veterans last two periods of service in Persian Gulf.)
N = No (If the veteran did not serve in Persian Gulf, the veteran is not eligible for a GWR
examination.)
(2) Item 14A. Enter the numerical equivalent of the month and also two digits of the year of
last period of service in Persian Gulf (e.g., from 02/91 to 05/91).
(3) Item 14B. If veteran had two or more periods of service in Persian Gulf, the longest
period of service should be entered. If only one period of service in Persian Gulf, enter in 14A
and leave 14B blank.
o. Item 15, 15A, and 15B. In What Area(s) Did Veteran Serve?
(1) Item 15A. Enter one of the following codes from the pull-down menu:
1 = Combat Zone
2 = Other Land Area
3 = Sea Duty
(2) Item 15B. If other service is indicated or, if the response is “Don’t Know” enter
appropriate code from pull-down menu.
4 = Other (Specify i.e., Air Force: Ground or Air Crew, etc.)
5 = Don’t Know
p. Item 16, 16A-16E. Military Units, Military Occupational Specialty (MOS) and MOSDifferent
Duties.
(1) Item 16A. Military Units. Enter the military unit in which the veteran served. Specify
complete unabbreviated title, i.e., company, battalion, corps, ship, division, etc., (e.g., Company
C, 1st Battalion, 4th Army).
(2) Item 16B. Military Occupational Specialty (MOS): Enter the veteran’s MOS.
(3) Item 16C. Were actual duties different from MOS? Enter one of the following codes
from the pull-down menu: If no, go to Item 16E.
Y = Yes
N = No
(4) Item 16D. If yes, enter actual duties that were different from MOS.
(5) Item 16E. Enter the name of unit with which the veteran had the longest and next to
longest period of service while in the Persian Gulf.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX C
C-5
NOTE: Items 16A and 16E: These units could be different from the one to which the veteran
was assigned if the veteran was on detached duty.
q. Items 17, 17A, and 17B. Last two periods of service, (if different from 14A and 14B).
Enter the numerical equivalent of the month and the last two digits of the year for the last two
periods of service regardless of whether or not they were in the Persian Gulf (e.g., from 12/90 to
04/91 and 9/90 to 11/90). If veteran did not have more than one period of service, leave blank.
For active duty military personnel, enter date when service began (e.g., 12/90) and enter nines
(e.g., 99/99) to indicate the veteran is still actively serving in the military.
r. Items 18, 18A-18Z1. Veteran’s Exposure to Environmental Factors. Enter the
following codes from pull-down menu:
Y = Yes
N = No
(1) Item 18A. Are you currently smoking cigarettes? If no, go to Item 18D.
(2) Item 18B. If yes, how many years have you been smoking cigarettes? Enter number of
years.
(3) Item 18C. If yes, on the average, how many packs are you smoking per day?
(4) Item 18D. Have you smoked cigarettes in the past? If no, go to Item 18G.
(5) Item 18E. If yes, how many years did you smoke?
(6) Item 18F. If yes, on the average how many packs did you smoke per day?
(7) Items 18G-Z1. While in the Persian Gulf do you believe you were exposed to any of the
following? Enter the following codes from the pull-down menus:
Y = Yes
N = No
U = Unknown
(8) Item 18G. Smoke from oil fires?
(9) Item 18H. Smoke or fumes from tent heaters?
(10) Item 18I. Cigarette Smoke (passive) from others?
(11) Item 18J. Diesel and/or other petrochemical fumes?
(12) Item 18K. Exposure to burning trash and/or feces?
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX C
C-6
(13) Item 18L. Skin exposure to diesel or other petrochemical fumes?
(l4) Item 18M. Chemical Agent Resistant Compound (CARC) paint?
(15) Item 18N. Other paints and/or solvents and/or petrochemical substances?
(16) Item 18O. Depleted uranium?
(17) Item 18P. Microwaves?
(l8) Item 18Q. Personal pesticide use, including creams, sprays, or flea collars?
(19) Item 18R. Nerve gas or other nerve agents?
(20) Item 18S. Drug (pyridostigmine) used to protect against nerve agents?
(21) Item 18T. Mustard gas or other nerve agents?
(22) Item 18U. Ate or drank food contaminated with smoke, oil or other chemical?
(23) Item 18V. Ate food other than provided by Armed Forces?
(24) Item 18W. Bathed in or drank water contaminated with smoke, oil or other chemical?
(25) Item 18X. Bathed in water other than provided by Armed Forces?
(26) Item 18Y. Immunization against anthrax?
(27) Item 18Z. Immunization against botulism?
(28) Item 18Z1. Enter other exposures.
s. Items 19A-F. Gulf War Experience. Did you have any of the following experiences
while in the Persian Gulf? Enter codes from the pull-down menus:
(1) Item 19A. Did you ever go on combat patrols or have other very dangerous
duty? Enter one of the following codes:
1 = No
2 = 1-3 times
3 = 4-12 times
4 = 13-50 times
5 = 51 times, or more
6 = Unknown
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX C
C-7
(2) Item 19B. As far as you know, were you ever under enemy fire, including Soviet
designed surface to surface missiles (commonly known as SCUDS)? Enter one of the following
codes:
1 = Never
2 = less than 1 day
3 = less than 1 week
4 = 1-4 weeks
5 = 4 weeks or more
6 = Unknown
(3) Item 19C. What percentage of people in your unit (your immediate group) were Killed in
Action (KIA), wounded or Missing In Action (MIA)? Enter one of the following codes:
1 = None
2 = 1-25 percent
3 = 26-50 percent
4 = 51-75 percent
5 = 76 percent or more
6 = Unknown
(4) Item 19D. How often did you see someone hit by incoming or outgoing rounds? Enter
one of the following codes:
1 = Never
2 = 1-2 times
3 = 3-12 times
4 = 13-50 times
5 = 51 times or more
6 = Unknown
(5) Item 19E. How often were you in danger of being injured or killed (i.e., pinned down,
overrun, ambushed, near miss, etc.)? Enter one of the following codes:
1 = Never
2 = 1-2 times
3 = 3-12 times
4 = 13-50 times
5 = 51 times or more
6 = Unknown
(6) Item 19F. Witnessed chemical alarms? Enter one of the following codes:
Y = Yes
N = No
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX C
C-8
U = Unknown
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX C
C-9
t. Item 20. Veteran’s Health (Veteran’s evaluation) Item 20A. Enter one of the following
codes from pull-down menu that best describes veteran’s health after GW Service:
1 = Very good
2 = Good
3 = Fair
4 = Poor
5 = Very poor
u. Item 21. Veteran's Functional Impairment
(1) Item 21A. Enter code that describes veteran’s assessment of the veteran’s functional
impairment, after GW Service, using one of the following assessment codes from the pull-down
menu:
1 = No impairment
2 = Slight impairment
3 = Moderate impairment
4 = Severe impairment
(2) Item 21B. How many workdays were lost by veteran due to illness in the past 90 days?
Enter number of days lost.
v. Item 22. Evidence of Birth Defects and Infant Death(s) among veteran’s children and
problems with pregnancy and infertility NOTE: Birth defects are any structural, functional,
or biochemical abnormality at birth whether genetically determined or induced during gestation
that is not due to injuries suffered during birth.
(1) Item 22A. How many children does the veteran have? If none, go to 22C.
(2) Item 22B. Birth Defects. How many of these children were born with birth defects?
Enter number of children. If none, go to Item 22C.
(a) Item 22B1. How many of these children were conceived before and/or after the veteran’s
GW service? If none, go to Item 22B2.
(b) Item 22B1(a). If yes, enter the maternal age at conception of first child conceived before
GW service.
(c) Item 22B2. How many children were conceived during or after the veteran’s GW
service? If none, go to Item 22C.
(d). Item 22B2(a) If yes, Enter the maternal age at conception of first child conceived during
or after the veteran’s GW service.
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX C
C-10
(3) Item 22C. Infertility (Problems of veteran or spouse becoming pregnant). NOTE:
Infertility=relative sterility defined as inability to conceive after 12 or more months of
intercourse without use of contraception when neither spouse is surgically sterilized. Has
veteran or spouse had infertility problems? Enter one of the following codes:
Y = Yes
N = No (If No, go to Item 22D.)
(a) Item 22C1. Has veteran or spouse had infertility before GW service? Enter one of the
following codes:
Y = Yes
N = No (If No, go to Item 22C2.)
(b) Item 22C1(a). Enter the maternal age during first attempts to conceive.
(c) Item 22C2. Has veteran or spouse had infertility after return from GW service? Enter
one of the following codes:
Y = Yes
N = No (If No, go to Item 22D.)
(d) Item 22C2(a). Enter the maternal age during first attempts to conceive.
(4) Item 22D. Miscarriage(s). NOTE: Miscarriages are spontaneous expulsion of the
products of conception before 20 weeks of gestation (spontaneous abortion). Has veteran or
spouse had miscarriage(s)? Enter one of the following codes:
Y = Yes
N = No (If No, go to Item 22E.)
(a) Item 22D1. If yes, has veteran or spouse had miscarriage(s) before GW service? Enter
one of the following codes:
Y = Yes
N = No (If No, go to Item 22D2.)
(b) Item 22D1(a). If yes, enter the maternal age at conception.
(c) Item 22D2. Has veteran or spouse had miscarriage(s) after return from GW service?
Enter one of the following codes:
Y = Yes
N = No (If No, go to Item 22E.)
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX C
C-11
(d) Item 22D2(a). If yes, enter the maternal age at conception.
(5) Item 22E. Still Birth(s). NOTE: Still births are births after 20 weeks of gestation of an
infant who showed no evidence of life after birth. Has veteran or spouse had still birth(s)? Enter
one of the following codes:
Y = Yes
N = No (If No, go to Item 22F.)
(a) Item 22E1. Has veteran or spouse had still birth(s) before GW service? Enter one of the
following codes:
Y = Yes
N = No (If No, go to Item 22E2.)
(b) Item 22E1(a). Enter the maternal age at conception of the still born child.
(c) Item 22E2. Has veteran or spouse had still birth(s) after return from GW service? Enter
one of the following codes:
Y = Yes
N = No (If No, go to Item 22F.)
(d) Item 22E2(a). If yes, enter the maternal age at conception of the still born child. Enter
age.
(6) Item 22F. Infant Death(s). NOTE: Death that occurred within 1 year of birth among
babies born alive. Has veteran or spouse had babies with infant death(s)? Enter one of the
following codes:
Y = Yes
N = No (If No, go to Item 22G.)
(a) Item 22F1. Has veteran or spouse had babies with infant death(s) before GW service?
Enter one of the following codes:
Y = Yes
N = No (If No, go to Item 22F2.)
(b) Item 22F1(a). If yes, enter maternal age at conception of the infant who died.
(c) Item 22F2. Has veteran or spouse had babies with infant death(s) after return from GW
service? Enter one of the following codes:
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX C
C-12
Y = Yes
N = No (If No, go to Item 22G.)
(d) Item 22F2(a) Enter the maternal age at conception of the infant who died.
(7) Item 22G. If applicable and the woman veteran reports she was pregnant in the Persian
Gulf, record the date of child's birth and hospital of birth to facilitate follow-up, if needed.
3. Instructions for Completing GWR Code Sheet, Part II (Initial Examination). (To be
completed by the examining clinician) List up to ten major and current symptoms and/or
complaints. If veteran has more than ten, enter most severe. Any additional symptoms should
be entered under Remarks, Item 32.
NOTE: Coders, use ICD-9-CM “Symptom” codes from the current ICD-9-CM codebook. For
uncodable symptoms use “78999.” For no known complaints, use “78000.” However, ICD-9-
CM code 78999 should only be used if all possible codes have been reviewed; if necessary, seek
physician consultation to make a correct choice.
a. Item 23. Date of Examination. Enter the numerical equivalent for the month, day, and
year in that order (e.g., 9/22/1992).
b. Item 24. Total Number of Veteran’s Complaints.
c. Item 25, 25A-M. Veteran’s Complaints, Month and Year of Onset, Duration in
Months, Whether Symptom is Currently Present, and Most Severe Complaint.
(1) Items 25A-J.
(a) Describe veteran’s complaints/symptoms.
(b) State ICD-9-CM codes.
(c) State duration in Months.
(d) State whether the symptom is still present, using the following codes: Y=Yes or N=No
from the pull-down menu.
(e) State month and year of onset.
(2) Item 25K. Most Severe Symptom/Complaint. Enter the Item code from pull-down menu
for most severe symptom (Symptom from Items A-J, which the veteran considers the most
severe; i.e., the chief complaint).
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX C
C-13
d. Item 26, A-S. Diagnostic workup/consultation. Enter one of the following codes from
pull-down menus:
1 = No workup. No consultation done.
2 = Workup and/or consultation done. Unexplained illness.
3 = Workup and/or consultation done. Diagnosis established.
4 = Workup and/or consultation done. No diagnosis.
(1) Item 26A. Allergy and/or Immunology.
(2) Item 26B. Audiology.
(3) Item 26C. Cardiology.
(4) Item 26D. Dentistry.
(5) Item 26E. Dermatology.
(6) Item 26F. Ear, Nose, and Throat.
(7) Item 26G. Endocrinology.
(8) Item 26H. Gastroenterology.
(9) Item 26I. Hematology and/or Oncology.
(10) Item 26J. Infectious Diseases and/or Parasitology.
(11) Item 26K. Nephrology.
(12) Item 26L. Neurology.
(13) Item 26M. Occupational Medicine.
(14) Item 26N. Pulmonary.
(15) Item 26O. Psychiatry.
(16) Item 26P. Psychology and/or Psychometric Testing.
(17) Item 26Q. Rheumatology.
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX C
C-14
(18) Item 26R. Other. Were any additional workups and/or consultations performed as part
of GWR examination which were not listed in Items 26A-Q. Enter one of the following codes
from pull-down menu:
Y = Yes
N = No
(19) Item 26S. Specify on code sheet any additional workups and/or consultations performed
as part of GWR registry examination that were not listed in Item 26A-Q.
e. Item 27, 27A-B. Diagnoses. Item 27A. List up to ten major definite medical diagnoses
on lines 27A-J. The examining physician will select the ten most significant and/or serious in
the examining physician’s opinion, listing the primary diagnosis in Item A. Any additional
diagnosis(es) must be included in patient’s medical record. Coders are to code each diagnosis
listed from the current ICD-9-CM codebook. Leave blank if no diagnosis is made. Do not repeat
or enter symptom codes already listed under Item 25A-J.
f. Item 28. No Diagnosis Made. If no diagnosis is made, enter a “1,”otherwise leave this
block blank. This item must be considered in conjunction with Item 27, “Diagnoses.” A “1”
needs to be entered for Item 28 only when no diagnosis is given in Item 27 indicating that no
significant defect, disease, injury, or history of a relevant diagnosis in the past is detected.
g. Item 29, 29A-F. Disposition. Enter one of the following codes from the pull-down menu:
Y = Yes, or N = No.
(1) Item 29A. Examination completed?
(2) Item 29B. Hospitalized at the VAMC for further tests?
(3) Item 29C. Hospitalized at the VAMC for treatment?
(4) Item 29D. Referred for outpatient care?
(5) Item 29E. Referred to private physician, non-VA clinic or non-VA hospital?
(6) Item 29F. Biopsy?
h. Item 30. Phase I examination, refer to paragraph 5, has been completed and the
physician has determined that veteran has unexplained illness. Enter one of the following
codes from the pull-down menu: Y = Yes; or N = No.
i. Item 31. Has Phase II examination been initiated? Enter the following codes from the
pull-down menu: Y = Yes; N = No.
j. Item 32. Remarks. Utilize this section for any additional information.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX C
C-15
k. Item 33. Name of Examiner. Enter full name of examiner.
l. Item 34. Title of Examiner. Full title of examiner.
m. Item 35. Signature of Examiner. Signature of examiner, if electronic signature is
available. Item 35a. Signature of Physician. Signature of EH Clinician, if electronic signature
is available.
4. Follow-up Examinations. Follow-up examinations should be entered into the GWR using
Type C. The instructions for completing Parts I, II and III are available via website
http://vaww.registries.aac.va.gov . Only the first follow-up examination is entered into the GWR
unless subsequent follow-up examination data contains new diagnoses.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX D
D-1
EXAMPLE GULF WAR REGISTRY FOLLOW-UP LETTER
(MEDICAL PROBLEMS INDICATED)
DEPARTMENT OF VETERANS AFFAIRS
Medical Center
Anywhere, U.S.A. Zip
In Response Reply To:
(Date)
(Name/Address)
Dear __________________:
We sincerely appreciate your recent participation in the Department of Veterans Affairs
(VA) Gulf War Registry. This effort should prove to be helpful in assisting us to serve you and
other veterans who are concerned about the possible health problems that may have resulted
from service in Southwest Asia during the Gulf War and/or Operation Iraqi Freedom.
As discussed at the conclusion of your visit, results of your examination and laboratory tests
showed certain problems (optional--these findings may be described in lay terms). In view of
these findings, we have scheduled you for treatment of these health problems on (date). If for
any reason you cannot keep this appointment, please call (telephone number) at the earliest
possible time to cancel and reschedule.
The results of your examination will be maintained by VA and will be available for future
use as needed. If you have any questions or concerns about your Gulf War Registry
examination, please contact the Veterans’ Environmental Health Coordinator at (telephone
number) for assistance.
Whether you are eligible for cost-free treatment or will be responsible for co-payments will
be determined by your income and other factors unless the VA determines that your health
problems are service connected. You may wish to file a claim for compensation to establish
possible service connection. The injury or illness need not have been incurred in combat; the
law requires only that a disease or disability was incurred or aggravated during military service.
Please remember that this examination does not automatically initiate a claim for VA
benefits. If you wish to file a claim, please contact the nearest VA Regional Office. In your
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX D
D-2
area, the Regional Office is located at (address). Their telephone number is (telephone
number). If you need any further assistance, you may contact one of the following toll-free
numbers:
(1) Veterans Benefits Representative: 1-800-827-1000 (for information on filing claims);
(2) Veterans Health Benefits Service Center: 1-877-222-VETS (8387) or
(3) VA Helpline: 1-800-749-8387.
An outreach program has been implemented by which VA notifies all individuals listed in
the registry of significant VA activities, including the health consequences of military service
in the Gulf War theater of operations during the Gulf War or Operation Iraqi Freedom. You
will be receiving a “Gulf War Review” which is published periodically by VA’s Environmental
Agents Service. A copy of this “Review” is enclosed for your reference.
For other veterans who served on active duty in a designated theater of combat operations
after the Persian Gulf War or in combat against a hostile force during a period of hostilities
after November 11, 1998, VA is authorized to provide a broad range of health care services to
them for a 2-year period following separation from military service.
We trust this information is helpful to you. Once again, your participation in the registry is
appreciated.
Sincerely yours,
(Signature)
Name of Environmental Health Clinician
Enclosure
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX E
E-1
EXAMPLE GULF WAR REGISTRY FOLLOW-UP LETTER
(NO MEDICAL PROBLEMS INDICATED)
DEPARTMENT OF VETERANS AFFAIRS
VA Medical Center
Anywhere, U.S.A. Zip
In Response Reply To:
(Date)
Name/Address
Dear ___________________:
We sincerely appreciate your recent participation in the Department of Veterans Affairs
(VA) Gulf War (GW) Registry. This effort should prove to be helpful in assisting us to serve
you and other veterans who are concerned about the possible health problems that may have
resulted from service in Southwest Asia during the Gulf War or Operation Iraqi Freedom
(OIF).
As discussed at the conclusion of your visit, results of your examination and laboratory tests
indicate that there are no detectable medical problems. At this time you have no reason to be
concerned about any adverse health effects resulting from your service in the Persian Gulf.
However, in the future if you have a medical problem, I would encourage you to seek the help
and advice of Environmental Health Clinicians or Coordinators at the nearest VA medical
center or outpatient clinic. You may reach us at (telephone number).
The results of your examination will be maintained by VA and will be available for future
use as needed.
Please remember that this examination does not automatically initiate a claim for VA
benefits. If you wish to file a claim for compensation to establish possible service-connection,
please contact your nearest VA Regional Office. In your area, the Regional Office is located at
(address). Their telephone number is (phone number). VA may pay compensation for current
disability due to any injury or disease that was incurred or aggravated during military service.
The condition does not have to be related to combat.
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX E
E-2
If you need any further assistance, you may call one of the following toll-free numbers:
(1) Veterans Benefits Representative: 1-800-827-1000 (for information on filing claims)
(2) Veterans Health Benefits Service Center: 1-877-222-VETS (8387) or
(3) VA Helpline: 1-800-749-8387
An outreach program has been implemented by which VA notifies all individuals listed in
the registry of significant VA activities, including the health consequences of military service
in the Gulf War theater of operations during the Gulf War. You will be receiving a “Gulf War
Review” which is published periodically by VA’s Environmental Agents Service. A copy of
this “Review” is enclosed for your reference.
For other veterans who served on active duty in a designated theater of combat operations
after the Persian Gulf War or in combat against a hostile force during a period of hostilities
after November 11, 1998, VA is authorized to provide a broad range of health care services to
them for a 2-year period following separation from military service.
We trust this information is helpful to you. Once again, your participation in the registry is
appreciated.
Sincerely yours,
______(Signature)_____________________
Name of Environmental Health Clinician
Enclosure
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX F
F-1
UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)
1. Phase I-Level Laboratory Evaluations
a. Complete Blood Count (CBC),
b. Urinalysis, and
c. Blood Chemistry - SMA-6. (SMA is a Manufacturer’s Trademark for a Chemistry
Analyzer)
2. Phase II-Level Evaluation Protocol. Phase II-Level Evaluations are recommended for those
veterans after complete clinically-indicated evaluations are conducted and the clinician
determines that the patient has an unexplained illness. Individuals who, after completing Phase I
or registry evaluations, have a disability and do not have a clearly defined diagnosis which
explains their symptoms, must receive the following supplemental baseline laboratory tests and
consultations.
a. Supplemental Baseline Laboratory Tests
(1) CBC,
(2) Sedimentation Rate Erythrocyte Sedimentation Rate (ESR),
(3) C-Reactive Protein,
(4) Rheumatoid Factor,
(5) Anti-Nuclear Antibody (ANA),
(6) Liver Function,
(7) Creatine Phosphokinase (CPK),
(8) Hepatitis Serology,
(9) Human Immunodeficiency (HIV),
(10) Venereal Disease Research Laboratory (VDRL),
(11) B-12 and Folate,
(12) Thyroid Function Test,
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX F
F-2
(13) Urinalysis, and
(14) Tuberculosis (TB) skin test Purified Protein Derivative (PPD).
b. Consultations, to include:
(1) Dental, but only if participant’s annual screening is not done.
(2) Infectious Disease.
(3) Psychiatry, but only with physician-administered instruments.
(a) Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental
Disorders, Third Edition, Revised (DSM III-R). NOTE: Delete modules for mania and
psychosis.
(b) Clinician Administered Post-traumatic Stress Disorder (PTSD) Scale (CAPS).
(4) Neuropsychological Testing, but only as indicated by a psychiatry consult.
c. Symptom-specific Examination. Individuals who have the following symptoms need to
have the listed minimum work-up.
(1) Diarrhea, to include:
(a) Gastrointestinal (GI) consult,
(b) Stool for Ova and Parasites (O&P),
(c) Stool Leukocytes,
(d) Stool culture,
(e) Stool volume,
(f) Colonoscopy with biopsies, and
(g) Esophagastroduodenoscopy (EGD) with biopsies and aspiration.
(2) Abdominal pain to include:
(a) GI consult,
(b) EGD with biopsy and aspiration,
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX F
F-3
(c) Colonoscopy with biopsy,
(d) Abdominal Ultrasound,
(e) Upper Gastrointestinal (UGI) series with small bowel follow-through, and
(f) Abdominal Computed Tomography (CT) Scan.
(3) Headache
(a) Magnetic Resonance Imaging (MRI) of the head, and
(b) Lumbar Puncture (LP) to include:
1. Glucose,
2. Protein,
3. Cell Count,
4. VDRL,
5. Oligoclonal (lgG),
6. Myelin basic protein,
7. Opening pressure, and
8. Neurology.
(4) Muscle Aches and/or Numbness
(a) Electromyogram (EMG), and
(b) Nerve Conduction Velocity (NCV).
(5) Memory Loss, only if verified by neuropsychological testing, to include:
(a) Magnetic Resonance Imaging (MRI),
(b) LP, NOTE: See tests on headache evaluation.
(c) Neurology consult,
(d) Neuro-psychological testing,
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX F
F-4
(6) Vertigo and/or Tinnitus, to include:
(a) Audiogram,
(b) Electronystamogram (ENG), and
(c) Brainstem Auditory Evoked Response (BAER).
(7) Chronic Fatigue, to include:
(a) Polysomnography, and
(b) Multiple Sleep Latency Test (MSLT).
(8) Chronic Cough and/or Shortness of Breath, to include:
(a) Pulmonary Consult,
(b) Pulmonary Function Test (PFT) with exercise and Arterial Blood Gases (ABG),
(c) If routine PFT’s are negative, perform Methacholine challenge test, and
(d) Bronchoscopy with biopsy and/or lavage which is to be considered if PFTs are normal.
(9) Chest Pain and/or Palpitations, to include:
(a) Electrocardiogram (ECG),
(b) Exercise Stress Test, and
(c) Holter monitor.
(10) Skin Rash, to include:
(a) Dermatology consult, and
(b) Consider a biopsy.
(11) Reproductive Concerns, to include for:
(a) Males, an urology consult; and
(b) Females, a gynecology (GYN) consult.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX F
F-5
(c) Additional elements recommended for the evaluation of Gulf War veterans with
complaints of Reproductive Health Problems (RHP):
1. Detailed genitourinary history and/or problems, e.g.,:
a. Sexual,
b. Genitourinary symptoms,
c. Menstrual,
d. Contraceptive practices,
e. Pregnancy-related,
f. Conception,
g. Birth defects,
h. Congenital disorders,
i. Menopause,
j. Prior infections,
k Prior surgery, and
l. Exposures to toxic agents, etc.
2. Detailed genital and/or pelvic examination.
3. Laboratory and ancillary testing, e.g.;
a. Pap tests; and
b. Tests for genitourinary infections.
4. Urologist consultation for male veterans who have RHP that cannot be diagnosed or
managed successfully by primary care practitioners.
5. Gynecology consultation for female veterans who have RHP that cannot be diagnosed or
managed successfully by primary care practitioners.
(d) Additional elements for evaluation of Gulf War veterans with complaints of infertility.
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX F
F-6
1. Detailed menstrual and reproductive history (such as the Infertility Questionnaire utilized
by Walter Reed Army Medical Center).
2. Semen analysis, e.g.:
a. Volume,
b. pH,
c. Liquefaction,
d. Sperm concentration,
e. Motility,
f. Progressive motility,
g. Sperm viability,
h. Leukocytes, and
i. Morphology.
3. Referral to an infertility specialist or program.
(e) Additional elements for evaluation of GW veterans with complaints related to birth
defects or genetic disorders in offspring conceived during or after GW service.
1. Detailed history of congenital or genetic disorders (such as the Patient Genetic Screen
Questionnaire utilized by Walter Reed Army Medical Center).
2. Detailed occupational exposures questionnaire (such as Worker and Supervisor
Questionnaires utilized by National Naval Medical Center).
3. Referral to a genetic disease specialist or program.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX G
G-1
INSTRUCTIONS FOR COMPLETING GULF WAR
UNIFORM CASE ASSESSMENT PROTOCOL (UCAP), PHASE II, PART III
1. General Instructions for Completing Department of Veterans Affairs (VA) Gulf War
Registry Examination, Uniform Case Assessment Protocol (UCAP), Phase II.
a. The Phase II examination needs to be offered to all eligible Gulf War (including Operation
Iraqi Freedom) veterans with unexplained illnesses. The Phase II examination needs to be
performed after the completion of the Phase I registry examination and a thorough clinicallybased
evaluation of the veteran’s symptoms as deemed necessary by the examining physician.
b. Phase II needs to be performed at the local VA medical facility or if the medical expertise
is unavailable, local referral must be made to the nearest regional tertiary care center or War
Related Illness and Injury Study Center (WRIISC). NOTE: Refer to VHA Handbook 1303.5 or
website www.va.gov/environagents and video entitled War and Health: Treating War-Related
Illnesses at VA’s WRIISCs.
2. Instructions for Completing Part III, Phase II
a. Tests and Consultations. Only those entries which are related to the veteran’s symptoms
and deemed necessary by the examining physicians need to be completed; leave test and consult
questions that are not applicable blank Select either (Y)es or (N)o from the pull-down menu.
NOTE: Refer to website http://vaww.registries.aac.va.gov for instructions.
(1) Item 1. Were the following tests performed? Enter one of the following codes from the
pull-down menu:
(2) Item 2. Blood Tests
(a) Complete Blood Count (CBC)?
(b) Skin Erethyma Dose (SED) Rate?
(c) C-Reactive Protein?
(d) Rheumatoid Factor?
(e) Fluorescent Anti-Nuclear Antibody (ANA)?
(f) SGOT (AST) (Glutamic Oxaloacetic Transaminase)?
(g) SGPT (ALT) (Transaminase Glutamic Pyruvate)?
(h) Lactic Acid Hydrogenase (LDH)?
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX G
G-2
(i) Alkaline Phosphatase?
(j) Creatine Phosphokinase (CPK)?
(k) Hepatitis B Surface Antibody?
(l) Hepatitis B Core Antigen?
(m) Venereal Disease Research Laboratory (VDRL)?
(n) Vitamin B-12?
(o) Folate?
(p) Human Immuno-deficiency (HIV)?
(q) Thyroxine Total Serum (T4)?
(r) Thyroid Stimulating Hormone (TSH)?
(3) Item 3. Urinalysis?
(4) Item 4. Tuberculosis (TB) Skin Test Purified Protein Derivative (PPD)?
(5) Item 5. Chest X-ray?
(6) Item 6. Psychiatric Consultation?
(a) Item 6A. Structured Clinical Interview for Diagnosis (SCID) for Diagnostic and
Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R). Was the SCID
interview given?
(b) Item 6B. Clinical Administered Post-traumatic Stress Disorder (PTSD) Scale (CAPS).
Was the CAPS performed?
(c) Item 7. List of Diagnoses. Designated physician staff or clinical staff are to provide
narrative description of diagnoses. If none, leave blank. NOTE: Coders: Enter International
Classification of Diseases, Clinical Modification, 9th Edition (ICD-9) codes as required.
b. SYMPTOM-SPECIFIC EXAMINATIONS, PHASE II NOTE: Complete only those
questions which are appropriate to the veteran’s symptoms; otherwise leave these blank.
(1) Item 8. Psychology-Neuropsychological Test.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX G
G-3
(a) Was this test performed?
(b) List of Diagnoses and ICD-9 codes.
(2) Item 9. Infectious Disease-Screening Examination.
(a) Was this examination performed?
(b) List of Diagnoses and ICD-9 codes.
(3) Item 10. Dental Examination.
(a) If there was a medical indication, was this examination performed?
(b) List of Diagnoses and ICD-9 codes.
(4) Item 11. Diarrhea and/or Abdominal Pain.
(a) Did patient receive a GI (Gastroenterology) consult?
(b) List Diagnoses and ICD-9 codes.
(5) Item 12. Headache and/or Memory Loss.
(a) Did patient receive neurology consult?
(b) List Diagnoses and ICD-9 codes
(6) Item 13. Muscle Aches or Numbness.
(a) Did patient receive a neurology consult?
(b) List Diagnoses and ICD-9 codes.
(7) Item 14. Chronic Fatigue.
(a) Did patient receive consult(s) relating to chronic fatigue?
(b) List Diagnoses and ICD-9 codes.
(8) Item 15. Joint Pain.
(a) Rheumatology Consult. Did patient receive rheumatology consult?
(b). List Diagnoses and ICD-9 codes.
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX G
G-4
(9) Item 16. Chronic Cough and/or Shortness of Breath.
(a) Pulmonary Consult. Did patient receive pulmonary consult?
(b) List Diagnoses and ICD-9 codes.
(10) Item 17. Skin Rash.
(a) Dermatology Consult. Did patient receive a dermatology consult?
(b) List Diagnoses and ICD-9 codes.
(11) Item 18. Vertigo and/or Tinnitus.
(a) Audiology consult? Did patient receive an audiology consult?
(b) List Diagnoses and ICD-9 codes.
(12) Item 19. Chest Pain and/or Palpitations.
(a) Cardiology Consult. Did patient receive a cardiology consult?
(b) List Diagnoses and ICD-9 codes.
(13) Item 20. Reproductive Concerns.
(a) Did male patient receive a urology consult?
(b) Did female patient receive a gynecology consult?
(c) List Diagnoses and ICD-9 codes.
(14) Item 21. Final Diagnoses. List up to ten major definite medical diagnoses, with the
primary diagnosis listed on line 21A with ICD-9 codes. If no diagnosis is made, leave these
lines blank as well as the ICD-9 codes.
(15) Item 22. After completing the Uniform Case Assessment Protocol (UCAP), Phase II,
Part III, does the physician feel that the veteran has an unexplained illness? Enter either Y(es) or
N(o) from the pull-down menu.