Citation Nr: 0002199 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 96-16 131 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to service connection for post traumatic stress disorder (PTSD). 2. Entitlement to service connection for a psychiatric disability, other than PTSD. 3. Entitlement to a compensable rating for skin disability (diagnosed as tinea versicolor). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Ferrandino, Associate Counsel INTRODUCTION The veteran had active service from February 1991 to March 1995. The veteran filed a claim in May 1995 for service connection for PTSD. This appeal arises from the January 1996 rating decision from the Manchester, New Hampshire Regional Office (RO) that denied the veteran's claim for service connection for PTSD. A Notice of Disagreement was filed in February 1996 and a Statement of the Case was issued in February 1996. A substantive appeal was filed in April 1996 with a request for a hearing before a VA hearing officer. The veteran filed a claim in April 1995 for service connection for a skin disability. This appeal arises from the January 1996 rating decision from the Manchester, New Hampshire RO that granted service connection for tinea versicolor and assigned a noncompensable evaluation. A Notice of Disagreement was filed in April 1996 and a Statement of the Case was issued in May 1996. A substantive appeal was filed in June 1996 with a request for a hearing before a local hearing officer. Additionally, in June 1996, a request for a hearing at the RO before a Member of the Board was filed. In August 1996 a hearing at the RO before a local hearing officer was held. This appeal additionally arises from a June 1999 rating decision from the Manchester, New Hampshire RO that denied service connection for cyclothymic disorder or any nervous disorder. A Notice of Disagreement was filed in June 1999 and a Statement of the Case was issued in August 1999. A substantive appeal was filed in August 1999 with no hearing requested. In writing in January 2000, the veteran indicated that she no longer wanted a hearing. FINDINGS OF FACT 1. The claim for service connection for PTSD is plausible. 2. There is no competent medical evidence linking any currently existing psychiatric disability, other than PTSD, to the veteran's military service; the claim is not plausible. 3. The veteran's claim for a compensable rating for tinea versicolor is plausible. 4. The manifestations of the veteran's tinea versicolor do not demonstrate exfoliation, exudation, or itching of an exposed surface or extensive area. CONCLUSIONS OF LAW 1. The veteran has stated a well-grounded claim for service connection for PTSD. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim of entitlement to service connection for a psychiatric disability, other than PTSD, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The criteria for the assignment of a compensable rating for tinea versicolor have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.118, Diagnostic Codes 7806, 7899 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background On a service enlistment examination in April 1990, no history of nervous trouble was reported. The veteran reported that she had acne. On examination, the veteran's psyche and skin were clinically evaluated as normal; it was noted that the veteran had mild acne of the face and upper torso, not considered disabling. In March 1992, the veteran was seen for psychiatric testing. She was referred for a command directed evaluation; no significant mental health problems were identified. The assessment included mild phase of life problem and mild occupational problem. In July 1992, it was noted that the command directed evaluation at the mental health clinic was completed. The assessment included Axis I: occupational problem and Axis II: dependent, avoidant traits. On a dental patient medical history form in August 1994, it was noted that the veteran was taking antidepressant medication for sleep. On a dental patient medical history form in November 1994, the veteran reported that she was taking antidepressant medication to help her sleep. In February 1995, the veteran was evaluated by the mental health clinic for a Medical Board discharge. The veteran was going to be discharged for low back pain. The assessment included phase of life problem due to chronic low back pain and right knee pain. Other diagnoses were deferred. A mental health clinic evaluation from later in February 1995 includes an assessment of moderate sleep disorder, insomnia type, due to chronic low back pain and right knee pain; and phase of life problem due to chronic low back problem, right knee pain and resulting disability. On a separation examination in February 1995, no history of nervous trouble or skin disease was reported. On examination, the veteran's psyche was clinically evaluated as normal. In May 1995, the veteran filed a claim for service connection for PTSD or neuropsychiatric disability. On a VA examination for PTSD in May 1995, it was noted that the veteran's claim file was not available for review. The veteran reported that in the service in May 1992, she went to Cuba for the Joint Task Force on the Haitian refugee situation. She worked in food services, feeding the armed services and the refugees. Additionally, she was on a search and recovery crew and recovered wounded and deceased refugees along the shore line. Her most stressful experience was when she fell off a cliff and sustained neck, back, hip, and leg injuries. As well, she found a dead body along the shore, but did not report it. The assessment was that the veteran appeared to fulfill the criteria for PTSD secondary to the events that she witnessed while serving in the military on the Joint Task Force in Cuba. In addition, the physical injuries that she sustained had a secondary relationship in that once she experienced exacerbations of her pain, she had a flooding of the intrusive memories. The veteran did not seem to meet the criteria for any other psychiatric disorders at that time. The diagnoses included PTSD. On a VA general medical examination in May 1995, it was noted that the veteran had problems sleeping due to nightmares related to her job in Cuba in the service when she handled sick and dying patient refugees. The veteran had a history of depression treated with medication. In April 1995, the veteran filed a claim for service connection for a skin rash. On a statement received in June 1995, the veteran described stressful events in service from when she was in Guantanamo Bay, Cuba, from May or June 1992 to August 1992. She saw a dead person in the water, which she did not report. The body was later found. She saw many starving children and adults and many people were dying of AIDS and HIV and starvation. She became friendly with two girls and did not know what happened to them. At one time there was a riot in Camp 7, which was the AIDS and HIV area. The site commander lost his eye and other soldiers were wounded. She had to act as a military policeperson during the riot. On a VA examination in July 1995 the veteran complained of a scaly, hyperpigmented dermatitis under the breast and on the central chest. The lesions were asymptomatic and had been present for approximately 1 year. The veteran intermittently used medication, to which the dermatitis responded; however, it would always return when treatment was discontinued. On examination, the were several 2 to 3 cm. hyperpigmented slightly scaly patches. A KOH examination of one of the lesions was positive for hyphal elements. The diagnoses included tinea versicolor. On a VA mental disorders examination in July 1995, it was noted that the claims file was reviewed. The veteran reported stressors as noted above. The assessment included that the veteran appeared to meet the criteria for PTSD. It was noted that her insomnia while in the service would be consistent with PTSD. The veteran did not appear to meet the criteria for any other psychiatric diagnosis at that time, other than PTSD. The diagnoses included PTSD. On an undated statement, the veteran described stressors as noted above. By rating action of January 1996, service connection for PTSD was denied and service connection for tinea versicolor, claimed as skin rash, was granted with a 0 percent evaluation assigned. The current appeal to the Board arises from this action. Records from the Daniel Webster College Health Center from September 1995 to November 1995 show treatment for PTSD. The veteran stated that she had traumatizing experiences while in the military, and specifically mentioned witnessing a dead body in Cuba. An August 1996 letter to the veteran's representative from a VA mental health clinic therapist describes that the veteran had treatment there beginning in December 1995. Associated with the file were VA treatment records from May 1995 to May 1996 that show that the veteran was treated for PTSD. She described stressors previously related above. At the RO hearing in August 1996, the veteran testified regarding stressors previously related above. Her duty in Guantanamo Bay, Cuba was to deliver food. She stated that the Haitian refugees in the camps would attack the soldiers. Additionally, there was a threat that the Cuban people would attack the base on Cuban-American Friendship Day. During the riot of the refugees, the veteran was not involved, but was told to be on alert. As to her skin disability, the veteran stated that she would get skin rashes when it was hot. She had medication in the form of a cream. Even with use of the medication, she would have flare ups of the symptoms if it was really hot and she was sweating. She would renew her prescription for the medication by mail. She had only been seen once for the skin disability. In an August 1997 report from the U.S. Armed Services Center for Research of Unit Records (USASCRUR), it was indicated that the veteran's participation in search and recovery missions was unable to be documented. In addition, the veteran's witnessing of persons dying of AIDS could not be documented. In a January 1998 letter to the veteran's representative, a VA mental health clinic therapist indicated that the veteran was treated for PTSD since December 1995. The stressors included being fired on by snipers, being caught in a riot in Cuba, and taking care of Haitians in refugee camps. She was exposed to grossly deformed dead bodies and children who suffered from disease and malnutrition. Associated with the file were newspaper articles, magazine articles, and synopses of magazine articles that described events involving Haitian refugees in Guantanamo Bay, Cuba. Associated with the file were photographs of ships at docks, a group of large tents, one picture of groups of tents with two young children, and people standing near a wire fence. On a VA examination for PTSD in November 1998, it was noted that the veteran's claims file was reviewed. The veteran described stressors as related previously. An MMPI test was administered. It was noted that the veteran did not report cardinal features of PTSD diagnostic criteria. It was suggested that the veteran suffered from a mood disorder, which had been masked by advancing other psychiatric diagnosis. The diagnoses included cyclothymic disorder. On a VA examination of the skin in November 1998, the veteran reported using cream medication for her tinea versicolor. The veteran reported that she had a pigmented rash on her trunk, back, and under her breasts. At present the veteran was asymptomatic. The rash was described as intermittent. There was no pruritus or pain. On examination, there were no lesions on the anterior or posterior chest or under the breasts. No photographs were taken, as there were no lesions to photograph. The diagnoses included tinea versicolor in remission. By rating action of June 1999, service connection for cyclothymic disorder or any nervous disorder was denied. The current appeal to the Board arises from this action. II. Analysis A. Service connection Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if preexisting such service, was aggravated by service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(a) (1999). Where a veteran served 90 days or more during a war period and a psychosis becomes manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991 and Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). A claimant seeking benefits under a law administered by the Secretary of the Department of Veteran Affairs shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. The Secretary has the duty to assist a claimant in developing facts pertinent to the claim if the claim is determined to be well grounded. 38 U.S.C.A. § 5107(a). Thus, the threshold question to be answered is whether the veteran has presented a well grounded claim; that is a claim which is plausible. If she has not presented a well grounded claim, her appeal must fail, and there is no duty to assist her further in the development of her claim as any such additional development would be futile. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, to sustain a well grounded claim, the claimant must provide evidence demonstrating that the claim is plausible; mere allegation is insufficient. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). The determination of whether a claim is well grounded is legal in nature. King v. Brown, 5 Vet. App. 19 (1993). A well grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of 38 U.S.C.A. § 5107(a). Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). To be well grounded, a claim must be accompanied by supportive evidence, and such evidence must justify a belief by a fair and impartial individual that the claim is plausible. Where the determinative issue involves a question of either medical causation or diagnosis, medical evidence is required to fulfill the well grounded claim requirement of 38 U.S.C.A. § 5107(a). Lathan v. Brown, 7 Vet. App. 359 (1995). In particular, establishing a well-grounded claim for service connection generally requires medical evidence of a current disability, see Rabideau v. Derwinski, 2 Vet. App. 141 (1992); medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in- service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997) (expressly adopting definition of well- grounded claim set forth in Caluza, supra), petition for cert. filed, No. 97-7373 (Jan. 5, 1998); Heuer v. Brown, 7 Vet. App. 379 (1995); Grottveit v. Brown, 5 Vet. App. 91 (1993). The second and third Caluza elements can also be satisfied by evidence that a condition was "noted" during service or during an applicable presumption period; evidence showing post-service continuity of symptomatology; and medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See 38 C.F.R. § 3.303(b) (1999); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). In the case of a disease only, service connection also may be established by evidence of the existence of a chronic disease in service or of a disease, eligible for presumptive service connection pursuant to statue or regulation, during the applicable presumption period and present disability from it. Savage, 10 Vet. App. at 495. 1. PTSD A claim for service connection for PTSD requires three (3) elements to be well grounded. There must be competent evidence of a current disability (a medical diagnosis); medical or lay evidence of an in-service stressor; and medical evidence of a nexus (causal relationship) between service and the current PTSD disability. Cohen v. Brown, 10 Vet. App. 128 (1997). In the instant case, there is evidence that the veteran has been diagnosed as having PTSD. On VA examinations in May 1995 and July 1995, PTSD was diagnosed, and VA and private treatment records show treatment for PTSD, based on stressors alleged by the veteran from her experiences in the service in Guantanamo Bay, Cuba. The stressors include being on search and recovery crews working with deceased and wounded refugees, observing a dead body, working with starving and dying Haitian refugees, being involved in a riot of Haitian refugees where fellow soldiers were injured, being fired on by snipers, a threat that the Cuban people would attack the base on Cuban-American Friendship Day, and injuring her back by falling off of a cliff. Thus, as the veteran has asserted stressors that occurred in service and there are diagnoses of PTSD attributable to events in service, the Board finds that the veteran has presented a claim for service connection for PTSD that is well grounded. Further discussion of this issue appears in the Remand section below. 2. Cyclothymic disorder The veteran is claiming that she currently has a psychiatric disability, other than PTSD, that was incurred in service. The service medical records show the veteran was evaluated in the mental health clinic, and the assessments included phase of life problem, occupational problem, dependent and avoidant traits, and moderate sleep disorder. The first postservice evidence of a cyclothymic disorder or nervous disorder was several years postservice. The veteran has submitted no competent medical evidence to establish a nexus between any current psychiatric disability, other than PTSD, and military service. The only evidence that would support the veteran's claim is found in her statements and testimony. However, lay evidence is inadequate to establish a medical nexus. Epps v. Gober, 126 F.3d 1464 (1997). Since all three criteria to establish evidence of a well-grounded claim have not been met, it follows that the veteran claim must be denied based on her failure to submit evidence of a well-grounded claim. Absent a well-grounded claim, the Board has no duty to assist or decide the case on its merits. While it is argued that the VA has a duty to assist claimants whose claims are not well grounded, this proposition has been rejected by the United States Court of Appeals for Veterans Claims. On July 14, 1999, the Court affirmed a September 6, 1996 Board decision which denied claims for service connection for several disabilities as not well grounded. Morton v. West, 12 Vet. App. 477 (1999). In that case, the Court addressed and rejected the appellant's argument on appeal that, by virtue of various regulations, VA ADJUDICATION PROCEDURE MANUAL M21-1 provisions, and Compensation & Pension Service (C&P) policy concerning the development of claims, VA had taken upon itself a duty to assist in fully developing the facts pertinent to a claim even in the absence of a well- grounded claim. Because there is no duty to assist under 38 U.S.C. § 5107(a) absent the submission of a well-grounded claim, see Epps v. Gober, 126 F.3d 1464, 1467 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 2348 (1998), the Court held that the Secretary cannot undertake to assist a veteran in developing facts pertinent to his or her claim until such a claim has first been established. In the order, the Court addressed and rejected the request of a judge for en banc consideration. Morton v. West, 12 Vet. App. 477 (1999) (per curiam). The veteran having failed to present evidence of a plausible claim for entitlement to service connection for cyclothymic disorder or nervous disorder, that claim must be denied. B. Increased rating Initially, the Board notes that the veteran's claim for an increased rating is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). A claim that a service- connected condition has become more severe is well grounded where the claimant asserts that a higher rating is justified due to an increase in severity. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 631-632 (1992). The Board also finds that all relevant evidence for equitable determination of the claim has been obtained, and that no further assistance to the veteran is required to comply with VA's duty to assist her pursuant to 38 U.S.C.A. § 5107(a). In Fenderson v. West, 12 Vet. App. 119 (1999), the United States Court of Appeals for Veterans Claims held that there is a distinction between an original rating and a claim for an increased rating. The Court also held that the rule from Francisco v. Brown, 7 Vet. App. 55, 58 (1994) ("Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance."), is not applicable to the assignment of an initial rating for a disability following an initial award of service connection for that disability. Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. As this case involves a rating assigned in connection with a grant of service connection, the Board will follow the mandates of the Fenderson case in adjudicating this claim. Under applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. §§ 4.1 and 4.2. Also, 38 C.F.R. § 4.10 provides that, in cases of functional impairment, evaluations must be based upon lack of usefulness of the affected part or systems, and medical examiners must furnish, in addition to the etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, full description of the effects of the disability upon the person's ordinary activity. These requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based upon a single, incomplete, or inaccurate report, and to enable the VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath, 1 Vet. App. at 594. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. By rating action in January 1996, service connection was granted for tinea versicolor, claimed as skin rash, and a 0 percent evaluation was assigned under Diagnostic Code (DC) 7899 of VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4. The veteran's service connected tinea versicolor is an unlisted disability in VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4. Therefore, it is permissible to rate under a closely related disease or injury. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (1999). Therefore, the veteran's tinea versicolor shall be rated under Diagnostic Code (DC) 7806 for Eczema. Under applicable criteria, a 0 percent rating is warranted for eczema with slight, if any, exfoliation, exudation or itching, if on a nonexposed surface or small area. A 10 percent rating is warranted for eczema with exfoliation, exudation or itching, if involving an exposed surface or extensive area. A 30 percent rating is warranted for eczema with exudation or itching constant, extensive lesions, or marked disfigurement. A 50 percent rating is warranted for eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. 38 C.F.R. Part 4, Diagnostic Code 7806. The record does not support the veteran's claim for a compensable rating for tinea versicolor, as there is no evidence of exfoliation, exudation or itching of an exposed surface or extensive area. On the July 1995 examination, it was noted that the veteran had small scaly patches on the chest that resolved with medication. On the November 1998 examination, no lesions were present. The evidence establishes that the symptoms do not meet the criteria for an increased rating. ORDER To the limited extent that the appellant's claim of entitlement to service connection for PTSD is well grounded, the appeal is granted. As a well grounded claim has not been presented, entitlement to service connection for a psychiatric disability, other than PTSD, is denied. Entitlement to a compensable rating for tinea versicolor is denied. REMAND As the veteran's claim for service connection for PTSD has been found to be well grounded, the VA has a duty to assist the appellant in the development of facts pertaining to her claim. 38 U.S.C.A. § 5107(a) (West 1991). The duty to assist is neither optional nor discretionary. Littke v. Derwinski, 1 Vet. App. 90 (1990). In addition to establishing a well-grounded claim for PTSD, a veteran must establish as follows: (1) a current, clear medical diagnosis of PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. If the claimed stressor is not combat related, a veteran's lay testimony is insufficient to establish the occurrence of the stressor and must be corroborated by "credible supporting evidence". On the other hand, if the veteran did engage in combat with the enemy, she is entitled to have her lay statements accepted, without the need for further corroboration, as satisfactory evidence that the claimed events occurred, unless her descriptions are not consistent with the circumstances, conditions, or hardships of service or unless the VA finds by clear and convincing evidence that a particular asserted stressful event did not occur. If it is not determined that the veteran was involved in combat, the Board nevertheless has a duty to assist the veteran under 38 U.S.C.A. § 5107(a) with respect to verification of her claimed stressors. The question of whether the veteran was exposed to a stressor in service is a factual determination and VA adjudicators are not bound to accept such statements simply because treating medical providers have done so. Wood v. Derwinski, 1 Vet. App. 190 (1991) (affirmed on reconsideration, 1 Vet. App. 406 (1991)); Wilson v. Derwinski, 2 Vet. App. 614 (1992). In Zarycki v. Brown, 6 Vet. App. 91 (1993), the Court set forth the framework for establishing the presence of a recognizable stressor, which is the essential prerequisite to support the diagnosis of PTSD. The Court's analysis divides into two major components: The first component involves the evidence required to demonstrate the actual occurrence of an alleged stressor event; the second involves a determination as to whether the stressor event is of the quality required to support the diagnosis of PTSD. See also Cohen v. Brown, 10 Vet. App. 128 (1997). In this case, the veteran has described several stressors that occurred while she was in Guantanamo Bay, Cuba from May or June 1992 to August 1992. The stressors include being on search and recovery crews working with deceased and wounded refugees, observing a dead body, working with starving and dying Haitian refugees, being involved in a riot of Haitian refugees where fellow soldiers were injured, being fired on by snipers, a threat that the Cuban people would attack the base on Cuban-American Friendship Day, and injuring her back by falling off of a cliff. A service personnel record dated in June 1992 shows that the veteran was assigned to travel to Guantanamo Bay, Cuba for 90 days. The RO should provide the U.S. Armed Services Center for Research of Unit Records with all available stressor information. Prior thereto, another attempt should be made to obtain more detailed information from the veteran. The importance of her providing this evidence should be made clear. It must then be determined whether any of the veteran's putative stressors, if corroborated, contributed to the veteran's current PTSD symptoms. The veteran should then be afforded a thorough and contemporaneous VA psychiatric examination that takes into account records of prior medical treatment. Accordingly, the case is REMANDED to the RO for the following: 1. The RO should request a comprehensive statement from the veteran containing as much detail as possible regarding the who, what, where, and when as to each of the putative stressors which she alleges she was exposed to in service. The veteran should provide specific details of the claimed stressors such as dates, places, detailed descriptions of events, and identifying information concerning any other individuals involved in the events including their full names, rank, units of assignment, or any other identifying detail. She must also provide the unit to which she was assigned at the time of each incident. In particular, the veteran should respond to the following questions with as much specificity as possible: (a) With regard to being exposed to sniper fire, was anyone injured by the attacks? Was counter fire employed to drive off the sniper(s)? Were the attacks reported? Under what circumstances did the attacks occur? Where did the attacks occur? What was the time period of the incidents? (b) With regard to the riot and the injured soldiers, what was the time period of the incident? Under what circumstances did the riot occur? Can the veteran provide names and/or units of those involved? (c) With regard to the search and recovery assignments, where did the work take place? What was the time period of the assignments? What was involved in the assignments? Can the veteran provide names and/or units of those involved? (e) With regard to witnessing starving and dying refugees, what was the time period involved? In what capacity was the veteran involved? (f) With regard to the threat that the Cuban people would attack the base on Cuban-American Friendship Day, what was the name of the unit to which the veteran was assigned at the time? What was the approximate time frame? Where special precautions taken against such an attack? Did the veteran play any role in preparing for the attack? The veteran is advised that this information is vitally necessary to obtain supportive evidence of the stressful events, and that she must be as specific as possible to facilitate a search for verifying information. 2. The RO should then review the file and prepare a summary of the veteran's claimed stressors. This information should be sent to the U.S. Armed Services Center for Research of Unit Records, 7798 Cissna Road, Springfield, Virginia, 22150, for verification of the veteran's putative stressors. If appropriate to verify any reported stressors, unit histories should be obtained for the time periods specified. 3. The RO should then carefully review all evidence obtained pursuant to the development requested above. In the event these records suggest the presence of other sources of relevant evidence, such leads should be followed to the logical conclusion. 4. The RO should also accomplish the following: a. Contact the veteran and obtain the names and addresses of all health care providers where she has received treatment for PTSD since service. Thereafter, the RO should obtain legible copies of all records of treatment that have not already been obtained. All records, once obtained, should be associated with the claims folder. b. Afford the veteran a current VA psychiatric examination. This should include providing the physician with a list of all verified stressors. It is imperative that the examiner review the claims folder prior to the examination, and that all indicated psychological testing is undertaken. The psychiatrist should then render an opinion as to whether the veteran currently suffers from PTSD. It should also be noted whether a current diagnosis of PTSD is linked to a specific corroborated stressor event experienced while in service pursuant to the diagnostic criteria set forth in Diagnostic And Statistical Manual of Mental Disorders (DSM-IV). In so considering, the veteran's reported stressor of injuring her back falling off a cliff in service, which is verified, should be considered. If a diagnosis of PTSD is rendered, the examiner should specify the stressor(s) upon which the diagnosis is based and provide all factors upon which the diagnosis was made. 5. Following completion of the foregoing, the RO must review the claims folder and ensure that all requested development has been completed in full. If any development is incomplete, appropriate corrective action should be implemented. When the requested development is complete, the RO should readjudicate this claim. If the benefit sought remains denied, the veteran and her representative should be furnished an appropriate supplemental statement of the case. The veteran and her representative should then be afforded an opportunity to respond. Thereafter, the case should be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. Iris S. Sherman Member, Board of Veterans' Appeals