BVA9504629 DOCKET NO. 93-13 312 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder, currently rated at 30 percent. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and a friend ATTORNEY FOR THE BOARD C. M. Flatley, Counsel INTRODUCTION The veteran had active service from August 1969 to June 1971. REMAND Review of the record indicates that the veteran has submitted a well-grounded claim. 38 U.S.C.A. § 5107(a). The Department of Veterans Affairs (VA) therefore has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet.App. 78, 81-82 (1990). In this regard, we note that the veteran has alleged that his most recent VA examination was inadequate. The record also indicates that the veteran continues to receive outpatient psychiatric treatment. Further, documents attached to a September 1993 letter from the veteran's representative indicate that the veteran is in receipt of disability benefits from the Social Security Administration. In addition, at the veteran's personal hearing before the Board of Veterans' Appeals (Board), his representative requested consideration of the veteran's post-traumatic stress disorder in accordance with the provisions of 38 C.F.R. § 4.16(c) (1993). His allegations included reference to both an increased schedular evaluation and unemployability; it appears that the veteran wishes to pursue a claim of a total rating on the basis of individual unemployability. Upon review of the record, the Board is of the opinion that additional action may prove helpful in evaluation of the veteran's claim. In order to fully assist the veteran in the development of his case, and extend to the veteran every equitable consideration, we conclude that additional development is warranted. This case is therefore REMANDED for the following: 1. After any necessary information and authorization are obtained from the veteran, duplicates of records of any post July 1993 treatment, VA or private, inpatient or outpatient, associated with the veteran's post-traumatic stress disorder should be obtained by the regional office (RO) and incorporated into the claims folder. 2. The RO should obtain from the Social Security Administration the records upon which the veteran's disability determination was based. Any records obtained should be associated with the veteran's claims folder. 3. The RO should ascertain the circumstances of the veteran's job termination (as a paramedic) in November 1991. If this can be accomplished by correspondence, that should suffice; if not, a field survey should be conducted for this purpose. 4. A special VA psychiatric examination should be arranged to determine the current severity of the veteran's service-connected post-traumatic stress disorder. The examination should be conducted in accordance with Chapter 1, Section II, paragraphs 1.12 and 1.13 and Chapter 14, Sections I and II of the VA's Physician's Guide for Disability Evaluation Examinations. All indicated studies should be conducted. The examination report should include a detailed description of the veteran's symptoms, clinical findings, and associated functional impairment; all indicated studies should be done. The examiner should identify the level of functional impairment associated with the veteran's service- connected post-traumatic stress disorder in accordance with the "Global Assessment of Functioning Scale" found in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. The examiner should explain the meaning of the numerical score assigned. The presence of any psychiatric disorders other than the veteran's service-connected post-traumatic stress disorder should be identified; any interrelationship between such disorder and the veteran's post-traumatic stress disorder and, if possible, the degree of impairment associated with each, should be discussed. A comprehensive report, which includes the examiner's conclusions and the foundation upon which they are based, should be provided and associated with the veteran's claims folder. The veteran's claims folder (including all data obtained pursuant to the requests above) must be available to and reviewed by the examiner prior to the examination. 5. The RO should then review the veteran's claim and should also address the claim of entitlement to a total rating on the basis of individual unemployability under the applicable provisions of 38 C.F.R. § 4.16. Any additional pertinent law, regulations, and United States Court of Veterans Appeals (Court) decisions should be considered, including Schafrath v. Derwinski, 1 Vet.App. 589 (1991). If the veteran's claim remains denied, he and his representative should be provided with a supplemental statement of the case, which includes any additional pertinent law and regulations and a full discussion of action taken on the claim, consistent with the Court's instruction in Gilbert v. Derwinski, 1 Vet.App. 49 (1990). Reasonable response time should be allowed. The case should then be returned to the Board, if in order, for further appellate review. No action is required of the veteran until he is notified. The Board intimates no opinion as to the ultimate decision warranted in this case. GEORGE R. SENYK 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. (CONTINUED ON NEXT PAGE) 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 remand 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) (1994).