VA Form 10-9009a PDF Details

The VA Form 10-9009A is an essential document that delves into the intricate details of veterans' health, specifically focusing on those who served in the Persian Gulf. It's structured to capture comprehensive information that spans from personal identification to more sensitive data concerning health and military service exposures. The form is meticulously designed to gather data on a breadth of topics such as the veteran's demographic information, military service history, including periods of service in the Persian Gulf, units served in, and military occupational specialty. Additionally, it dives into more detailed inquiries about environmental exposures encountered during service, covering a wide range of potential hazards from smoke from oil fires to exposure to depleted uranium and various chemical agents. It also addresses personal health assessments post-service, including health status, functional impairments, experiences with combat or dangerous duties, and exposures to environmental factors. Furthermore, the form seeks information on birth defects and pregnancy issues among veterans' children, potentially linked to service-related exposures. This form is a critical tool in supporting veterans as it helps in the evaluation for health benefits by providing a detailed account of their service and health post-service, ensuring that they receive the support and care they are entitled to.

QuestionAnswer
Form NameVA Form 10-9009a
Form Length10 pages
Fillable?Yes
Fillable fields1
Avg. time to fill out2 min 42 sec
Other names9009a, va 10 9009a fillable, 10 9009a, va 9009a sheet pdf

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1. Use PTF

FACILITY NO.

 

SUFFIX

 

 

 

PERSIAN GULF REGISTRY CODE SHEET

 

#

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1

Number Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 1 (PHASE I)

 

 

 

 

 

 

 

 

 

 

The information the veteran supplies may be disclosed outside the VA to Federal, State and local government agencies and National Health Organizations to assist in the development of programs for research purposes and other uses as stated in the "Notice of Systems of VA Records" published in the Federal Register in accordance with the Privacy Act of 1974

INSTRUCTIONS: Please print. Use only one letter or number per block. If possible use black ballpoint or felt-tip pen. Shaded areas for VA use only. (DO NOT USE BLUE INK)

2. LAST NAME (8-33)

3. FIRST NAME (34-48)

 

 

 

 

 

4. MIDDLE NAME (49-58)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. SOCIAL SECURITY NUMBER (60-69)

7. D.O.B. (Complete all blanks)

 

 

 

(60)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO (70-71)

DAY (72-73 )

YR (74-75)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.ADDRESS (Street Name and Apartment Number, If applicable) 76-101

8A. CITY OR TOWN (102-127)

5.TYPE (59)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8B. COUNTY

 

 

 

 

 

 

 

 

STATE

 

8C. ZIP CODE (128-132)

8D. LEAVE BLANK

 

 

8E. COUNTY (137-139)

STATE (140-141)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(133)

 

 

(134)

 

(135)

 

(138)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. RACE/ETHNICITY (Enter one code at right)

 

 

 

 

 

 

 

 

 

 

 

 

142

10. MARITAL STATUS (Enter one code at right)

 

 

 

143

 

1=American Indian or Alaskan Native 3=Black, Not of Hispanic Origin

5=Hispanic

 

 

 

 

 

 

 

1=Married

 

3=Separated

5=Single, Never Married

 

 

2=Asian or Pacific Islander

 

4=White, Not of Hispanic Origin

6=Unknown

 

 

 

 

 

 

 

2=Divorced

 

4=Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. SEX (Enter one

144

12. CURRENT STATUS (Enter one code at right)

 

 

 

 

 

 

 

145

13. BRANCH OF SERVICE (If more than one, enter latest Persian Gulf Service)

146

 

code at right

 

1= Inpatient

3=Incarcerated

 

 

5. Active Duty (Inpatient)

 

 

1=Army

 

3=Navy

5=Coast

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M=Male F=Female

 

 

 

 

 

 

 

 

 

 

 

 

2= Outpatient

4=Active Duty (Outpatient)

 

 

 

 

 

 

 

 

 

2=Air Force

4=Marine

6=Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. DID VETERAN HAVE MILITARY SERVICE IN PERSIAN GULF AREA?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

147

 

Y=Yes (If "Yes", list below the dates of veteran’s last two periods of service there)

N=No (If "No", Persian Gulf Veterans not eligible for PGR exam.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

MO(148-149)

YR (150-151)

 

 

MO(152-153)

YR (154-155)

 

 

 

 

F

 

 

MO(156-157)

 

YR (158-159)

 

MO(160-161)

YR (162-163)

 

A. LAST PERIOD

R

 

 

 

 

 

T

 

 

 

 

 

 

 

B. NEXT TO LAST

R

 

 

 

 

 

 

 

 

 

 

T

 

 

 

 

 

O

 

 

 

 

 

O

 

 

 

 

 

 

 

PERIOD

O

 

 

 

 

 

 

 

 

 

 

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15A. IN WHAT AREAS DID VETERAN SERVE?

 

164

15B. IF OTHER SERVICE OR "DON’T

 

 

16. MILITARY UNITS AND MOS

 

 

 

 

 

 

 

 

 

 

 

(Enter appropriate code in block 164)

 

KNOW"

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Enter appropriate code in block 164)

 

 

16A. LIST MILITARY UNITS IN WHICH VETERAN SERVED.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE SPECIFY COMPLETE UNABBREVIATED TITLE. (Company, battalion, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 = Combat Zone

 

 

 

 

 

4 = Other (Specify i.e. Air Force,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2 = Other Land Area

 

 

 

 

 

Ground or Air Crew, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 = Sea Duty

 

 

 

 

 

 

5 = Don’t Know

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16B. LIST MILITARY OCCUPATIONAL SPECIALTY (MOS)

 

 

 

 

 

 

 

 

16C. WERE ACTUAL DUTIES DIFFERENT FROM MOS?

 

 

 

 

 

166

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTER EITHER OF THE FOLLOWING CODES IN BLOCK 166

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y =Yes

 

 

N =No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16D. IF YES, LIST HERE AND IN CONSOLIDATED HEALTH RECORD

16E. ENTER THE NAME OF THE UNIT IN WHICH VETERAN HAD THE LONGEST AND NEXT TO LONGEST PERIOD OF SERVICE WHILE IN THE PERSIAN GULF

NOTE A&E: These units could be different from the one to which the veterans was assigned if veterans was on detached duty.

17. ENTER THE DATES OF THE LAST TWO PERIODS OF SERVICE (If deferent from above)

F

MO(167-168)

YR (169-170)

MO(171-172)

YR (173-174)

F

MO(175-176)

YR (177-178)

MO(179-180)

YR(181-182)

A. LAST PERIOD

R O M

T O

B. NEXT TO LAST PERIOD

R O M

T O

VA Form JUL 1995

10-9009A(RS)JETFORM

 

 

 

-

-

NAME:

 

 

 

 

 

 

 

 

 

 

 

 

SSN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. VETERANS EXPOSURE TO ENVIRONMENTAL FACTORS (ENTER APPROPRIATE CODES)

 

 

 

 

 

 

 

 

 

 

 

 

18A. ARE YOU CURRENTLY SMOKING CIGARETTES? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

 

(183)

 

 

 

 

 

 

 

183. IF NO, GO TO ITEM 18D.

Y=YES N=NO

 

 

 

 

 

 

 

 

 

 

18B. IF YES, HOW MANY YEARS HAVE YOU BEEN SMOKING CIGARETTES? ENTER THE NUMBER OF

 

(184)

(185)

 

 

 

 

 

 

YEARS IN BLOCK 184 AND 185.

 

 

 

 

 

 

 

 

 

 

 

 

18C. ON THE AVERAGE HOW MANY PACKS ARE YOU SMOKING PER DAY? ENTER THE NUMBER OF

 

(186)

(187)

 

 

 

 

 

 

 

PACKS IN BLOCKS 186 AND 187

 

 

 

 

 

 

 

 

 

 

 

 

18D. HAVE YOU SMOKED CIGARETTES IN THE PAST? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

 

(188)

 

 

 

 

 

 

 

188. IF NO, GO TO ITEM 18G.

Y=YES N=NO

 

 

 

 

 

 

 

 

 

 

 

18E. IF YES, HOW MANY YEARS HAD YOU SMOKED? ENTER NUMBER OF YEARS IN BLOCKS 189 AND

 

(189)

(190)

 

 

 

 

 

 

 

190.

 

 

 

 

 

 

 

 

 

 

 

 

18F. ON THE AVERAGE, HOW MANY PACKS DID YOU SMOKE PER DAY? ENTER THE NUMBER OF PACKS

 

(191)

(192)

 

 

 

 

 

 

IN BLOCKS 191 AND 192.

 

 

 

 

 

 

 

 

 

 

 

18G-Z1.WHILE IN THE PERSIAN GULF DO YOU BELIEVE YOU WERE EXPOSED TO ANY OF THE FOLLOW-

 

 

 

 

 

ING.

 

 

 

 

 

 

 

 

 

 

 

18G. SMOKE FROM OIL FIRES? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(193)

 

 

 

 

 

 

193.

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

18H. SMOKE OR FUMES FROM TENT HEATERS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(194)

 

 

 

 

 

 

194.

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

181. CIGARETTE SMOKE (PASSIVE) FROM OTHERS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(195)

 

 

 

 

 

 

195.

 

 

 

 

 

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18J. DIESEL AND/OR OTHER PETROCHEMICAL FUMES? ENTER ONE OF THE FOLLOWING CODES IN

Y=YES N=NO

(196)

 

 

 

 

 

 

BLOCK 196.

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

18K. EXPOSURE TO BURNING TRASH/FECES? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(197)

 

 

 

 

 

 

197.

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

18L. SKIN EXPOSURE TO DIESEL OR OTHER PETROCHEMICAL FUEL? ENTER ONE OF THE

Y=YES N=NO

(198)

 

 

 

 

 

 

FOLLOW-

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18M. CARC (CHEMICAL AGENT RESISTANT COMPOUND)? ENTER ONE OF THE FOLLOWING CODES IN

Y=YES N=NO

(199)

 

 

 

 

 

 

BLOCK 199.

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18N. OTHER PAINTS AND/OR SOLVENTS AND/OR PETROCHEMICAL SUBSTANCES? ENTER ONE OF THE

Y=YES N=NO

(200)

 

 

 

 

 

 

FOLLOWING CODES IN BLOCK 200.

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=YES N=NO

(201)

 

 

18O. DEPLETED URANIUM? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 201.

 

 

 

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=YES N=NO

(202)

 

 

18P. MICROWAVES? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 202.

 

 

 

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18Q. PERSONAL PESTICIDE USE, INCLUDING CREAMS, SPRAYS OR FLEA COLLARS? ENTER ONE

Y=YES N=NO

(203)

 

 

 

 

 

 

OF

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18R. NERVE GAS OR OTHER NERVE AGENTS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(204)

 

 

 

 

 

 

204.

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

18S. DRUG (PYRIDOSTIGMINE) USED TO PROTECT AGAINST NERVE AGENTS? ENTER ONE OF THE

Y=YES N=NO

(205)

 

 

 

 

 

 

FOLLOWING CODES IN BLOCK 205.

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

18T. MUSTARD GAS OR OTHER AGENTS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(206)

 

 

 

 

 

 

206.

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18U. ATE OR DRANK FOOD CONTAMINATED WITH SMOKE, OIL OR OTHER CHEMICAL? ENTER ONE OF

Y=YES N=NO

(207)

 

 

 

 

 

 

THE FOLLOWING CODES IN BLOCK 207.

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

JETFORM

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