BVA9502706 DOCKET NO. 91-50 849 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. D. Regan, Associate Counsel REMAND The veteran had active service from October 1961 to November 1974. This matter came before the Board of Veterans' Appeals (hereinafter "the Board") on appeal from an April 1990 rating decision of the Newark, New Jersey Regional Office (hereinafter "the RO") which confirmed and continued a 10 percent disability evaluation for the veteran's post-traumatic stress disorder. In April 1992, the Board remanded this appeal to the RO so that additional treatment records could be obtained from the VA Medical Center in East Orange, New Jersey and so that the veteran could be afforded an additional Department of Veterans Affairs (hereinafter "VA") psychiatric evaluation. The veteran has been represented throughout this appeal by the Disabled American Veterans. The veteran asserts on appeal that the RO erred in denying an increased evaluation for his post-traumatic stress disorder. In reviewing the record, the Board notes that the April 1992 remand instructions requested that the RO obtain treatment records from the VA Medical Center in East Orange, New Jersey including clinical records pertaining to the veteran's hospitalization in November 1990, a report of psychological testing conducted in March 1991 and updated counseling records. The veteran was also to be afforded an additional VA psychiatric examination. The RO received the November 1990 discharge summary of the veteran's hospitalization as well as an undated clinical record and a November 1990 electrocardiographic record. No reports of psychological testing were included nor were any daily progress notes or counseling reports. In June 1994, the indicated VA medical center notified the RO that all available records pertaining to psychological testing had been sent to the RO and that no other records were available. Further, it is observed that the veteran failed to appear for the VA psychiatric examination. The Board notes that in June 1993, the veteran submitted a direct deposit form which indicated a new address of 71 Union Street, Jersey City, New Jersey. The previous address of record was c/o A. Taylor, 391 Forest Street, Apartment 6, Jersey City, New Jersey. The notice of the VA examination was forwarded to the new address in June 1994. However, the August 1994 supplemental statement of the case and a June 1993 request to the veteran to assist in obtaining treatment records were sent to the previous address. The Board notes that the provisions of 38 C.F.R. § 19.31 (1993) require that a supplemental statement of the case be furnished to the appellant and his or her accredited representative when additional pertinent evidence is received after a statement of the case or most recent supplemental statement of the case has been issued. Given these facts, the Board finds that additional development of the record is necessary. An additional attempt should be made to obtain any available recent VA treatment records pertaining to the veteran's service-connected psychiatric disorder. Also, a VA psychiatric examination should be scheduled, preceded by a VA social and industrial survey. The Board also observes that the veteran has advanced contentions on appeal which the Board has construed as a claim for an increased evaluation for his left leg disorder. The RO should formally adjudicate this issue. In light of the VA's duty to assist the veteran in the proper development of his claim as mandated by the provisions of 38 U.S.C.A. § 5107(b) (West 1991) and as interpreted by the United States Court of Veterans Appeals (hereinafter "the Court") in Littke v. Derwinski, 1 Vet.App. 90, 92-93 (1990), this case is REMANDED for the following action: 1. The RO should contact the veteran through his accredited representative and request that he provide information as to the VA medical facilities at which he received treatment pertaining to his service-connected psychiatric disorder from January 1989 to the present. Upon receipt of the requested information, the RO should contact the identified facilities, including the VA Medical Center, East Orange, New Jersey and/or the Veteran's Center in Jersey City, New Jersey and request that all available clinical documentation be forwarded for incorporation into the record. 2. A social and industrial survey by a VA social worker for purposes of developing information pertaining to the veteran's social and industrial adaptability. Information regarding the veteran's educational level and past employment should be sought. The social worker is requested to furnish an opinion regarding the extent to which impairment is shown to be attributable to post traumatic stress disorder. 3. The RO should then schedule the veteran for a VA psychiatric examination to determine the present extent and severity of his service-connected psychiatric disorder. The examiner should describe the impairing effects of the veteran's psychopathology upon his ordinary activities. A Global Assessment of Functioning (GAF) score should also be assigned. The examiner is also requested to render an opinion as to whether or not the veteran's alcohol abuse, if existent, is a manifestation of his post-traumatic stress disorder. This study should be conducted in accordance with the Physician's Guide for Disability Evaluation Examinations. All indicated tests and studies should be accomplished and reported in detail. The claims folder should be made available to the examiner prior to the examination. 4. The RO should formally adjudicate the veteran's entitlement to an increased evaluation for his service-connected left leg disorder. 5. Following completion of the above and following any additional development deemed necessary, the RO should prepare and issue to the veteran at 71 Union Street, Jersey City, New Jersey, or at his latest address of record if changed since June 1993, a supplemental statement of the case which addresses all issues for which a timely notice of disagreement has been received. When the requested action has been completed, and if his claim continues to be denied, the veteran should be afforded a reasonable period of time in which to respond to a supplemental statement of the case. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration if appropriate. The veteran need not take any action unless he is further informed. The purpose of this REMAND is to allow for further development of the record. No inference should be drawn from it regarding the final disposition of the veteran's claim. While regretting the delay involved in again remanding this case, this action is being taken to comply with continually evolving Court doctrine. JEFF MARTIN 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 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) (1993).