to provide new registry data entry procedures required to access the reconstructed Environmental

to the new method of entering and retrieving data from the reconstructed EAS web site

children of Gulf War veterans has been discontinued. These new procedures allow

Environmental Health (EH) Clinicians and EH Coordinators to search for, and access exam

information by veteran’s name or social security number, and provide the ability to retrieve all

exam information, historical and current, regardless of point of entry. Additionally, the form

used for data entry procedures has changed from a code sheet to a worksheet. Copies of these

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

the last working day of June 30, 2012.

Michael J. Kussman, MD, MS, MACP

Under Secretary for Health

DISTRIBUTION: CO: E-mailed 6/5/2007

FLD: VISN, MA, DO, OC, OCRO, and 200 – E-mail 6/5/2007

1. Purpose ...... 1

2. Background ............................................................................................................................... 1

3. Registry Evaluation ................................................................................................................... 2

4. Responsibilities ......................................................................................................................... 3

5. Gulf War Registry (GWR) Examination .................................................................................. 3

a. Purpose ... 3

b. Eligibility Criteria .................................................................................................................. 4

c. Program Management ............................................................................................................ 5

d. Responsibilities ...................................................................................................................... 5

6. Gulf War (GW) Uniform Case Assessment Protocol (UCAP) ............................................... 12

a. Background .......................................................................................................................... 12

b. Authority .............................................................................................................................. 13

c. Scope .... 13

d. Responsibilities .................................................................................................................... 13

7. Media and Other External Contacts ........................................................................................ 14

A Definitions and Acronyms ................................................................................................... A-1

B Protocol for Conducting the Physical Examination and Ordering Diagnostic Studies,

Phase I. B-1

C Instructions for Completing VA Form 10-9009A, Gulf War Registry Worksheet, Phase I

(Parts 1, 2 and 3) ................................................................................................................. C-1

D Example of Gulf War Registry Follow-up Letter (Medical Problems Indicated) ............... D-1

E Example of Gulf War Registry Follow-up Letter (No Medical Problems Indicated) ........... E-1

F Conducting the Uniform Case Assessment Protocol (UCAP), Phase II ............................... F-1

G Instructions for Completing Gulf War Worksheet, Phase II, (Part 3), UCAP ..................... G-1

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

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 support of 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 theatre of operations. The British deployed approximately 53,000 military

personnel, the French deployed 25,000 military personnel, and the Canadians deployed 4,500

military personnel. In contrast to previous conflicts, a larger proportion (e.g., 17 percent) of U.S.

troops were from the Reserves and/or National Guard and another 7 percent were women.

Along with the rapid buildup of coalition combat forces, an extensive medical care infrastructure

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 (Pub. L.)

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

subpar. 5b). 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:

(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) Oil, smoke, and other petrochemical agents for veterans of the first Gulf War; and

(b) Leishmaniasis (spread by sand flies) for veterans of all Gulf Wars including OIF.

presenting to VA with a wide range of both medical and psychological conditions similar to

f. With the exception of health problems relating to exposure to oil fires, the type of

g. During the examination process, these exposures and health conditions are identified and

documented in the veteran’s health record.

h. The GW registry contains medical and other data regarding possible health exposures that

veterans may have experienced. The registry signals VA’s commitment to address questions

concerning possible future effects of air pollutant exposure and other environmental agents, as

well as to serve as the basis for future medical surveillance.

Veterans claiming health conditions related to an exposure to a toxic substance or an

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 facility Business Office to

determine if the veteran is eligible for treatment.

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 patient handbook (both inpatient and outpatient, if available), 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 Corporate Franchise Data (CFD) Center, in Austin, TX.

(2) The GWR consists of medical examinations and other data from 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

c. The EH Clinician and EH Coordinator at each VA facility have 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 CFD registry database on the web site at

examination and who served on active military duty in Southwest Asia during the GW which

began in 1990, and continues to the present (Title 38 United States Code (U.S.C.) § 101(33)),

(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 Persian Gulf, the Arabian Sea, and the Red Sea.

(2) Eligible GW and/or OIF veterans applying for treatment in a VA medical center and/or

outpatient clinic must be encouraged to undergo an initial (i.e., "first-time") GWR examination.

Veterans are also eligible for follow-up (2nd, 3rd, etc.) registry examinations if requested by an

EH Clinician or if a veteran reports new symptoms. The follow-up exams are not routine, but

(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 is not a compensation claim.

(b) Veterans who wish to submit a claim for conditions possibly related to GW service need

to do so by 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 national toll-free numbers:

1. Veterans Health Eligibility and/or Enrollment: 1-877-222-VETS (8387);

2. VA Gulf War, Agent Orange, and Other Environmental Programs: 1-800-749-8387; or

3. VA Regional Offices provide information about disability compensation benefits, as

well as vocational rehabilitation and education programs available to veterans: 1-800-827-1000.

EH Coordinators, and Business Office employees must familiarize themselves with the materials

other materials distributed by VA Central Office. In addition, appropriate program officials need

to attend the quarterly EAS conference calls from VA Central Office.

administration or appropriate administrative staff of each VA facility 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.

(a) Providing clinical management of the veteran receiving a registry examination, and

serving as the primary health care provider, unless another has been assigned.

(b) Serving in an advisory capacity for the administrative management of the program.

(c) Discussing the results of the examination(s) with the patient 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).

(d) Counseling the veteran on the purpose of the physical registry examination.

(e) Informing how the data supplied by the veteran and obtained during each registry

examination may be used. The veteran needs to be advised that the information the veteran

supplies and the medical data obtained during the GWR examination allows:

1. VHA to track patient demographics, medical diagnosis, and related medical data for

workload analysis to assist in budget planning and possibly generating hypotheses for future

research studies.

2. The information to be disclosed outside of VA to Federal, State, and local government

agencies as stated in the "Notice of Systems of VA Records" published in the Federal Register in

accordance with the Privacy Act of 1974.

3. The veteran to be informed that by participating in the registry, the veteran is consenting

(f) 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.

(g) Conducting and documenting the physical registry examination in the veteran’s health

record.

(h) Providing a complete medical history including:

1. Family;

2. Occupation;

3. Social, including tobacco, alcohol, and drug use;

4. Civilian exposure to possible toxic agents;

5. Psychosocial condition; and

6. Review of systems.

(i) Completing all elements of the registry examination, no later than 10 working days, after

examination, then reviewing and reporting the worksheet data to the EAS database, located at the

(j) 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.

(k) Personally discussing each veteran’s need for a follow-up examination either

recommended by the EH Clinician or requested by the veteran. These follow-up exams are not

performed routinely, but need to be based on new symptoms reported by the veteran.

(l) Documenting these discussions and/or findings in each veteran’s health record.

(m) Encouraging the veteran to contact a VA medical center to document additional

diagnoses in an appropriately-titled progress note in the veteran’s 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

for inclusion in the registry database.

(n) Preparing and signing a follow-up letter to each veteran explaining the results of the

1. 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.

2. A copy of this dated and signed letter must be filed and/or scanned into the veteran’s

health record.

3. It is essential that this letter be written in language that can be easily understood by the

4. The letter must explain that:

a. 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.

b. If it is determined upon examination that the veteran does have medical problems, it is

not necessary to specify the problems in the letter; however, the veteran must advised the recent

examination indicated a health condition or problem which may require further examination

and/or treatment.

c. 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.

d. If the veteran is not eligible for treatment, the letter needs to so advise and recommend

that the veteran seek appropriate medical care elsewhere.

e. 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 (RO).

future use, as needed.

g. If the veteran changes place of residence, the veteran needs to provide the new address

to the EH Coordinator whose address and phone number are provided.

administrative management of the program, including:

(a) Completing Registry Worksheets (see App. C).

(b) Scheduling of appointments. 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 need to be scheduled on the same day so that the veteran is not

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/or the

use of fee-basis sources or contracting out some or all examinations with other health care

providers in order 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 at (202) 273-8463 or (202) 273-

8465.

(c) Monitoring timeframe compliance.

(d) Reviewing records for accuracy and completeness.

(e) Providing each veteran with a brief oral explanation of the purposes of the GWR and the

examination process, and responding to any questions the veteran might have. This can be

accomplished during the EH Coordinator’s initial contact with the veteran.

(f) 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. Upon distribution by VA EAS, provide each GW

veteran, reporting to the outpatient area, with the following:

1. Information Bulletin (IB) 10-41, "VA Gulf War Veterans’ Illnesses, Questions and

Answers," which describes the purpose of the examination and its limitations;

2. IB 10-42, "Gulf War Research, A Report to Veterans," which is for veterans specifically

interested in research;

3. If appropriate, IB 10-166, "Operation Iraqi Freedom and Enduring Freedom Review,"

and

4. IB 10-57, "Special Health Registry Examination Programs," which describes the

purpose of all EAS registry programs, Agent Orange, Gulf War and Operation Iraqi Freedom,

Depleted Uranium and Ionizing Radiation.

5. "The "Gulf War Review," which is published annually.

(g) Completing data entry. The EH Coordinator, or designee, must:

1. Complete the demographic sections of the GWR worksheet and ensure that all

before the veteran is referred to the clinician for the examination.

2. Complete the Symptoms and Exams Section of the GWR worksheet. This data may be

3. In the event that a veteran requests a GW examination, but does not wish to be included

in the registry database, perform a registry examination. In the "Remarks," indicate the current

date and note that the veteran chose not to participate in the registry. This GW worksheet needs

to be filed in the veteran’s electronic health record. Do not enter the data from the worksheet in

(h) 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 post "Gulf War Registry Examination," in

the Computerized Patient Record System (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 worksheet, 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.

a. 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 a GWR examination, VA may conduct such

an examination in a VA facility, but only if accompanied by officials of the releasing agency

who is responsible for custodial restraint and safe return of the inmate. 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

(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

(5) Copies of this Handbook, GWR examination worksheets, etc., must be provided to

penal institutions upon request.

(6) 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.

(7) A recommendation can be made to the penal institution to retain a copy of the

b. Veterans With Other Than Honorable Discharges. Current VHA policy applies to

c. Active Duty Military Personnel

(1) 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 current VHA

requirements of M-1, Part I, Chapter 15, or current policy regarding the authorization and billing

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.

(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 the exception of the facility number, suffix (if applicable),

and county and state. This information must be completed by the VA EH Coordinator.

(4) Military facilities must provide completed copies of the worksheets, physical

examination, laboratory tests, etc., to the nearest VA medical center or outpatient clinic. The EH

Coordinator must:

(a) Complete the GWR data worksheets to include facility number (and suffix, if

applicable), and county and state codes.

(b) Transmit the worksheet data to the AAC on the EAS web site at

(c) Establish a health record if one does not already exist, and maintain in the

administrative health record or scanned health record, an appropriately titled CPRS Progress

Note; and

(d) If requested, and only with a signed request for release of information (ROI) 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.

1. Separate listings of the EH Clinicians and EH Coordinators are maintained within EAS

2. In an effort to keep these listings current, facilities are mandated to notify EAS of

changes as they occur in the status of EH Clinicians and Coordinators at their respective

facilities and/or satellite clinics.

3. As changes in appointments occur, the name, title, mail routing symbol, telephone and

facsimile (FAX) numbers including area code must be submitted to the Environmental Health

Coordinator, EAS (131), Department of Veterans Affairs, 810 Vermont Avenue, NW,

Washington, DC 20420.

(1) Most personnel who served in the GW have reported health problems since their return

to the U.S. 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 GW 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 worked cooperatively to develop a Uniform Case Assessment Protocol

(UCAP) for the evaluation of these GW veterans who, after a thorough routine medical

(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

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

established by the Under Secretary for Health to assist in addressing the unique health concerns

of the GW veterans. On November 2, 1994, Pub. L. 103-446 amended Title 38 U.S.C. 1117

implementing the uniform and comprehensive medical evaluation protocol for the GW veterans.

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.

(a) Conducting the Registry examination (Phase I), which is the first step toward diagnosis

of the health problems of a GW or OIF veteran (see App. B and App. C); and

(b) If a diagnosis is not readily apparent after conducting routine medical evaluations,

initiating the UCAP, (Phase II) using the protocol provided in Appendix G.

(c) Initiating the UCAP (Phase II) and, if the health problems are still unexplained, the EH

clinician might consider a referral to one of the WRIISCs (see App G).

(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, consulting with EH Clinician, or designee.

(c) Completing and entering the UCAP data on the Web site

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 a response with the regional VA public

affairs representative.

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;

(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.

computerized registry for worksheet data collection and database entry. This was formerly

known as the Austin Automation Center (AAC),

identity, diagnosis, prognosis, or treatment at a Department of Veterans Affairs (VA) facility.

Revised)

to coordinate and monitor all VHA activities, research, and otherwise, relating to the Gulf War

(GW) issue.

is responsible for the clinical management of the GW Program at each VA medical facility.

responsible for the administrative management of the GW program at each VA facility.

a. Initial. The first physical examination which is completed, and data entered in the GW

b. Follow-up. Examination performed subsequent to the initial (first) examination and data

entered in GW registry database, located at the AAC, on the EAS Web site at

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 on

and Answers."

provides standardized classification of diseases.

Asia during the Gulf War included service in one or more of the following areas: Iraq, Kuwait,

Saudi Arabia, the neutral zone (between Iraq and Saudi Arabia), Bahrain, Qatar, the United Arab

Emirates, Oman, waters of the Persian Gulf, Red Sea, Arabian Sea, and Gulfs of Aden and

Oman.

(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.

disposition.

It is actually the NATO designator given to the missile.

1. It is essential that a complete medical history, physical examination, and interview be

performed and documented on appropriate forms.

a. The required forms that must be fully completed are: VA Form 10-9009a, Gulf War

Registry (GWR) Worksheet; dated follow-up letters which must be maintained, as well as

scanned documents attached to appropriately titled Computerized Patient Record System

Progress Notes (CPRS); and all medical records of the registry examination, i.e., Standard Form

(SF) 88, Report of Medical Examination, and SF 509, Medical Record Progress Report (for

b. The complete medical history needs to address the following:

(1) Family history;

(2) Occupational history;

(3) Social history including tobacco, alcohol, and drug use;

(4) Civilian exposure(s) history to possible toxic agents;

(5) Psychosocial history; and

(6) Review of systems.

2. The person actually performing the physical examination must be identified by name,

signature, and title (i.e., Doctor of Osteopathy (D.O.), Doctor of Medicine (MD), Physician’s

Assistant (PA), etc.).

3. When a GWR examination is done as part of a compensation and pension (C&P)

examination, the physical examination must be done by, or under, the direct supervision of the

EH Clinician or designee.

4. The physician needs to be aware of the variety of exposures endemic to the Gulf War area.

These are listed in subparagraph 5b of the Handbook. 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. Following (for

informational purposes) is a list of some of the health problems and/or diseases that need to be

considered:

a. Recommended coding (see International Classification of Diseases, Current Edition).

Complaints Symptom Code Diagnosis Diagnostic Code

(1) Other Symptoms involving:

(2) Nervous and Musculoskeletal

(3) Systems for Pain in the joint 78199 Arthralgia 71940-71949

(4) Malaise and Fatigue 78079 Chronic Fatigue Syndrome 78071

Fibromyalgia 7291

(5) Insomnia with sleep apnea 78051 Sleep Apnea 99001

or 78053

(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;

(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; and

(35) Drug dependence.

5. In gathering these data, it is important to determine and record the:

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 must be given the following baseline laboratory studies (Phase I Registry

Examination):

a. Complete Blood Count (CBC);

b. Comprehensive metabolic panel or blood chemistries and enzyme studies; and

c. Urinalysis.

7. Appropriate additional diagnostic studies need to be performed and consultations obtained, as

a. Other diagnostic studies, such as pulmonary function tests and sperm counts, need to be

performed if medically indicated.

b. Laboratory tests results need to be filed in the Consolidated Health Record (CHR) and/or

CPRS.

a. All Gulf War Registry (GWR) worksheet data are required to be entered into the GWR

database located at the Corporate Franchise Data (CFD) Center on the Environmental Agents

Blank registry worksheets are available on this web site and a User’s Guide with a Table of

Contents provides instructions on:

(1) How to Get Access to EAS Registries,

(2) EAS Registries Logon,

(3) Main Page,

(4) Patients,

(5) Exams,

(6) Agent Orange Exam,

(7) Depleted Uranium Exam,

(8) Gulf War Exam,

(9) Gulf War Phase II,

(10) Ionizing Radiation,

(11) Reports,

(12) Appendix A, Sample 9957 for EAS Coordinator,

(13) Appendix B, Sample 9957 for EAS Coder,

(14) Appendix C, Sample 9957 for EAS Clinician, and

(15) Appendix D, Sample 9957 for EAS Depleted Uranium Follow-up Sample Worksheets.

registry entry instructions carefully to ensure that all data fields are accurately completed. Edits

completed registry worksheet must be maintained in the administrative health record or scanned

and attached to an appropriately titled Computerized Patient Record System (CPRS) progress

note.

c. Part 1 of the worksheet may be completed in the presence of the veteran.

d. Parts 2 and 3 of the worksheet need to be completed at the time of the examination by the

Environmental Health (EH) or Primary Care Clinician and coded by appropriate staff, either the

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 and/or Operation Iraqi Freedom (OIF).

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 as a result of 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 area, the 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. VA’s

Environmental Agents Service (EAS) periodically publishes a newsletter entitled "Gulf War

Review." A copy of the current "Review" is enclosed for your reference. If you would like to

view or print this newsletter, you should visit the EAS web site at:

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 health care services to them for a 2-year period

following separation from military service for conditions possibly related to their combat

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

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 as a result of military service. The

condition does not have to be related to combat.

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 or Operation Iraqi Freedom. VA’s

Environmental Agents Service (EAS) periodically publishes a newsletter entitled "Gulf War

Review." A copy of the current "Review" is enclosed for your reference. If you would like to

view or print this newsletter, you should visit the EAS web site at:

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 health care services to them for a 2-year period

following separation from military service for conditions possibly related to their combat

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

Even though the following base-line studies were completed during the Phase I-level

laboratory evaluations, they must be repeated at this time.

a. Complete Blood Count (CBC);

b. Comprehensive metabolic panel or blood chemistries and enzyme studies; and

c. Urinalysis.

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.

(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,

(13) Urinalysis, and

(14) Tuberculosis (TB) skin test Purified Protein Derivative (PPD).

(1) Dental, but only if participant’s annual screening is not done.

(2) Infectious Disease.

(3) Psychiatry, but only with physician-administered instruments as:

(a) Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental

(b) Clinician Administered Post-Traumatic Stress Disorder (PTSD) Scale (CAPS).

(4) Neuropsychological testing, but only as indicated by a psychiatry consult.

have the listed minimum work-up.

(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.

(a) GI consult,

(b) EGD with biopsy and aspiration,

(c) Colonoscopy with biopsy,

(d) Abdominal Ultrasound,

(e) Upper Gastrointestinal (UGI) series with small bowel follow-through, and

(f) Abdominal Computed Tomography (CT) Scan.

(a) Magnetic Resonance Imaging (MRI) of the head.

(b) Lumbar Puncture (LP) to include:

1. Glucose,

2. Protein,

3. Cell Count,

4. Venereal Disease Research Laboratory (VDRL),

5. Oligoclonal (lgG),

6. Myelin basic protein,

7. Opening pressure, and

8. Neurology.

(a) Electromyogram (EMG), and

(b) Nerve Conduction Velocity (NCV).

(a) MRI.

(c) Neurology consult.

(d) Neuro-psychological testing.

(a) Audiogram,

(b) Electronystamogram (ENG), and

(c) Brainstem Auditory Evoked Response (BAER).

(a) Polysomnography, and

(b) Multiple Sleep Latency Test (MSLT).

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.

(a) Electrocardiogram (ECG),

(b) Exercise Stress Test, and

(c) Holter monitor.

(a) Dermatology consult, and

(b) Consider a biopsy.

(a) Males, a urology consult.

(b) Females, a gynecology (GYN) consult.

(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, including:

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, and

k Prior surgery.

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 infection.

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 (GW) veterans with complaints of

infertility.

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.

a. The Phase II examination needs to be offered to all eligible Gulf War (GW) (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

clinically-based 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-

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.