BVA9504568 DOCKET NO. 93-13 610 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, claimed as post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for residuals of a low back injury, including arthritis of the spine. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Richard E. Coppola, Associate Counsel INTRODUCTION The veteran had active service from April 1969 to November 1970. This matter came before the Board of Veterans' Appeals (Board) on appeal from a rating decision of December 1991 from the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for a nervous disorder characterized as situational depression, and residuals of a low back injury, including arthritis of the spine. It is clear from the evidence submitted subsequent to that rating decision that the veteran is seeking service connection for PTSD. REMAND In several statements the veteran described an incident that occurred while stationed at Duc Pho in the Republic of Vietnam which he claims is the stressful event precipitating PTSD. He indicated that this occurred at "Landing Zone Bronco" on the side of a mountain known as "Montezuma." He alleges that while climbing a hill to reach the base camp's defense and electronic equipment, the soldier behind him stepped off the trail and onto a land mine. He claims that the soldier, who was of Indian ethnicity and was from Oklahoma, was killed in that incident. He alleges that another soldier was severely wounded and may have also died. He claims that he was thrown from the hill by the impact of that explosion and injured his back at that time. He indicated that the name of his sergeant who was present at the time of that incident was named "Poole." It does not appear that the RO attempted to verify the veteran's reported stressful event through the United States Army and Joint Services Environmental Support Group (ESG). The veteran's service records indicated that the veteran served as a rifleman with Company A, 4th Battalion, 3rd Infantry, 11th Brigade, from September 28, 1969 to October 9, 1969. He served as a light truck driver with HHC 11th Infantry Brigade, from October 10, 1969 to May 30, 1970, and as a wireman with HHC 11th Brigade, from May 30, 1970 to November 1, 1970. The records show that he was awarded the Army Commendation Medal (ARCOM) and the Bronze Star Medal (BSM), but they do not indicate that these awards were issued as a result of combat exposure. In his application for disability compensation, the veteran reported that he had received post-service treatment for his psychiatric disorder and residual back disability from 1977 to the present at the VA Medical Center, Gainesville, Florida. It does not appear that the RO requested copies of any available treatment records from that facility. The Board notes that the claims folder does contain an August 1980 report of VA hospitalization showing treatment by lumbar puncture and drainage of a left antecubital abscess. That report indicates a five year history of head trauma secondary to an automobile accident and the diagnoses included situational depression. The evidence in the claims folder indicates that the veteran was scheduled for a VA compensation examination for the claimed PTSD in June 1992. In a May 1991 letter to the RO, the veteran reported his new address. Although notice was sent to the veteran prior to the examination, the notice shows that the RO sent it to his previous address. It appears that a VA examination was rescheduled in September 1992; however, the claims folder does not contain evidence that the RO provided to the veteran notice of that examination. In October 1992, the RO denied service connection for PTSD. The RO cited the veteran's failure to report for the scheduled VA examination as the basis of that denial. 38 C.F.R. § 3.655 (1993). In a recent statement, the veteran indicated that he had been confused and unaware that he had missed a scheduled examination. Additionally, he indicated that he had undergone a psychiatric evaluation at the VA during that time. This also was not requested by the RO. The United States Court of Veterans Appeals (Court) has indicated that service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by the medical evidence, between current symptomatology and the claimed in-service stressor. See Zarycki v. Brown, 6 Vet.App. 91, 97 (1993). The Court also held that in addition to demonstrating the existence of a stressor, the facts must also establish that the alleged stressful event was sufficient to give rise to PTSD. Id. at 98- 99. In West v. Brown, 7 Vet.App. 70, 79 (1994), the Court held that the sufficiency of the stressor is a medical determination and may not be adjudicated in the absence of independent medical evidence. Under the present circumstances, the Board finds that additional development of the evidence is necessary. Accordingly, the case is REMANDED for the following actions: 1. The veteran should identify the names and addresses of any medical care providers, VA or otherwise, who have treated him for a psychiatric disorder and residuals of a back injury since separation from active duty. The veteran reported that he had received post-service treatment for his psychiatric disorder and residual back disability from 1977 to the present at the VA Medical Center, Gainesville, Florida. The veteran also indicated that he had recently undergone a psychiatric evaluation at the VA. After obtaining any needed authorization from the veteran, the RO should obtain copies of all these records. 2. The veteran should be requested to provide more specific information, if possible, regarding the stressors he allegedly experienced while in Vietnam, including the specific dates and locations for each event, the unit to which he was assigned at the time of each event, the names and units of persons he witnessed being wounded or killed, and the dates, places and circumstances of the deaths or injuries. The veteran is advised that this information is necessary in order to obtain supportive evidence of the stressful events and that he must be as specific as possible because without such details an adequate search for verifying information cannot properly be conducted. The alleged stressful events are generally set forth in the notice of disagreement and the substantive appeal. 3. The RO should then review the veteran's list of stressors and the evidence in the claims folder and prepare a summary of all claimed stressors. This summary, together with a copy of the veteran's DD Form 214 and service personnel records and a copy of this remand, should be referred to the United States Army and Joint Services Environmental Support Group (ESG) 7798 Cisna Road, Springfield, Virginia 22050. ESG should be asked to verify the claimed stressors, or certify that the claimed stressors cannot be verified. Also, any unit histories or similar documents pertaining to the veteran's units should be requested. Any records or information obtained must be made part of the claims folder. 4. If, and only if, the RO determines that the additional evidence corroborates the existence of a stressor(s), the veteran should then be afforded a VA psychiatric examination and evaluation to determine whether PTSD is present. The RO must specify for the physician the stressor(s) it has determined are corroborated by the evidence of record and instruct the physician that only those events may be considered for the purpose of determining whether exposure to a stressor in service has resulted in current psychiatric symptoms and, whether the diagnostic criteria to support a diagnosis of PTSD have been satisfied. The examination should be conducted in accordance with the Physician's Guide for Disability Evaluation Examinations, and should include all appropriate tests and evaluations, including psychological testing with PTSD subscales. The physician should utilize the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (3d ed. rev. 1987), in arriving at diagnoses, enumerating the specific diagnostic criteria satisfied and the specific findings meeting the criteria for any disorder found. If PTSD is diagnosed, the stressors supporting the diagnosis must be identified as must be the evidence documenting the stressors The claims folder, including a copy of this remand decision, MUST be made available for review by the physician prior to the examination and evaluation. 5. The RO should then review the record and ensure that all the above actions have been requested or completed. After reviewing the case, the RO should provide the veteran and his representative with a supplemental statement of the case which summarizes the pertinent evidence, fully cites the applicable legal provisions not previously provided, including 38 C.F.R. § 3.304 (f) (1993), and reflects detailed reasons and bases for the decision. The parties should then be afforded the applicable time period to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. Further action with respect to the claim for service connection for a low back disability is deferred pending completion of the requested development. CHARLES E. HOGEBOOM 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 determination. 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).