VA Form 10-9009a – Fill Out and Use This PDF

TT

1. Use PTF

FACILITY NO.

SUFFIX

PERSIAN GULF REGISTRY CODE SHEET

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1

Number Only

PART 1 (PHASE I)

8B. COUNTY

STATE

8C. ZIP CODE (128-132)

8D. LEAVE BLANK

8E. COUNTY (137-139)

STATE (140-141)

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(134)

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(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

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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

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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

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YEARS IN BLOCK 184 AND 185.

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

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PACKS IN BLOCKS 186 AND 187

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

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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

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190.

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

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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

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193.

U=UNKNOWN

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

Y=YES N=NO

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194.

U=UNKNOWN

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

Y=YES N=NO

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195.

U=UNKNOWN

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

Y=YES N=NO

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BLOCK 196.

U=UNKNOWN

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

Y=YES N=NO

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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

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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

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

U=UNKNOWN

Y=YES N=NO

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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

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OF

U=UNKNOWN

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

Y=YES N=NO

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204.

U=UNKNOWN

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

Y=YES N=NO

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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

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206.

U=UNKNOWN

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

Y=YES N=NO

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THE FOLLOWING CODES IN BLOCK 207.

U=UNKNOWN

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NAME:

SSN:

18V. ATE FOOD OTHER THAN PROVIDED BY ARMED FORCES? ENTER ONE OF THE FOLLOWING

Y=YES N=NO

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CODES

U=UNKNOWN

18W. BATHED IN OR DRANK WATER CONTAMINATED WITH SMOKE OR OTHER CHEMICAL? ENTER ONE

Y=YES N=NO

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OF THE FOLLOWING CODES IN BLOCK 209.

U=UNKNOWN

18X. BATHED IN WATER OTHER THAN PROVIDED BY ARMED FORCES? ENTER ONE OF THE FOLLOW-

Y=YES N=NO

(210)

ING CODES IN BLOCK 210.

U=UNKNOWN

Y=YES N=NO

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18Y. IMMUNIZATION AGAINST ANTHRAX? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 211.

U=UNKNOWN

Y=YES N=NO

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18Z. IMMUNIZATION AGAINST BOTULISM? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 212.

U=UNKNOWN

18Z1. OTHER EXPOSURES? ENTER HERE AND IN CHR ONLY.

19A. DID YOU EVER GO ON COMBAT PATROLS OR HAVE OTHER VERY DANGEROUS DUTY? ENTER

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ONE OF THE FOLLOWING CODES IN BLOCK 213

1 =NO 2=1-3X 3=4-12X 4=13-50X 5=51+TIMES

19B. WERE YOU EVER UNDER ENEMY FIRE (INCLUDING "SCUDS")? ENTER ONE OF THE FOLLOWING

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CODES IN BLOCK 214

1 = NEVER 2=1 DAY 3=<1 WEEK 4=1-<4 WEEKS 5=4 WEEKS OR MORE

19C. WHAT PERCENTAGE OF PEOPLE IN YOUR UNIT WERE KILLED (KIA), WOUNDED OR MISSING IN AC-

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TION (MIA), ENTER ONE OF THE FOLLOWING CODES IN BLOCK 215.

1=NONE 2=1-25% 3=26-50% 4=51-75% 5=76% OR MORE

19D. HOW OFTEN DID YOU SEE SOMEONE HIT BY INCOMING OR OUTGOING ROUNDS? ENTER ONE OF

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THE FOLLOWING CODES IN BLOCK 216.

1=NEVER 2=1-2X 3=3-12X 4=13-50X 5=51 OR MORE TIMES

19E. HOW OFTEN WERE YOU IN DANGER OF BEING INJURED OR KILLED (I.E. PINNED DOWN, OVERRUN,

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AMBUSHED, NEAR MISS, ETC.)? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 217.

1=NEVER 2=1-2X 3=3-12X 4=13-50X 5=51 OR MORE TIMES

19F. DID YOU WITNESS CHEMICAL ALARMS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

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218.

Y=YES N=NO

U=UNKNOWN

20. VETERAN’S HEALTH (VETERAN’S EVALUATION)

20A. WHICH BEST DESCRIBES VETERAN’S HEALTH AFTER PERSIAN GULF SERVICE? ENTER ONE OF

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THE FOLLOWING CODES IN BLOCK 219.

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

21. VETERAN’S FUNCTIONAL IMPAIRMENT

21A. WHICH BEST DESCRIBES VETERAN’S OWN ASSESSMENT OF FUNCTIONAL IMPAIRMENT? ENTER

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ONE OF THE FOLLOWING CODES IN BLOCK 220

1=NO IMPAIRMENT 2=SLIGHT IMPAIRMENT 3=MODERATE IMPAIRMENT 4=SEVERE IMPAIRMENT

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JETFORM

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NAME:

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22B. HOW MANY OF THESE CHILDREN WERE BORN WITH BIRTH DEFECTS? (BIRTH DEFECTS ARE

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ANY STRUCTURAL, FUNCTIONAL, OR BIOCHEMICAL ABNORMALITY AT BIRTH WHETHER GE-

NETICALLY DETERMINED OR INDUCED DURING GESTATION THAT IS NOT DUE TO INJURIES SUF-

FERED DURING BIRTH.) ENTER NUMBER IN BLOCKS 225 AND 226. IF NONE, GO TO ITEM 22C.

22B1.HOW MANY OF THESE CHILDREN WERE CONCEIVED BEFORE GULF SERVICE? ENTER THE NUM-

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BER OF CHILDREN IN BLOCKS 227 AND 228. IF NONE, LEAVE BLANK AND GO TO ITEM 22B2.

22B1(a) STATE MATERNAL AGE AT CONCEPTION OF FIRST CHILD CONCEIVED BEFORE GULF

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SERVICE? ENTER AGE IN BLOCKS 229 AND 230.

22B2.HOW MANY OF THESE CHILDREN WERE CONCEIVED DURING AND AFTER GULF SERVICE? EN-

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TER NUMBER IN BLOCK 231 AND 232. IF NONE, LEAVE BLANK AND GO TO ITEM 22C.

22B2(a) STATE MATERNAL AGE AT CONCEPTION OF FIRST CHILD CONCEIVED DURING AND AFTER

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GULF SERVICE? ENTER AGE IN BLOCKS 229 AND 230.

22C. HAS VETERAN OR SPOUSE HAD INFERTILITY PROBLEMS? (INFERTILITY PROBLEMS OF

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VETERAN

OR SPOUSE BECOMING PREGNANT. NOTE: INFERTILITY - RELATIVE STERILITY DEFINED AS IN-

ABILITY TO CONCEIVE AFTER 12 OR MORE MONTHS OF INTERCOURSE WITHOUT USE OF CON-

TRACEPTION AND WHEN NEITHER SPOUSE IS SURGICALLY STERILIZED.) ENTER ONE OF THE

Y=YES N=NO

22C1.HAS VETERAN OR SPOUSE HAD INFERTILITY BEFORE GULF SERVICE? ENTER ONE OF THE FOL-

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LOWING CODES IN BLOCK 236. IF NO, GO TO ITEM 22C2.

Y=YES N=NO

22C1(a). STATE MATERNAL AGE DURING FIRST ATTEMPTS TO CONCEIVE. ENTER AGE IN BLOCKS

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237 AND 238.

22C2.HAS VETERAN OR SPOUSE HAD INFERTILITY AFTER RETURN FROM GULF SERVICE? ENTER ONE

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OF THE FOLLOWING CODES IN BLOCK 239. IF NO, GO TO ITEM 22D.

Y=YES N=NO

22C2(a). STATE MATERNAL AGE DURING FIRST ATTEMPTS TO CONCEIVE. ENTER AGE IN BLOCKS

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240 AND 241.

22D. HAS VETERAN OR SPOUSE HAD MISCARRIAGE(S) (NOTE: MISCARRIAGES ARE SPONTANEOUS

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EXPLUSION OF THE PRODUCTS OF CONCEPTION BEFORE 20 WEEKS OF GESTATION - SPONTA-

NEOUS ABORTION) ENTER ONE OF THE FOLLOWING CODES IN BLOCK 242. IF NO, GO TO ITEM

22E.

Y=YES N=NO

22D1.HAS VETERAN OR SPOUSE HAD MISCARRIAGES BEFORE PERSIAN GULF? ENTER ONE OF THE

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FOLLOWING CODES IN BLOCK 243. IF NO, GO TO ITEM 22D2.

Y=YES N=NO

22D1(a). STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 244 AND 245.

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22D2.HAS VETERAN OR SPOUSE HAD MISCARRIAGES AFTER PERSIAN GULF? ENTER ONE OF THE

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FOLLOWING CODES IN BLOCK 246. IF NO, GO TO ITEM 22E.

Y=YES N=N O

22D2(a).STATE MATERNAL AGE AT CONCEPTION, ENTER AGE IN BLOCKS 247 AND 248.

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22E. HAS VETERAN OR SPOUSE HAD STILL BIRTH(S)? (NOTE: STILL BIRTH IS BIRTH AFTER 20 WEEKS

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OF GESTATION OF AN INFANT WHO SHOWED NO EVIDENCE OF LIFE AFTER BIRTH.) ENTER ONE

OF THE FOLLOWING CODES IN BLOCK 249. IF NO, GO TO ITEM 22F.

Y=YES N=N O

22E1.HAS VETERAN OR SPOUSE HAD STILL BIRTH(S) BEFORE GULF SERVICE? ENTER ONE OF THE

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FOLLOWING CODES IN BLOCK 250. IF NO, GO TO ITEM 22E2.

Y=YES N=N O

22E1(a).STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 251 AND 252.

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(252)

22E2.HAS VETERAN OR SPOUSE HAD STILL BIRTH(S) AFTER RETURN FROM GULF SERVICE? ENTER

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ONE OF THE FOLLOWING CODES IN BLOCK 253. IF NO, GO TO ITEM 22F.

Y=YES N=N O

22E2(a).STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 254 AND 255.

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(255)

22F. HAS VETERAN OR SPOUSE HAD INFANT DEATH(S). (NOTE: DEATH THAT OCCURRED WITHIN ONE

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YEAR OF BIRTH AMONG BABIES BORN ALIVE.) ENTER ONE OF THE FOLLOWING CODES IN BLOCK

256. IF NO, GO TO ITEM 22G.

Y=YES N=N O

22F1.HAS VETERAN OR SPOUSE HAD INFANT DEATH(S) BEFORE GULF SERVICE? ENTER ONE OF THE

(257)

FOLLOWING CODES IN BLOCK 257. IF NO, GO TO ITEM 22F2.

Y--YES N=N O

22F1(a). STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 258 AND 259.

(258)

(259)

22F2.HAS VETERAN OR SPOUSE HAD INFANT DEATH(S) AFTER GULF SERVICE? ENTER ONE OF THE

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FOLLOWING CODES IN BLOCK 260. IF NO, GO TO ITEM 22G.

Y=YES N=N O

4

(1) DESCRIBE SYMPTOM

(2) ICD-9-CODES

(3) MO. & YR OF ONSET

(4) DURATION

(5) CURRENTLY

NARRATIVE

MONTH

YEAR

(MONTHS)

PRESENT?

Y=YES N=NO

(273-322)

(323-382)

(383-402)

(403-412)

A

(273-277)

(323-328)

(383-384)

(403)

B

(278-282)

(329-334)

(385-386)

(404)

C

(283-287)

(335-340)

(387-388)

(405)

D

(288-292)

(341-346)

(389-390)

(406)

E

(293-297)

(347-352)

(391-392)

(407)

F

(298-302)

(353-358)

(393-394)

(408)

G

(303-307)

(359-364)

(395-396)

(409)

H

(308-312)

(365-370)

(397-398)

(410)

I

(313-317)

(371-376)

(399 400

(411)

J

(318-322)

(377-382)

(401-402)

(412)

5

JETFORM

NAME:

SSN:

I. HEMATOLOGY/ONCOLOGY. BLOCK 426

(426)

J. INFECTIOUS DISEASES/PARASITOLOGY. BLOCK 427

(427)

K. NEPHROLOGY. BLOCK 428

(428)

L. NEUROLOGY. BLOCK 429

(429)

M. OCCUPATIONAL MEDICINE. BLOCK 430

(430)

N. PULMONARY. BLOCK 431

(431)

O. PSYCHIATRY. BLOCK 432

(432)

P. PSYCHOLOGY/PSYCHOMETRIC TESTING. BLOCK 433

(433)

Q. RHEUMATOLOGY. BLOCK 434

(434)

6

JETFORM

DESCRIBE DIAGNOSIS (Narrative)

(27B)

27A.

ICD-9-CM (Codes)

(436)

(437)

(438)

(439)

(440)

A. (PRIMARY)

(441)

(442)

(443)

(444)

(445)

B.

(446)

(447)

(448)

(449)

(450)

C.

(451)

(452)

(453)

(454)

(455)

D.

E

(456)

(457)

(458)

(459)

(460)

.

(461)

(462)

(463)

(464)

(465)

F.

(466)

(467)

(468)

(469)

(470)

G.

(471)

(472)

(473)

(474)

(475)

H.