Citation NR: 9605602 Decision Date: 03/07/96 Archive Date: 03/16/96 DOCKET NO. 94-16 482 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to service connection for a psychiatric disability. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD Howard A. Dean, Associate Counsel REMAND The veteran served on active duty from December 1979 to May 1982. This matter is before the Board of Veterans' Appeals (Board) on appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The veteran contends, in essence, that he was first treated for a psychiatric disability while in active service, and that service connection should be granted in light of the lay evidence submitted. The veteran’s service medical records show that on his separation examination “39-12” is listed in the “purpose of examination “section. Air Force Manual 39-12 addresses “[s]eparation for unsuitability, misconduct, personal abuse of drugs; resignation or request for discharge for the good of the service; and procedures for the rehabilitation program.” Thus, it appears that he was being separated for one of the above mentioned reasons. However, his complete personnel file, which undoubtedly includes information regarding the precise basis of his separation from service, has not been obtained. Information which may tend to confirm the veteran’s assertions regarding pertinent treatment may also be located therein. Accordingly, a request for those records should be made. It also appears that the veteran’s post-service medical records are incomplete. The veteran has reported treatment at two different locations after separation from service: a San Diego mental health clinic in 1983, and a San Jose mental health clinic from 1983-1984, and subsequent treatment. The records received from Santa Clara County Mental Health begin in January 1985 reporting the veteran’s history of hearing voices for “several years” and his brief participation in a San Diego residential program named “Isis House”(date unspecified). It is also reported that he had been seen at “CMH” several months previously where he was given medication. Other treatment record on file refer to more recent psychiatric treatment. It appears to the Board that records of psychiatric treatment prior to 1985 likely exist and would be necessary to provide a record upon which an informed determination of the matter could be made. Robinette v. Brown, 8 Vet.App. 69 (1995). In support of his claim the veteran has submitted written statements from his mother, step mother and former spouse. His former spouse recalled several sessions with a marriage counselor during service and a visit to the base chaplain who apparently referred the veteran to a mental health specialist. His step mother recalled his demeanor during his stay during late 1982 and early 1983. He reportedly resided with his sister in San Diego for an unknown period of time prior to 1985. No statement has been received from the veteran’s sister and his mother’s statement is not precise regarding the approximate time that he resided with her after service. The Board is of the opinion that these family members could offer probative evidence to supplement the record. Where the record before the Board is inadequate to render a fully informed decision on the issue under consideration, a remand to the RO is required in order to fulfill the statutory duty to assist. Ascherl v. Brown, 4 Vet.App. 371, 377 (1994). Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should contact the National Personnel Records Center and request that a comprehensive search be conducted for additional service medical records for the veteran. In addition, his complete military personnel file should be obtained. Of significance are all records from George Air Force Base, Victorville, California from December 1979 to May 1982. The RO should specifically request records from the base mental health clinic to include counseling services. All attempts to locate additional service medical records should be documented in the claims folder. 2. The RO should request that the veteran identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for any psychiatric disorder since service. To ensure that all records are located, the veteran’s current address should be verified prior to the mailing of materials. With any required authorization from the veteran, the RO should attempt to obtain copies of pertinent treatment records identified by the veteran which have not been previously secured. Of significance are records of psychiatric treatment he received prior to January 1985. The RO should request that the veteran’s representative provide necessary assistance in all development actions ordered herein. 3. The RO should order field interviews of the veteran’s mother, step mother, former spouse, sister and brother-in-law, in order to obtain additional evidence to assist in the determination of the nature and probable onset of the veteran’s current psychiatric disorder, and to assist in identifying any additional pertinent evidence. All persons interviewed should be asked to recall as precisely as possible, the time and extent of their contact with the veteran either during or after service. In particular, the veteran’s former spouse should be asked to identify the source of the marriage counseling she reported to have received with the veteran during service. All persons interviewed should be asked to state their knowledge as to when the veteran initially obtained psychiatric treatment following service. 4. The RO should schedule the veteran for a VA psychiatric examination. The claims folder must be made available to the examiner for review in conjunction with the examination of the veteran and should include all information obtained pursuant to the aforementioned actions. The examiner should be specifically requested to review the historical data in the claims folder in order to obtain a true picture of the progress of the veteran's psychiatric disorder. The examiner should also elicit a detailed history of the onset of psychiatric symptoms from the veteran. The examiner should provide an opinion as to the probable etiology and onset of the veteran's psychiatric disability, to include an opinion as to whether his current psychiatric disability may be dissociated from psychiatric symptoms observed or reported during or subsequent to service. The examiner should indicate the basis for the opinion and fully explain the rationale for the opinion. 5. After the development requested above has been completed, the RO should undertake any other indicated development and then readjudicate the veteran’s claim of entitlement to service connection for a psychiatric disability. If the benefit sought is not granted, a supplemental statement of the case should then 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 the final outcome warranted. No action is required of the veteran until he is otherwise notified. MARK J. SWIATEK Acting Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. 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 remand 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) (1995). - 2 -