BVA9500045 DOCKET NO. 92-53 094 ) DATE ) RECONSIDERATION ) ) On appeal from the decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUE Entitlement to a total rating for compensation purposes based on individual unemployability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD W. Pope, Counsel INTRODUCTION The veteran had active service from May 1969 to January 1972, and from August 1974 to July 1975. Service connection has been established for a disability described as "cerebral concussion with organic brain syndrome also diagnosed as post-traumatic stress disorder," evaluated as 30 percent disabling; impairment of the right upper extremity secondary to cerebral trauma, evaluated as 20 percent disabling; impairment of the right lower extremity secondary to cerebral trauma, evaluated as 10 percent disabling; mild expressive dysphasia secondary to cerebral trauma, evaluated as 10 percent disabling; and spurring and disc space narrowing at the level of the fifth and sixth cervical vertebrae secondary to cerebral trauma, evaluated as 10 percent disabling. The combined disability rating is 60 percent, including the bilateral factor for the right upper and right lower extremities. This matter originally came to the Board of Veterans' Appeals (Board) on appeal from a January 1991 rating decision. The Board entered a decision in this case on July 29, 1992. A motion for reconsideration of that decision was filed with the Board in September 1992. In March 1993 reconsideration of the decision was ordered by the authority granted to the Chairman in 38 U.S.C.A. § 7103 (West 1991), and the case is now before an expanded reconsideration section of the Board. The decision by the reconsideration section will replace the decision of July 29, 1992. In a September 1994 written presentation, the veteran's representative raised the issues of increased schedular evaluations for cerebral concussion with organic brain syndrome, also diagnosed as post-traumatic stress disorder; and impairment of the right upper extremity secondary to cerebral trauma. These matters are referred to the RO for action deemed appropriate. REMAND The veteran and his representative contend that his service- connected disabilities are productive of impairment which prevent him from obtaining and maintaining gainful employment. It is asserted that his medications including Prozac and Thorazine impair his ability to function properly and that the evidence of record indicates that he could only work within a "sheltered" environment. A review of the veteran's claims file discloses that following his retirement from the United States Post Office in 1987 he enrolled in a VA vocational rehabilitation training program at Methodist College and has been pursuing a Bachelor of Science Degree in Business Administration. The Board believes that the records of his vocational rehabilitation training, which are not of record, would be beneficial in evaluation of his claim. A review of the claims file also discloses that none of the veteran's service-connected disabilities has been evaluated to include a "full description of the effects of disability" upon his ordinary activities as required under 38 C.F.R. § 4.10 (1993). In this regard, the United States Court of Veterans Appeals has pointed out that VA's duty to assist under 38 U.S.C.A. § 5107 (West 1991) includes the conduct of a thorough and contemporaneous examination which considers the "disability 'from the point of view of the veteran working or seeking work.' 38 C.F.R. § 4.2" (1993) Schafrath v. Derwinski, 1 Vet.App. 589, 595 (1991). In view of the foregoing, this case is REMANDED to the RO for the following: 1. The RO should take appropriate steps to obtain from the United States Post Office copies of the records pertinent to the veteran's retirement in September 1987, including the specific reasons for such retirement and related medical documents, if any. 2. The RO should contact the veteran to clarify his employment status since October 1990. If he has had and then left a job since that time, the RO should take appropriate steps to obtain a statement from the employer as to the reason the veteran is no longer employed in that position. 3. The RO should take appropriate steps to obtain from the Social Security Administration copies of the records pertinent to any claim the veteran has made for disability benefits from that agency, as well as copies of the medical records relied upon concerning such claim. 4. The RO should take appropriate steps to obtain the veteran's VA vocational rehabilitation training program folder and associate it with his claims file. 5. The RO should take appropriate steps to obtain the names and addresses of all medical care providers who have treated the veteran for his service-connected disabilities since 1989, including all VA facilities. After securing any necessary releases, the RO should obtain copies of the records from the identified sources. 6. The veteran should be afforded a VA social and industrial survey to assess his employment history and day-to-day functioning. A written copy of the report should be inserted into the claims file. 7. The veteran should be afforded a VA psychiatric examination to evaluate the current extent of his service connected disability described as "cerebral concussion with organic brain syndrome also diagnosed as post-traumatic stress disorder." The claims file, including a copy of this REMAND, should be made available to the examiner before the examination, for proper review of the medical history. All indicated tests should be conducted. The examiner should provide an opinion as to the effects of the veteran's medications with regard to his ability to perform employment tasks. The examination report should include a full diagnostic assessment, including a Global Assessment of Functioning (GAF) score on Axis V, with an explanation of the significance of the currently considered levels of psychological, social and occupational functioning which support the score. 8. The veteran should be afforded VA examinations by appropriate specialists in rehabilitative medicine in order to evaluate the current extent of his service-connected impairment of the right upper extremity, right lower extremity, cervical spine, and his impairment due to mild expressive dysphasia, and their overall effect on his ability to work at substantially gainful employment. The claims file, including a copy of this REMAND, should be made available to each examiner prior to the examination, for proper review of the medical history. Any indicated tests should be conducted. A medical opinion should be provided with regard to the effect each of the veteran's service-connected disabilities has on his ability to work. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. VICKY L. JORDAN JANE E. SHARP BARBARA B. COPELAND WILLIAM J. REDDY JOHN E. ORMOND M. SABULSKY 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).