VA Form 10-9009 PDF Details

The VA Form 10-9009, known as the Agent Orange Worksheet, plays a crucial role for veterans seeking recognition and benefits related to Agent Orange exposure. This comprehensive form is designed to meticulously document a veteran’s contact with Agent Orange, including personal information, periods of service, and detailed accounts of exposure. It delves into demographics, military service history, and specifies the locations and circumstances under which a veteran was exposed to Agent Orange. Furthermore, it assesses the veteran's health, including any direct effects on offspring, consultations, symptoms, and eventual diagnoses related to the exposure. Through pages dedicated to documenting not just the exposure but also the implications it has had on a veteran's health, it serves as a foundational document in evaluating claims for benefits. This form is essential in ensuring veterans receive the recognition and support they deserve for their service and sacrifices, especially considering the delayed health repercussions of Agent Orange exposure. It underscores the importance of detailed record-keeping and serves as a bridge between veterans’ service histories and their health claims, making it a vital tool for both veterans and the Department of Veterans Affairs.

QuestionAnswer
Form NameVA Form 10-9009
Form Length4 pages
Fillable?Yes
Fillable fields106
Avg. time to fill out22 min 12 sec
Other namesva agent orange registry form 10 9009, agent orange registry, 10 9009, orange registry

Form Preview Example

Agent Orange Worksheet

Page 1

Name

SSN

Demographics

Last Name

 

First Name

 

Middle Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

Zip Code

Plus 4

 

 

 

 

 

 

 

 

 

 

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex

F = Female

 

 

Marital Status 1

= Married

4

= Widowed

 

 

 

M = Male

 

 

2

= Divorced

5

= Single, Never Married

 

 

 

 

 

3

= Separated

 

 

 

 

Race

Enter all races that apply below. One entry per row.

1

= American Indian or Alaskan Native

5 = White

 

 

1

= Observer

3 = Self-identification

2

= Asian

 

 

 

6 = Declined to answer

 

2

= Proxy

4 = Unknown

3

= Black or African American

 

7 = Unknown by patient

 

 

 

 

4

= Native Hawaiian or other Pacific Islander

 

 

 

 

 

 

 

Race Code

 

 

 

 

 

 

Collection Method

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity

 

 

 

 

 

 

 

 

 

 

Enter all ethnicities that apply. One entry per row.

 

 

 

 

 

1

= Hispanic or Latino

3 = Declined to answer

 

 

1

= Observer

3 = Self-identification

2

= Not Hispanic or Latino

4 = Unknown by patient

 

 

2

= Proxy

4 = Unknown

 

Ethnicity Code

 

 

 

 

Collection Method

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Periods of Service

 

 

 

 

 

 

 

 

Enter all periods of service that apply. One entry per row.

 

 

 

 

1

= Army

2 = Air Force

3 = Navy

4 = Marines

5 = Coast Guard

6 = Other

 

 

Branch of Service

Start Date

End Date

Remarks

 

 

 

 

 

(mm/dd/yyyy)

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA Form 10-9009 (Supersedes VA Form 10-9009, May 2001)

June 2005

Agent Orange Worksheet

Page 2

Name

SSN

General

Facility Number

Facility Suffix

 

Date of Exam

 

 

 

 

 

Examiner Name

 

Examiner Title

 

 

 

 

Examiner Signature

 

Private Physician?

 

 

 

Y = Yes; N = No

 

 

 

 

 

 

Remarks

Military

Current Status

 

1 = Inpatient

4

= Active Duty (Inpatient)

 

 

2

= Outpatient

5

= Active Duty (Outpatient)

 

 

3

= Incarcerated

 

 

 

 

 

 

Branch of Service

 

1 = Army

4

= Marines

 

 

2

= Air Force

5

= Coast Guard

 

 

3

= Navy

6

= Other

 

Does veteran have military service in Vietnam, Korea, or other locations where

1

= Vietnam

 

Agent Orange or other herbicides were tested, transported, or sprayed for

2

= Korea (1968 or 1969)

 

3

= Both

 

military purposes?

 

 

 

 

 

 

 

 

 

4

= Neither (Other Locations)

 

 

 

 

 

 

 

If other location, describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did veteran serve in any of the following?

I Corps

II Corps

III Corps

 

 

IV Corps

Sea Duty

Other

Y = Yes; N = No; U = Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If other, describe:

 

 

 

 

 

 

 

 

 

 

List military units in which veteran served. Specify complete unabbreviated title (Company, Battalion)

VA Form 10-9009 (Supersedes VA Form 10-9009, May 2001)

June 2005

Agent Orange Worksheet

Page 3

Name

SSN

Exposure Periods

Location

1

= Vietnam

4 = Other

 

 

2

= Korea

Location Description

Start Date End Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exposures

1 = Definitely Yes; 2 = Not Sure; 3 = Definitely No

Veteran was involved in handling or spraying Agent Orange.

Veteran was not directly sprayed but was in a recently sprayed area.

Veteran was exposed to herbicides other than Agent Orange.

Veteran was directly sprayed with Agent Orange.

Veteran ate food or drink that could have been sprayed with Agent Orange.

Self Assessment

1 = Very Good; 2 = Good; 3 = Fair; 4 = Poor; 5 = Very Poor

Which best describes veteran’s health?

Birth Data

How many children does veteran have?

How many children were born before veteran's military service in the Republic of Vietnam?

How many of the children born before the veteran's military service in the Republic of Vietnam showed evidence of spina bifida?

State maternal age at conception.

How many of the children born before the veteran's military service in the Republic of Vietnam showed evidence of other birth defects?

State maternal age at conception.

How many children were born during or after veteran's military service in the Republic of Vietnam?

How many of the children born during or after veteran's military service in the Republic of Vietnam showed evidence of spina bifida?

State maternal age at conception.

How many of the children born during or after veteran's military service in the Republic of Vietnam showed evidence of other birth defects?

State maternal age at conception.

VA Form 10-9009 (Supersedes VA Form 10-9009, May 2001)

June 2005

Agent Orange Worksheet

Page 4

Name

Consultations

SSN

1 = No workup, no consultation done.

2 = Workup/consultation done. Has symptoms/diagnosis undetermined.

3 = Workup/consultation done. Diagnosis established.

4 = Workup/consultation done. No symptoms/no illness evident.

5 = Workup/consultation in progress. Results pending.

6 = Workup/consultation scheduled. Veteran no show.

Dermatology

Pulmonary

Reproductive Health

Hematology/Oncology

Urology

Neurology

ENT

Other

Y = Yes; N = No

Hepatitis C (with veteran's consent)

P = Positive; N = Negative; X = No testing done

Additional workups

Disposition

Y = Yes; N = No

Exam Completed?

Hospitalized at VAMC for further tests?

Hospitalized at VAMC for treatment?

Referred for VA outpatient treatment?

Referred to private physician; non-VA clinic or non-VA hospital?

Biopsy?

Specimens to be sent to AFIP?

VA Form 10-9009 (Supersedes VA Form 10-9009, May 2001)

June 2005

Agent Orange Worksheet

Page 5

Name

SSN

Symptoms/Complaints

 

 

Date of

 

Currently

 

 

 

Onset

Duration

Present

 

 

Description

(mm/dd/yyyy)

ICD-9 Code

 

(months)

Y = Yes; N = No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnoses

 

 

 

 

 

 

Description

 

 

 

ICD-9 Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA Form 10-9009 (Supersedes VA Form 10-9009, May 2001)

June 2005

How to Edit VA Form 10-9009 Online for Free

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This document will require specific information; in order to ensure accuracy, don't hesitate to consider the suggestions further on:

1. To begin with, when filling out the va agent orange registry form 10 9009, start in the area containing subsequent blank fields:

form 10 9009 completion process described (step 1)

2. Right after the previous section is filled out, go to enter the suitable details in these - Race Enter all races that apply, Observer Proxy Collection, Selfidentification Unknown, Branch of Service, Start Date mmddyyyy, End Date mmddyyyy, and Remarks.

Stage # 2 for filling in form 10 9009

3. The following section is related to Agent Orange Worksheet Name, SSN, Page, Facility Suffix, Date of Exam, Examiner Title Private Physician Y, General Facility Number Examiner, Inpatient Outpatient, and Active Duty Inpatient Active - fill out each of these blank fields.

Ways to fill out form 10 9009 step 3

4. Now proceed to the next segment! In this case you have these Branch of Service, Inpatient Outpatient, Active Duty Inpatient Active, Marines Coast Guard Other, Vietnam Korea or Both, Does veteran have military service, If other location describe Did, II Corps, III Corps, IV Corps, Sea Duty, Other, I Corps, and If other describe List military blank fields to fill in.

form 10 9009 writing process clarified (portion 4)

Be extremely mindful when filling out If other location describe Did and Active Duty Inpatient Active, since this is the part in which most users make some mistakes.

5. Since you get close to the end of this file, you'll notice several more points to do. Notably, Agent Orange Worksheet Name, SSN, Page, Start Date End Date, Exposure Periods Location, Other, Location Description, Exposures Definitely Yes Not, Veteran was not directly sprayed, Veteran was exposed to herbicides, Veteran was directly sprayed with, Veteran ate food or drink that, and Self Assessment Very Good Good must all be filled in.

Part no. 5 in submitting form 10 9009

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