BVA9501219 DOCKET NO. 93-09 661 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to an increased evaluation for schizophrenia, undifferentiated type, currently rated as 70 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Auer, Counsel REMAND The veteran served on active duty from January 1988 to February 1989. This appeal arises from an August 1991 rating decision of the Department of Veterans Affairs (VA), Pittsburgh, Pennsylvania, Regional Office (RO). In January 1991 the veteran submitted an application for increased compensation based on unemployability. On VA Form 21- 8940 and on VA Form 21-4138, both dated in January 1991, the veteran related that a VA medical facility had referred him to the Beaver County Rehabilitation Center, Beaver Falls, but that he had to discontinue work after only two days in December 1990 because of psychiatric symptoms. Applications for VA vocational rehabilitation (Chapter 31) are in the claims folder. No records from the Beaver County Rehabilitation Center are of record. Likewise, there is nothing in the claims folder to indicate the disposition of the veteran's application for VA vocational rehabilitation. Additionally, the veteran reported at a July 1992 hearing and at a September 1992 VA examination that he was in receipt of disability benefits from the Social Security Administration (SSA). No records from the SSA are of record. The veteran's claim was received at the Board of Veterans' Appeals (Board) in May 1993. Since that time, additional evidence in the form of a VA hospital report has been received. This additional evidence was received without a waiver of the veteran's right to have that evidence initially considered by the RO. Any pertinent evidence submitted by the veteran or representative that is accepted by the Board must be referred to the RO for review and preparation of a supplemental statement of the case, unless this procedural right is waived by the appellant. See 38 C.F.R. § 20.1304(c) (1993). In a statement dated in April 1993, the veteran's representative reported that the veteran had had two hospital admission for his service-connected psychiatric disorder in 1993 and that these records, as well as out-patient treatment records should be added to the records assembled for appellate review. The VA hospital report, dated in March 1994, also indicates that the veteran had been hospitalized in 1993. No medical records for 1993 are contained in the claims file. At the time of the September 1992 examination, it was noted that the veteran had not worked successfully since his discharge from the service. While a Global Assessment of Function Scale (GAF Scale) code of 60 (indicating the presence of moderate symptoms) was given on the September 1992 examination, a GAF code of 25 (indicating deterioration of the veteran's functioning) was reported on the March 1994 hospital records. However, the March 1994 VA hospital records indicate that the veteran was working and taking two classes at a Community College. In view of the above, the Board finds that further development is warranted before a final decision in this appeal. Accordingly, the claim is REMANDED for the following actions: 1. The RO should contact the veteran and ask him to furnish the names and addresses of all private medical personnel and facilities from whom he has received treatment for the disability at issue since September 1992. After obtaining the necessary authorization from the veteran, the RO should obtain available records from the named sources. 2. The RO should obtain any available treatment records from the VA hospitals or medical centers where the veteran has received treatment since September 1992. Care should be taken by the RO so that duplicate records are not placed in the claims file. 3. The RO should obtain from the SSA a copy of any disability determination it has made for the veteran and copies of the medical records upon which any such determination was made. 4. The RO should obtain from the Beaver County Rehabilitation Center, Beaver Falls, copies of all records of the veteran's attempt at rehabilitation training at that facility. Additionally, the RO should obtain and associate with the claims folder any VA vocational rehabilitation folder or counseling folder which may have been created in response to the veteran's application for VA vocational rehabilitation. 5. A VA social and industrial survey should be conducted in order to clarify the veteran's medical, social, educational, and employment history. The social worker should elicit and set forth pertinent facts regarding the veteran's medical history, education, employment history, social adjustment, and current behavior and health. The social worker should offer an assessment of the veteran's current functioning and identify the conditions which limit his employment opportunities. Any potential employment opportunities should be identified. The claims folders must be made available to the social worker in conjunction with the survey as it contains important historical data. 6. Following completion of the above development, the veteran should be accorded a VA psychiatric examination to determine the severity of the service-connected psychiatric disorder. The claims folder must be made available to the examiner prior to the evaluation so that the examiner may review the pertinent historical data contained therein. The examiner should utilize the social work service report as well as pertinent data in the claims folder in order to obtain a true picture of the progress of the veteran's psychiatric disorder. The psychiatrist should utilize any psychological testing deemed pertinent in making a complete diagnostic evaluation. Based upon a review of the record and the examination, the physician should provide a Global Assessment of Functioning (GAF) scale code and discuss the nature and meaning of the GAF scale. In addition, the examiner should also discuss the veteran's ability to perform substantially gainful employment and the factors attributable to the service- connected psychiatric disorder which limit his employment opportunities. 7. After the above actions have been completed, the case should again be reviewed by the RO. The rating decision should reflect consideration of 38 C.F.R. §§ 3.321(b)(1) and 4.16(c). If his claim remains denied, the veteran and his representative should be provided with a supplemental statement of the case that includes any additional pertinent law and regulations and a full discussion of the evidence in his case. The appropriate response time should be allowed. The case should then be returned to the Board, if in order, after compliance with all regulatory appellate procedures. 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).