Citation Nr: 0119519 Decision Date: 07/27/01 Archive Date: 07/31/01 DOCKET NO. 00-21 516 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Brian J. Milmoe, Counsel INTRODUCTION The veteran served on active duty from March 1966 to January 1970, with additional, unverified service during the 1980s. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision entered in December 1998 by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania, denying entitlement of the veteran to service connection for post-traumatic stress disorder (PTSD). Such claim was denied on the basis that evidence of a verifiable stressor was not presented, without regard to prior, final RO determinations entered in 1996 and 1997. A notice of disagreement as to the December 1998 denial was submitted to the RO in October 1999, wherein the veteran indicated that he would be requesting both RO and Board hearings. An RO hearing was scheduled to occur in December 1999 and prior to its occurrence, the veteran through his representative communicated with the RO that he did not desire to have a personal hearing, but wished to have his pending appeal processed. A statement of the case, including reference to the modification to 38 C.F.R. § 3.304(f), effective from March 7, 1997, see 64 Fed. Reg. 32807 (1999), was furnished to the veteran in August 2000. A substantive appeal was submitted to the RO in September 2000, wherein it was specifically noted that the veteran did not wish to appear for a Board hearing. The RO advised the veteran by a letter, dated in November 2000, of the transfer of his appeal to the Board, as well as the procedure for the submission of additional evidence, among other things. Received by the Board in January 2001 were additional items of evidence, along with waiver of initial consideration by the RO. Further evidence was also received by the Board in May 2001, without a waiver of RO consideration, but the Board through internal procedures thereafter contacted the veteran's representative, who in turn furnished in July 2001 a written waiver of initial consideration by the RO. While the submission of such evidence is outside the 90-day period allotted following the certification of the veteran's appeal to the Board, the favorable disposition herein reached as to the newness and materiality of the evidence presented to reopen the veteran's claim, based on other evidence submitted, obviates the need to undertake those actions set forth in 38 C.F.R. § 20.1304 (2000). It is also noted that, while the veteran's claim for PTSD remained pending at the RO, he initiated claims for service connection for fecal incontinence and for an increased rating for service-connected hemorrhoids in March 1999. Only the claim for increase was addressed by the RO in a rating decision of September 1999 or thereafter, and such claim was denied. A notice of disagreement with the September 1999 denial was submitted in October 1999. Following the receipt of additional evidence, the RO in a rating determination entered in August 2000 increased the rating for hemorrhoids from 10 to 20 percent, the maximum rating possible, noting that such action granted all the benefits for which a notice of disagreement had been filed. Based on the RO's grant, no further development as to that issue was undertaken, nor was such issue certified to the Board for review. The issue of entitlement to a schedular rating in excess of 20 percent has been granted in full and is not herein addressed. AB v. Brown, 6 Vet. App. 35 (1993). However, the issue of entitlement to an extraschedular rating should be considered by the RO. The issue of entitlement to service connection for fecal incontinence is referred to the RO for consideration. Finally, the veteran appears to be raising a claim for a total disability rating based on individual unemployability. This issue is referred to the RO for appropriate action. FINDINGS OF FACT 1. The veteran's entitlement to service connection for PTSD was denied by the RO in June and July 1996, and most recently, in January 1997; written notice of the most recent denial was provided to the veteran later in January 1997; a timely appeal of the January 1997 denial was not thereafter initiated within the time limits prescribed by law. 2. A claim to reopen for entitlement to service connection for PTSD was submitted to the RO in January 1998. 3. The evidence added to the record since entry of the RO's determination in January 1997 at least in part bears directly and substantially upon the specific matter under consideration, is not duplicative or cumulative of previously submitted materials, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to decide fairly the merits of the claim to reopen for service connection for PTSD. CONCLUSIONS OF LAW 1. The rating decision of the RO in January 1997, wherein the veteran's claim of entitlement to service connection for PTSD was most recently denied, is final. 38 U.S.C.A. § 7105(a), (b), (c) (West 1991). 2. Since entry of the RO's determination in January 1997, denying entitlement to service connection for PTSD, new and material evidence to reopen the previously denied claim has been presented. 38 U.S.C.A. § 5108 (West 1991 & Supp. 2000); Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000); 38 C.F.R. § 3.156 (2000). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initial consideration of the veteran's entitlement to service connection for PTSD was accorded by the RO in its rating decisions of June and July 1996, and following such denials, no appeal was initiated. The RO again considered the veteran's entitlement to service connection for PTSD in January 1997, when it was determined that it was not shown by the evidence that PTSD was incurred in or caused by service, and specifically, that the evidence presented failed to identify a verifiable stressor. The veteran was advised by letter, dated later in January 1997, of the action taken, but no timely appeal was thereafter initiated. Consequently, the RO's denial in January 1997 became final. 38 U.S.C.A. § 7105(a), (b), (c). The veteran now seeks to reopen his previously denied claim of entitlement to service connection for PTSD with the presentation of new and material evidence. The United States Court of Appeals for the Federal Circuit in Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998), rejected the test for determining the materiality of evidence originally set forth in Colvin v. Derwinski, 1 Vet. App. 171 (1991) (evidence was deemed "material" when there was a reasonable possibility that the additional evidence presented, when viewed in the context of all the evidence, both new and old, would change the outcome of the claim) in favor of the test outlined in 3.156(a); that is, whether the newly presented evidence is so significant that it must be considered to decide fairly the claim. Since Hodge, reviewing a final decision based on new and material evidence became potentially a three-step process. See Elkins v. West, 12 Vet. App. 209 (1999) (en banc). The Court in Elkins held that the two-step process set forth in Manio v. Derwinski, 1 Vet. App. 140, 145 (1991), for the reopening of claims had become a three-step process under the holding of the Federal Circuit in Hodge. The three-step process for review of finally adjudicated claims enumerated in Elkins was as follows: The Secretary must first determine whether new and material evidence has been presented under 38 C.F.R. § 3.156(a); second, if new and material evidence has been presented, immediately upon reopening the Secretary must determine whether, based upon all the evidence and presuming its credibility, the claim as reopened is well grounded pursuant to 38 U.S.C. § 5107(a); and third, if the claim is well grounded, the Secretary may evaluate the merits after ensuring the duty to assist has been fulfilled. New and material evidence means evidence not previously submitted to agency decision makers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to decide fairly the merits of the claim. 38 C.F.R. § 3.156(a). It is noteworthy that a significant change in the law that was effectuated during the pendency of this appeal. Specifically, on November 9, 2000, the President of the United States signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). Among other things, this law eliminated the concept of a well-grounded claim, thereby further changing the Elkins standard. It also redefined and expanded the obligations of VA with respect to the duty to assist, and superseded the decision of the United States Court of Appeals for Veterans Claims (Court) in Morton v. West, 12 Vet. App. 477 (1999), withdrawn sub nom. Morton v. Gober, No. 96-1517 (U.S. Vet. App. Nov. 6, 2000) (per curiam order), which had held that VA cannot assist in the development of a claim that is not well grounded. This change in the law is applicable to all claims filed on or after the date of enactment of the VCAA, or filed before the date of enactment and not yet final as of that date. Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, § 7, subpart (a), 114 Stat. 2096, 2099-2100 (2000). See also Karnas v. Derwinski, 1 Vet. App. 308 (1991). It is evident that the RO has not considered this matter in light of the changes effected by the VCAA. As well, it is possible that the veteran was not fully informed that new and material evidence is required for the reopening of his claim or what that evidence might encompass; that notwithstanding, in light of the favorable action herein taken with respect to the limited question of the newness and materiality of the evidence presented to reopen the previously denied claim, no possibility of prejudice to the veteran is found. See Bernard v. Brown, 4 Vet. App. 384 (1993); VAOGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). Similarly, all evidence needed to adjudicate the issue herein addressed on the merits has been obtained and no prejudice to the veteran would therefore result, despite the fact that the RO has not been afforded the opportunity to consider whether any additional notification or development actions are required under the VCAA. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(a) (2000). Evidence on file at the time of entry of the RO's decision in January 1997, denying most recently the veteran's claim for service connection for PTSD, consisted of service medical records and other documents compiled by the service department and the National Personnel Records Center. Also then on file were his initial application for VA compensation of March 1996; the RO's letter of April 1996 requesting that he furnish information regarding his claimed stressors leading to PTSD, to which he failed to respond; the report of a VA psychiatric examination in June 1996, findings from which culminated in Axis I diagnoses of PTSD and a major depressive disorder; the veteran's written account of his in- service stressors, dated in September 1996; and the report of a VA general medical examination in November 1996. The evidence submitted since entry of the January 1997 rating decision includes, in pertinent part, a duplicate copy of the veteran's stressor statement of September 1996, as well as an in-service photograph of the veteran while aboard an aircraft, April 2001 correspondence from the Department of the Air Force, records of treatment compiled by VA and non-VA medical professionals, and two lay statements, one of which is provided by the veteran's spouse, and the other by a fellow serviceman. In his statement of November 1997, a former serviceman who served with the veteran in the United States Air Force, reported that he had served on active duty with the veteran, including a tour of duty at Dover Air Force Base in receiving war dead being returned from Vietnam, and in Thailand, where the veteran was noted to have flown as an armed crewman on Air Force missions. Also set forth was the fact that the veteran had informed him at the time of an incident occurring on New Year's Eve in 1969, in which the veteran was attacked by a sexual deviate. The veteran's spouse, in her statement of January 2001, indicates that, while in service at Dover Air Force Base, the veteran was profoundly affected by the death of his best friend in combat in Vietnam. She also reported that, in letters sent to her by the veteran during service, the veteran indicated that he was required to make numerous flights into undesignated areas in Laos and Cambodia. Lastly, it was noted that the single, most stressful event was a sexual assault of the veteran by another service person on December 31, 1969. She recalled that, within two weeks of the veteran's discharge from service in January 1970, she was initially made aware of the event occurring on the evening of December 31, 1969, in the presence of military investigators who had come to their home for information regarding the assailant and the December 1969 assault. The evidence submitted by the veteran to reopen his claim for service connection for PTSD must be presumed as true, solely for purposes of determining whether new and material evidence has been presented. See Justus v. Principi, 3 Vet. App. 510 (1992). That being the case, the undersigned, in addressing only the above-cited statements from the veteran's spouse and fellow serviceman, finds that such evidence was not before the RO in January 1997, that it bears directly and substantially upon the specific matter under consideration, that it is not duplicative or cumulative of previously submitted materials, and by itself is so significant that it must be considered in order to decide fairly the merits of the claim to reopen for service connection for an acquired psychiatric disorder. While it is noted that there was of record in January 1997 a statement of the veteran as to the various stressors he encountered in service, the statements from the veteran's spouse and a fellow Air Force serviceperson are supportive of the existence of the veteran's allegations of a 1969 sexual assault, based on the veteran having shared details of the incident with each lay affiant contemporaneous with the event itself or shortly thereafter. Accordingly, the lay statements of the spouse and fellow serviceman are found to constitute new and material evidence under 38 C.F.R. § 3.156(a), and, as such, the previously denied claim is reopened, although consideration of the merits of the reopened claim is deferred pending the completion of certain development requested below. ORDER New and material evidence has been presented to reopen the veteran's previously denied claim of entitlement to service connection for PTSD. To that extent alone, the appeal is granted. REMAND As noted in the Introduction section of this decision, there is a pending claim of entitlement to an extraschedular rating for service connected hemorrhoids. This issue must be addressed by the RO as directed below. With respect to the veteran's reopened claim for service connection for PTSD, further development of the evidence both as to the veteran's claimed stressors and applicable diagnosis is found to be in order for compliance with the VA's duty-to-assist obligation. Additional attempts at stressor verification are needed, and in light of the occurrence of various assaults on the veteran during post- service years in connection with his employment as a high school principal, further clarification is needed as to the extent of such assaults and their effect, if any, on development of his PTSD. Further medical input, including a psychiatric examination, is also indicated. In Patton v. West, 12 Vet. App. 272, 283 (1999), the Court discussed VA Adjudication Procedure Manual M21-1 (Manual M21- 1), Part III, paragraph 5.14c (Feb. 20, 1996), noting that such is a substantially expanded version of former Manual M21-1, Part III, paragraph 7.46c(2) (Oct. 11, 1995) (evidence of behavior changes that may indicate occurrence of personal assault as an in-service stressor in a PTSD context). See YR v. West, 11 Vet. App. 393, 398-99 (1998). The Court found that such Manual provision was regulatory in nature. The Manual provisions set forth the development actions necessary to assist the veteran in obtaining supportive evidence of the claimed personal assault during service. The general Manual M21-1 provisions on PTSD claims in paragraph 5.14 require that in cases where available records do not provide objective or supportive evidence of the alleged in-service stressor, it is necessary to develop for this evidence. Manual M21-1, Part III, paragraph 5.14b(3). As to personal-assault PTSD claims, more particularized requirements are established. Specifically, Manual M21-1, Part III, paragraph 5.14c, provides in pertinent part: The service records may be devoid of evidence [of personal assault] because many victims of personal assault, especially sexual assault and domestic violence, do not file official reports either with military or civilian authorities. Therefore, development to alternative sources for information is critical. Alternative sources that may provide credible evidence of the in- service stressor include: (a) Medical records from private (civilian) physicians or caregivers who may have treated the veteran either immediately following the incident or sometime later; (b) Civilian police reports; (c) Reports from crisis intervention centers, such as rape crisis centers or centers for domestic abuse; (d) Testimonial statements from confidants such as family members, roommates, fellow service members, or clergy; (e) Copies of personal diaries or journals. Manual M21-1, Part III, paragraph 5.14c (5). Rating board personnel must carefully evaluate all the available evidence. If the military record contains no documentation that a personal assault occurred, alternative evidence might still establish an in-service stressful incident. Behavior changes that occurred at the time of the incident may indicate the occurrence of an in- service stressor. Examples of behavior changes that might indicate a stressor are (but not limited to): (a) Visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment; (b) Sudden requests that the veteran's military occupational series or duty assignment be changed without other justification; (c) Lay statements indicating increased use or abuse of leave without an apparent reason such as family obligations or family illness; (d) Changes in performance and performance evaluations; (e) Lay statements describing episodes of depression, panic attacks or anxiety but no identifiable reasons for the episodes; (f) Increased or decreased use of prescription medications; (g) Increased use of over-the-counter medications; (h) Evidence of substance abuse such as alcohol or drugs; (i) Increased disregard for military or civilian authority; (j) Obsessive behavior such as overeating or undereating; (k) Pregnancy tests around the time of the incident; (l) Increased interest in tests for HIV or sexually transmitted diseases; (m) Unexplained economic or social behavior changes; (n) Treatment for physical injuries around the time of the claimed trauma but not reported as a result of the trauma; (o) Breakup of a primary relationship. Manual M21-1, Part III, paragraph 5.14(c) 7. Rating boards may rely on the preponderance of evidence to support their conclusions even if the record does not contain direct contemporary evidence. In personal assault claims, secondary evidence may need interpretation by a clinician, especially if it involves behavior changes. Evidence that documents such behavior changes may require interpretation in relationship to the medical diagnosis by a VA neuropsychiatric physician. Manual M21-1, Part III, paragraph 5.14c (8), Regarding personal-assault cases, the Court noted in Patton, supra, that VA has provided for special evidentiary- development procedures, including interpretation of behavior changes by a clinician and interpretation in relation to a medical diagnosis. The Court further pointed out that, in YR, where the veteran had been placed under hypnosis by a licensed social worker who concluded thereafter that there was no doubt that the veteran had been raped traumatically, a remand was required because, among other deficiencies in the adjudication, the Board had "entirely failed to consider the hypnosis evidence, let alone discuss its weight and credibility" or provide an adequate statement of "reasons [or] bases . . . for its acceptance or rejection". YR, 11 Vet. App. at 397-99. Moreover, the Court noted in Patton that in two places Manual M21-1, Part III, paragraph 5.14c, appears improperly to require that the existence of an in-service stressor be shown by "the preponderance of the evidence". Manual M21-1, Part III, paragraph 5.14c(3), (9). Any such requirement would be inconsistent with the statutory requirement that when there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. As additional medical examination is deemed to be necessitated, the veteran is hereby advised of the importance of appearing for such evaluation. In that vein, the veteran's attention is directed to the following: Sec. 3.655 Failure to Report for Department of Veterans Affairs Examination. (a) General. When entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination, or reexamination, action shall be taken in accordance with paragraph (b) or (c) of this section as appropriate. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. For purposes of this section, the terms examination and reexamination include periods of hospital observation when required by VA. (b) Original or reopened claim, or claim for increase. When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination was scheduled in conjunction with any other original claim, a reopened claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied. 38 C.F.R. § 3.655 (2000). Accordingly, based on the foregoing, this matter is hereby REMANDED to the RO for the following actions: 1. The RO must review the claims file and ensure that all notification and development actions required by the VCAA are completed with regard to the issues of service connection for PTSD and an extraschedular rating for hemorrhoids. In particular, the RO should ensure that the new notification requirements and development procedures contained in sections 3 and 4 of the Act (to be codified as amended at 38 U.S.C. §§ 5102, 5103, 5103A, and 5107) are fully complied with and satisfied. 2. The RO should contact the veteran in writing for the purpose of advising him of the evidence needed to substantiate his reopened claim for service connection for PTSD based on governing laws and regulations and his claim for an extraschedular rating for hemorrhoids. The RO should also advise the veteran of his right to submit any additional argument and/or evidence in support of his claims. Such evidence may be of a lay or medical variety. 3. The RO should advise the veteran in writing that he may submit proof of marked interference with his employment due to his hemorrhoids. He should also be requested to submit evidence of frequent periods of hospitalization for this disorder in support of his claim for an extraschedular evaluation. Any evidence submitted by the veteran in this regard should be permanently associated with the claims file. 4. The veteran must also be requested to submit a comprehensive written statement containing as much detail as possible regarding any and all claimed in-service stressors, including the sexual assault of December 31, 1969, which led to the onset of his PTSD. He should be asked to provide specific details of the claimed stressful events during service, such as the dates of any and all incidents to within seven days, types and locations of the incidents, full names and service numbers of any other persons present, detailed descriptions of events, and any other identifying information. The veteran must be advised that this information is necessary to obtain supportive evidence of his claimed stressors, and that he must be as specific as possible because without such details adequate research for verifying information cannot be conducted. He must also be advised to obtain and submit any verifying data from individuals who might have knowledge of the in-service stressors claimed to have led to the onset of PTSD, such as statements from fellow servicemen or family members. In particular, the veteran should respond to the following with as much specificity as possible: (a) Was any medical care sought from service department or civilian medical personnel immediately following the incident or in the months following the incident? (b) Was the incident ever reported to civilian or military authorities, and, if so, to whom and at what location? (c) Were the services of a crisis intervention center, such as a rape crisis center, ever sought? (d) To which person or persons did the veteran confide that a sexual assault had occurred on or about December 31, 1969, including any family members, roommates, fellow service members, or clergy, and at what point in time was this information shared by the veteran with any of the foregoing? Is the veteran able to obtain any statements from these individuals? (e) Was an entry made contemporaneous with the in-service sexual assault in any personal diary or journal of the veteran regarding the assault in question? (f) Did any behavioral changes occur at the time of the incident indicating the occurrence of an in-service stressor, including but not limited to (i) a visit to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment; (ii) a sudden request that the veteran's military occupational specialty or duty assignment be changed without other justification; (iii) the occurrence of episodes of depression, panic attacks or anxiety but no identifiable reasons for the episodes; (iv) substance abuse involving alcohol or drugs; (v) increased use of leave without immediate reason; (vi) changes in performance evaluations; (vii) increased or decreased use of prescribed or over- the-counter medications; (viii) disregard for military or civilian authority; (ix) obsessive behavior such as over or under eating; (x) human immunodeficiency virus, and/or sexually transmitted disease testing following the in-service assault; or (xi) unexplained economic or social behavior changes? The veteran should also be requested to provide complete details regarding the incidents occurring post-service in which he was assaulted by students in his capacity as a high school principal, as well as any other events occurring during post-service years which may have led to the onset of PTSD. Any documentary evidence as to the foregoing that the veteran holds in his possession or may be obtained with the assistance of VA should be fully noted. 5. Based on the information provided by the veteran, and that already demonstrated by the record, the RO should undertake those actions necessary to assist the veteran in obtaining evidence corroborative of the alleged in-service stressors, including the sexual assault. 6. In addition, the veteran should be contacted by the RO for the specific purpose of requesting that she provide a listing of the names and addresses of those VA and non-VA medical professionals or institutions who have evaluated and/or treated him for PTSD or any other psychiatric disorder prior to and since his discharge from military service. The approximate dates of any such evaluation or treatment should also be provided, to the extent possible. Permission should also be obtained from him to contact the Duquesne City School District and obtain any administrative and medical records in their possession which might pertain to psychiatric illness or hemorrhoids. He should also be requested to provide a listing of medical providers from whom he obtained treatment for hemmorhoids in recent years. Thereafter, the RO should, after obtaining proper authorization, obtain treatment records from those medical professionals or institutions referenced in connection with the aforementioned request that are not already contained in the claims folder, to include all clinical records from Dr. David R. Allen and Dr. Alan A. Summers. Any and all VA treatment records must be obtained regardless of whether in fact the veteran responds to the foregoing request. Such records, once obtained, must then be added to the claims folder. 7. The RO should through contact with the National Personnel Records Center and/or the Department of the Air Force obtain a complete set of service medical and personnel records of the veteran, including any and all records of neuropsychiatric treatment or counseling. Once obtained, those records must then be made a part of the veteran's claims folder. 8. Based on any additional information obtained regarding the claimed stressor(s), as well as the information relating thereto previously supplied by the veteran and any pertinent evidence currently of record, the RO should prepare a summary of all the claimed stressors, with as much detail as possible. This summary, along with a copy of the veteran's Department of Defense Form 214 and the applicable Department of the Air Force Form, his service personnel records, and all associated documents should then be sent to the United States Armed Services Center for Research of Unit Records Army (USASCRUR) and/or the United States Air Force with a request to provide any information that may corroborate the veteran's alleged stressor(s). If this organization is unable to research the type of stressor involved in this case, it should so note that fact for the record. 9. Following receipt of the USASCRUR/United States Air Force report, as well as the completion of any additional development requested above or suggested by those agencies, the RO should prepare a report detailing the nature of any in-service stressful event(s), verified by the USASCRUR/United States Air Force or through other documents. If no stressor is verified, the RO should so state that fact in its report. Such report should then to be added to the claims file. 10. Thereafter, the veteran is to be afforded a VA medical examination by physician in the specialty of psychiatry for the purpose of determining the nature and etiology of his claimed PTSD. The veteran's claims folder in its entirety is to be furnished to the examiner prior to any evaluation of the veteran for use in the study of this case. Such examination is to include a review of the veteran's history and current complaints, as well as a comprehensive mental status evaluation. Any indicated diagnostic studies, including psychological testing and PTSD sub-scales, must also be accomplished if deemed warranted by the examiner. All established psychiatric diagnoses are then to be fully set forth. It is requested that the psychiatric examiner offer a professional opinion, with full supporting rationale, as to the following: (a) Is it at least as likely as not, based on clinical observations made to date and a review of the behavioral changes noted by the record since the incident in question, that the veteran was the victim of a sexual assault in service on or about December 31, 1969? (b) Does the veteran have PTSD meeting the criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994), and, if so, is it at least as likely as not that the veteran's PTSD is the result of an in-service sexual assault or some other documented in-service stressor? Use by the examiner of the italicized standard of proof in formulating a response is requested. 11. The veteran should also be afforded a surgical examination to determine whether and to what degree the veteran's hemorrhoids would interfere with his ability to pursue gainful employment. A work history should be obtained from the veteran with a listing of the reasons for leaving employment. The claims folder must be made available to the examiner prior to the examination. All indicated tests and studies should be accomplished. 12. Following the completion of the foregoing actions, the RO should review the examination reports. If such reports are not in complete compliance with the instructions provided above, appropriate action should be taken to return such examination reports for any and all needed action. 13. Lastly, the RO should readjudicate the veteran's reopened claim of entitlement to service connection for PTSD on the basis of all the evidence on file and all governing legal authority, including the VCAA and as applicable, 38 C.F.R. § 3.655. In the event that the veteran fails to appear for the scheduled VA examination, the letter notifying him of the date and time of the examination and the address to which the letter was sent should be included in the claims folder. The RO should also adjudicate the issue of entitlement to an extraschedular rating for hemorrhoids. If the benefits sought on appeal are not granted, the veteran and his representative should be provided with a supplemental statement of the case which should include a summary of the evidence and applicable law and regulations considered pertinent to the issues currently on appeal, inclusive of 38 C.F.R. § 3.655. An appropriate period of time should then be allowed for a response, before the record is returned to the Board for further review. The veteran and his representative are advised of the need to submit a substantive appeal to the issue of entitlement to an extraschedular rating for hemorrhoids if the Board is to address this matter. The veteran need take no action until otherwise notified. The purpose of this remand is to obtain additional evidentiary and procedural development. No inference should be drawn regarding the final disposition of the claim in question as a result of this action. The law requires full compliance with all orders in this remand. See Stegall v. West, 11 Vet. App. 268 (1998). Moreover, this claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. Iris S. Sherman Member, Board of Veterans' Appeals