BVA9502705 DOCKET NO. 93-10 484 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The veteran had active service from August 1970 to August 1971. He served in Vietnam as a light truck driver with the 585th Transportation Company, United States Army, from January 1971 to July 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which denied service connection for post-traumatic stress disorder (PTSD). The RO's attention is directed to the veteran's claim for pension benefits which has not yet been developed or adjudicated. REMAND The veteran was hospitalized at the VA Medical Center, Brecksville, Ohio, from February 8, 1993, to March 15, 1993. The claims folder does not contain any medical records pertaining to this period of hospitalization. In April 1993, the RO ordered general medical and psychiatric examinations for the veteran. Records of these examinations have not been added to the claims folder. A review of the evidence of record discloses that the veteran was discharged from service because of an emotionally unstable character disorder, manifested by low frustration tolerance, poor judgment, impulsivity, immaturity, and drug abuse. The stress was reported as "routine military duty, reinforced by being in Vietnam." Elaboration was not provided. In his initial claim for disability benefits which was received in August 1974, he referred to having received treatment for nervousness in January 1971 at Camp Vandergrift in Vietnam. He also stated he received treatment for nervousness in July 1971 at the Valley Forge Army Hospital in Pennsylvania. Service personnel records reflect that the veteran was hospitalized in June 1971 prior to his return from Vietnam and that he was then hospitalized at Valley Forge, Pennsylvania during July 1971. No records from these facilities are in the claims folder. Also not in the claims folder are records from Alex Tokarevich, M.D., who in a March 1979 statement related that he had treated the veteran from December 1973 and that he strongly believed that the veteran's illness had originated or been severely aggravated by his military experience in Vietnam. The record further reflects that the veteran was hospitalized on more than one occasion at Windsor Hospital during the period from 1973 to 1979, and that no records have been obtained from this facility. Additionally, no records have been obtained pertaining to indicated periods of hospitalization in December 1985 (with an admission diagnosis of undifferentiated schizophrenia and a history of alcohol abuse) and in April 1986 (with an admission diagnosis of substance abuse and a multiborderline personality disorder) at the VA Medical Center in Brecksville, Ohio. Also, the Board notes that the veteran has provided no specific details regarding any stressful events he may have experienced while serving in Vietnam. Additional development in this area is desirable. The veteran's principal duty assignment while in Vietnam was as a light truck driver with the 585th Transportation Company. He has claimed that he saw limited combat action and experienced "all the stress and terror 'normally' associated with the said conditions." However, he has given no elaboration or detail regarding any stressful event or events. In light of the above discussion, the Board finds that the appellant should be provided the opportunity to submit additional evidence and VA should fulfill its duty to assist the veteran in the development of facts pertinent to his claim. Therefore, the case is REMANDED to the RO for the following actions: 1. The RO should attempt to obtain and associate with the file additional service medical records, particularly any records relating to medical treatment at Camp Vandergrift in Vietnam and treatment at the Valley Forge Army Hospital in Valley Forge, Pennsylvania, in July 1971. 2. The RO should obtain and associate with the claims file records from the Windsor Hospital and from Dr. Tokarevich, as well as all inpatient and outpatient records regarding treatment and evaluation of the veteran at the VA Medical Center in Brecksville, Ohio, particularly reported periods of hospitalization in 1985, 1986, and 1993. Additionally, the RO should associate with the claims folder the results of the general medical and psychiatric examinations which were ordered in April 1993. 3. The RO should request from the veteran a statement containing as much detail as possible regarding the alleged stressful event or events to which he was exposed in service. The veteran should be asked to provide specific details of the claimed stressful events during service, such as dates, places, detailed descriptions of the events, and any other identifying informa- tion concerning any individuals involved in the events. He should be told that the information is necessary to obtain supportive evidence of the stressful event or events and that failure to respond may result in adverse action. 4. If the veteran provides details of stressful events which are subject to verification, the RO should attempt to obtain corroborating data to support the stressful events alleged by the veteran. 5. Following the above, the RO must make a specific determination, based upon the complete record, with respect to whether the appellant was exposed to a stressor or stressors in service, and if so, what was the nature of the specific stressor or stressors. The RO must specifically render a finding as to whether the appellant "engaged in combat with the enemy." 6. If, and only if, the RO determines that the record establishes the existence of a stressor or stressors, then the RO should arrange for the appellant to be accorded a psychiatric examination to determine the diagnoses of all psychiatric disorders that are present. The RO must specify for the examiners the stressor or stressors that it has determined are established by the record. The examiner must determine whether exposure to a stressor in service has resulted in current psychiatric symptoms and whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. The claims folder must be made available to the examiner prior to the examination. The examiner should review pertinent material in the claims folder and integrate the previous psychiatric findings and diagnoses with current findings to obtain a true picture of the nature of the appellant's psychiatric status. If the diagnosis of PTSD is deemed appropriate, the examiner should comment upon the link between the current symptomatology and one or more of the inservice stressors found to be established by the RO. Psychological testing deemed necessary should be accomplished. 7. The RO should then review the record and ensure that all the above actions have been completed. When the RO is satisfied that the record is complete, the claim should be readjudicated. If the benefit sought is not granted to the veteran's satisfaction, he and his representative should be provided with a supplemental statement of the case and be given the applicable period of time in which to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. No action is required of the veteran until he receives further notice. The Board does not intimate any factual or legal conclusions as to the ultimate outcome warranted in the appeal. GARY L. GICK Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a deter- mination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).