BVA9503170 DOCKET NO. 93-25 188 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an increased rating for post-traumatic stress disorder, currently rated 30 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The appellant and his spouse ATTORNEY FOR THE BOARD Mark J. Swiatek, Counsel REMAND The veteran had active duty from August 1940 to October 1945. This matter comes before the Board of Veterans' Appeals (Board) from a February 1993 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The record reflects that the most recent comprehensive VA psychiatric examination was obtained in January 1992. The record includes the report of a private hospitalization in August 1992 for post-traumatic stress disorder. At the June 1993 hearing, the veteran and his spouse testified regarding the current extent of his psychiatric symptoms and the impact on his ability to work. In August 1994, the representative requested that the case be returned to the RO for further development of a claim for a total rating based on individual unemployability that was raised in the hearing testimony. In view of the foregoing, it is the opinion of the Board that further development, as outlined below, is warranted to ensure that the VA has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements. Accordingly, the case is REMANDED to the RO for the following action: 1. The veteran should be provided with an application for increased compensation based on individual unemployability due to service- connected disability. He should also be requested to identify all sources of recent treatment for his service-connected psychiatric disability. With any necessary authorization from the veteran, the RO should attempt to obtain copies of all indicated records which have not been previously secured. 2. A VA social and industrial survey should be conducted in order to clarify the veteran's medical, social, educational, and employment history. The social worker should elicit and set forth pertinent facts regarding the veteran's medical history, education, employment history, social adjustment, and current behavior and health. The social worker should offer an assessment of the veteran's current functioning and identify the conditions which limit his employment oppor- tunities. Any potential employment opportunities should be identified. The claims folder must be made available to the social worker in conjunction with the survey as it contains important historical data. 3. Following completion of the above development, the veteran should be accorded a VA psychiatric examination to determine the severity of the post-traumatic stress disorder. The claims folder must be made available to the examiner prior to the evaluation so that the examiner may review the pertinent historical data contained therein. The examiner should utilize the social work service report as well as pertinent data in the claims folder in order to obtain a true picture of the progress of the veteran's psychiatric disorder. The examination should be comprehensive enough to determine the nature and extent of all psychiatric symptoms. Any relationship between the post-traumatic stress disorder and any other psychiatric disorder should be identified. The psychiatrist should utilize any psychological testing deemed pertinent in making a complete diagnostic evaluation and in differentiating the post-traumatic stress disorder symptoms from those attributable to other conditions. Based upon a review of the record and the examination, the physician should provide a Global Assessment of Functioning (GAF) scale code and discuss the meaning of the GAF scale code assigned. In addition, the examiner should also discuss the impairment of the veteran's ability to establish and maintain relationships as well as the reduction in initiative, efficiency and reliability levels which may be attributable to the post- traumatic stress disorder (as distinct from impairment attributable to other conditions). The examination should be performed and reported in accordance with the VA Physician's Guide for Disability Evaluation Examinations. 4. When the above development has been completed the RO should readjudicate the veteran's claim. If it has not been rendered moot, the claim for a total rating based on individual unemployability on account of service-connected psychiatric disability should also be adjudicated. The rating should reflect consideration of the applicability of the provisions of 38 C.F.R. §§ 3.321(b)(1) and 4.16(b) or 4.16(c), whichever may be applicable. A supplemental statement of the case addressing all issues in appellate status then should be prepared and furnished to the veteran and his representative. They should be provided the applicable period in which to respond. Thereafter, in accordance with the proper appellate procedures, the case should be returned to the Board for further appellate review, if otherwise in order. In taking this action, the Board implies no conclusion, either legal or factual, as to any final outcome warranted. No action is required of the veteran until he is otherwise notified by the RO. 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 deter- mination. 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).