Citation Nr: 0810088 Decision Date: 03/27/08 Archive Date: 04/09/08 DOCKET NO. 04-41 955 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for shell fragment wounds of the back. 2. Entitlement to service connection for jungle rot. 3. Entitlement to service connection for emersion foot. 4. Entitlement to service connection for loss of teeth. 5. Entitlement to service connection for residuals of vampire bat bite. 6. Entitlement to service connection for residuals of a rabies shot. 7. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a concussion. 8. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for residuals of malaria. 9. Entitlement to service connection for tinnitus. 10. Entitlement to a compensable evaluation for bilateral hearing loss. 11. Entitlement to an evaluation in excess of 30 percent disabling for post traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and C.A. ATTORNEY FOR THE BOARD J.G. Reinhart, Associate Counsel INTRODUCTION The veteran served on active duty from October 1967 to August 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from May 2003, April 2005, and August 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In the August 2003 rating decision, the RO granted service connection for PTSD and assigned an initial evaluation. In the August 2006 rating decision, the RO denied service connection for tinnitus. All other issues listed on the title page arise from the April 2005 rating decision. In January 2006, the veteran and C.A. testified at a personal hearing before a Decision Review Officer (DRO). In February 2007, the veteran and C.A. testified at a personal hearing before the undersigned Veterans Law Judge. Transcripts of these hearings are of record. In his April 2007 substantive appeal of the RO's denial of his claim of entitlement to service connection for tinnitus, the veteran requested a hearing before a member of the Board. To the extent that failing to afford him the requested hearing prior to the Board's adjudication of that appeal is error, the Board finds this to be harmless error. The Board is granting the benefit sought and the RO will assign a disability rating and effective date in the first instance. If the veteran disagrees with those assignments, he will have an opportunity to appeal, including the opportunity for a hearing. Because a decision granting service connection for tinnitus will not prejudice the veteran, the Board is not precluded from adjudicating his appeal as to this matter at this time. See Bernard v. Brown, 4 Vet. App. 384, 393 (1993). FINDINGS OF FACT 1. As of December 2005, the veteran had perfected appeals to the Board of the RO's denial of claims of entitlement to service connection for shell fragment wounds of the back, jungle rot, emersion foot, loss of teeth, residuals of vampire bat bite, residuals of rabies shot, the RO's denial of claims to reopen previously denied claims of entitlement to service connection for a concussion and for residuals of malaria, and the RO's denial of higher ratings for bilateral hearing loss and PTSD. 2. In a January 2006 written statement, prior to the promulgation of a decision in the appeal, the veteran stated that he wanted to withdraw all issues on appeal except the issues of entitlement to increased evaluations for hearing loss and PTSD. 3. The veteran currently suffers from tinnitus that had its onset during his active service. 4. The veteran's hearing loss is manifested by an average pure tone threshold of 33.33 decibels for each ear with speech discrimination of 84 percent in the right ear and of 86 percent in the left ear. 5. The veteran's PTSD results in no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal pertaining to entitlement to service connection for shell fragment wounds of the back, jungle rot, emersion foot, loss of teeth, residuals of vampire bat bite, residuals of rabies shot, a concussion, and residuals of malaria have been met. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2007). 2. The criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2007). 3. The criteria for entitlement to a compensable evaluation for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.86 Diagnostic Code 6100 (2007) 4. The criteria for entitlement to an evaluation in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202 (2007). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204 (2007). Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. Id. In April 2005, the RO denied the appellant's claims for entitlement to service connection for shell fragment wounds of the back, jungle rot, emersion foot, loss of teeth, residuals of vampire bat bite, residuals of rabies shot; and to reopen previously denied claims of entitlement to service connection for a concussion and for residuals of malaria. The appellant appealed these decisions. In a writing dated in January 2006, the veteran stated that he wanted to withdraw all issues on appeal except the issues of entitlement to increased evaluations for hearing loss and PTSD. Accordingly, the Board has no jurisdiction to decide the veteran's claims for service connection for shell fragment wounds of the back, jungle rot, emersion foot, loss of teeth, residuals of vampire bat bite, and residuals of rabies shot, or to reopen his previously denied claims for entitlement to service connection for a concussion and residuals of malaria. Hence, the appeals regarding these matters must be dismissed. Service connection One of the matters the Board must address is which issue or issues are properly before it at this time. Under 38 U.S.C.A. § 7105(a), an appeal to the Board must be initiated by a notice of disagreement and completed by a substantive appeal after a statement of the case (SOC) is furnished to the veteran. In essence, the following sequence is required: There must be a decision by the RO; the veteran must timely express disagreement with the decision; VA must respond by issuing a statement of the case that explains the basis for the decision to the veteran; and finally the veteran, after receiving adequate notice of the basis of the decision, must complete the process by stating his or her argument in a timely-filed substantive appeal. 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.203. See also 38 U.S.C.A. § 7104; 38 C.F.R. §§ 19.4, 20.101 (the Board has jurisdiction to resolve questions as to its own jurisdiction). See also Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996) (it is a well-established judicial doctrine that any statutory tribunal must ensure that it has jurisdiction over each case before adjudicating the merits, and that a potential jurisdictional defect may be raised by the court or tribunal, sua sponte or by any party at any stage in the proceedings, and, once apparent, must be adjudicated). In August 2006, the RO denied the veteran's claim for entitlement to service connection for tinnitus. He timely filed a notice of disagreement with that decision in February 2007. In response, the RO issued a statement of the case in March 2007 and the veteran timely perfected his appeal to the Board in April 2004 by filing a properly executed VA Form 9. As the procedure outlined above has been completed, the Board has jurisdiction to decide his appeal as to this issue. The January 2006 withdrawal of many claims does not impact this finding as the veteran withdrew those claims at the same time he raised this new claim. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2007). In general, service connection requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in- service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in- service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In cases where chronicity of a disorder is not established during service or within a presumptive period, if applicable, service connection may still be granted upon a showing of continuity of symptomatology. 38 C.F.R. § 3.303(b). VA must consider both lay and medical evidence in deciding a claim for entitlement to service connection. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). Lay evidence may be sufficient to grant service connection. Id. When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In a January 2006 statement, the veteran claimed service connection for tinnitus, contending that his exposure to a land mine explosion caused this disability. Service medical records contain a January 1969 note that the veteran sustained a blast concussion of the right ear in the vicinity of Khe Sanh. Notes from the following month state that the veteran had a decrease in hearing acuity and suffered from tinnitus. These notes also report that his hearing had improved and that he no longer had tinnitus. The Board finds that the first element of a service connection claim has been met, that is, an injury or event during service involving the claimed disability. In February 2006, the veteran underwent a VA audiology examination. He reported ringing in his ears. The examiner thereafter referred to this condition as tinnitus. Hence, all lay and medical evidence of record indicates that the veteran currently has tinnitus; satisfying the second element of a service connection claim. The February 2006 examination report contains the examiner's statement that the veteran reported that his tinnitus began in 1995. In explaining his conclusion that the veteran's tinnitus was less likely than not the result of exposure to noise in military service, the examiner commented that the veteran was released from active service in 1970 with onset of tinnitus in 1995 and referred to the veteran's tinnitus as "late-appearing". Thus, the examiner's opinion was based on a factual determination that the veteran's tinnitus began many years after service. Also of record are clinical notes from a February 2007 VA audiology consult. These include the veteran's report that he had experienced tinnitus with onset in January 1969 and that he experienced symptoms day to day. The veteran is competent to report on symptoms that he has experienced. See Layno v. v. Brown, 6 Vet. App. 465, 470 (1994). This is evidence favorable to his claim as it tends to show that his current tinnitus has persisted since service. Based on the above, this claim comes down to determining whether to assign more weight to the report by the February 2006 examiner, coupled with the report in the service medical records that his tinnitus was gone the month following his exposure to the explosion, or, the veteran's written report in the February 2007 questionnaire that his tinnitus began in 1969 and his testimony that he had ringing in the ears since service. Between the two, only the veteran's report in the February 2007 questionnaire is unfiltered by any other individual, and is thus at least as probative as the other reports. Furthermore, the veteran's orally presented estimation of long time periods is not very accurate. During the January 2006 DRO hearing, he testified that he suffered from ringing in the ears for 20 years and that he had suffered from tinnitus since the mine explosion during service. DRO hearing at page 23. The veteran was discharged from service 36 years prior to that hearing. Clear from this testimony, in rendering his oral statements as to history the veteran does not accurately assign precise numbers. Thus, any report made to the examiner as to date of onset of tinnitus is not reliable. Notwithstanding the above, the Board finds that the evidence as to this third element is in equipoise. Hence, the Board must find in favor of the veteran. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. For these reasons, service connection for tinnitus is warranted, and his claim must be granted. Increased ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding the veteran's increased evaluation claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, No. 05-2424 (U.S. Vet. App. Nov. 19, 2007), and whether the veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the U.S. Court of Veterans Appeal (now the U.S Court of Appeals for Veterans Claims and herinafter referred to as the Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period (as in this case). Id. at 126. Hart appears to extend Fenderson to all increased evaluation claims. Hearing loss Service connection for bilateral hearing loss was established in an August 2003 rating decision and a noncompensable (0 percent) evaluation was assigned. That evaluation remained in place until the veteran filed his current claim for an increased rating, in November 2004. Evaluations of defective hearing are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level as measured by pure tone audiometric tests in the frequencies 1,000, 2,000, 3,000 and 4,000 Hertz. 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from defective hearing, the rating schedule requires assignment of a Roman numeral designation, ranging from I to XI. Other than exceptional cases, VA arrives at the proper designation by mechanical application of Table VI, which determines the designation based on results of standard test parameters. Id. Table VII is then applied to arrive at a rating based upon the respective Roman numeral designations for each ear. Id. For exceptional hearing impairment, 38 C.F.R. § 4.86 (2007), states that when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear is to be evaluated separately. Id. Of record are results from audiological testing conducted in February 2006 and in February 2007. The February 2006 testing was conducted pursuant to a VA examination for compensation purposes. That examination yielded test results of pure tone thresholds in the right ear at 500, 1000, 2000, 3000, and 4000 Hertz of 15, 15, 15, 40, and 6 decibels, respectively, for an average over the four frequencies of interest of 33.33 decibels. Pure tone thresholds measured in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz were 15, 15, 20, 30, and 65 decibels, respectively, with an average over the four frequencies of interest of 33.33 decibels. Speech audiometry revealed speech recognition ability of 84 percent in the right ear and of 86 percent in the left ear. Application of 38 C.F.R. § 4.85 Table VIA to the February 2006 measurements results in assignment of Roman Numeral II to each ear, for the purpose of determining a disability rating. A noncompensable, or 0 percent, rating is derived from Table VII of 38 C.F.R. § 4.85 by intersecting row II with column II. Also of record are results from audiological testing in February 2007, pursuant to an audiology consult. Word recognition was 96 percent for the right ear and 92 percent for the left ear. Pure tone threshold measurements are included, but only in graphical, rather than numerical, format. In Kelly v. Brown, 7 Vet. App. 471 (1995), the Court remarked as to the limitations of the Court when it comes to fact finding. In that case, the record included a graph comparing that appellant's current hearing acuity to his hearing acuity during service. Id. at 474. The Court stated: "[t]he Court is unable to interpret the results of this graph and, therefore, cannot determine whether the Board accurately applied the standards of the regulation. Interpretation of Dr. Lang's report requires a factual finding. [citation omitted] Thus, the Court is unable to review the record without engaging in fact-finding, which is not the role of this Court in the first instance." The Court remanded that matter to the Board because the Board had failed to provide adequate reasons and basis for its decision. Id. This is not a holding that the Board is precluded from interpreting graphical test results, only a statement of the Court's limitations as to fact finding. Regardless, the Board need not interpret the numbers represented by the graph of the February 2007 audiometric testing. Rather, the Board merely makes a determination here that the graph does not represent measurements that are even marginally near those necessary to satisfy the criteria for a compensable evaluation, therefore providing evidence against this claim. The graph clearly shows that the neither ear approached the following points: 40 decibels at 500 Hertz, 40 decibels at 1000 Hertz, 40 decibels at 2000 Hertz, 60 decibels at 3000 Hertz, and 80 decibels at 4000 Hertz. Even considering the outcome if both ears did meet these values, the largest average hearing loss over the four frequencies of interest would be 60 decibels in both ears. Given that the word recognition scores from that test fell within the 92 to 100 percent discrimination bracket, these hypothetical results would require assignment of Roman Numeral II to each ear. Intersection of column II with row II, of Table VI, would result in a noncompensable evaluation. Nor would the "worse than worst possible case" just described meet the criteria for exceptional hearing loss under 38 C.F.R. § 4.86. In short, the results from the February 2002 audiology testing do not provide, even with speculation overwhelmingly biased in favor of the veteran, for assigning a compensable evaluation for the veteran's bilateral hearing loss. The Board does not find evidence that the veteran's hearing loss disability should be increased for any period based on the facts found during the whole appeal period. The evidence of record from the day the veteran filed the claim to the present supports the conclusion that the veteran is not entitled to additional increased compensation during any time within the appeal period. As such, the claim for a higher evaluation for bilateral hearing loss must be denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2007). PTSD Service connection was established for PTSD in the May 2003 rating decision from which the veteran appeals. At that time, the RO assigned a 10 percent evaluation, effective in January 2003, the date of the veteran's claim for entitlement to service connection for PTSD. In March 2005, the RO changed this evaluation to 30 percent disabling, also effective in January 2003. Criteria for evaluating PTSD are found at 38 C.F.R. Part 4, Diagnostic Code 9411 (2007). A 30 percent evaluation is assigned where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. Part 4, Diagnostic Code 9411 (2007). A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. It is further noted that the nomenclature employed in the portion of VA's Schedule for Rating Disabilities ("the Schedule") that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130 (2007). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health - illness. Higher scores correspond to better functioning of the individual. GAF scores ranging between 61 and 70 are assigned in cases where symptoms, if present, are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th. ed., 1994). GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. Id. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a) (2007). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b) (2007). In April 2003, June 2004, and February 2005, the veteran underwent VA examinations with regard to his PTSD. VA outpatient clinic notes provide additional evidence relevant to determining the proper evaluation for his PTSD. All examiners reported the veteran to be neatly dressed and cooperative and without delusions, hallucinations, abnormal speech, abnormal thought processes, or mood impairment. His principle symptoms include some insomnia, mostly waking at night if he hears a sound and having to investigate its source, intrusive thoughts, nightmares, irritability, heightened startle response, and problems with anger. He reported a history of violent behavior. He has, however, consistently reported that he has a number of friends. During the last two examinations, the veteran reported working full time as an electrician. During the February 2005 examination, he expressed his fear of an inability to keep a job and reported that he had had three jobs since the prior examination. However, he explained that that the first job ended due to expiration of the contract, a cause clearly not attributable to the veteran's PTSD. As to the other two positions, his explanations indicate a number of factors, including safety issues not caused by his behavior. The April 2003 examiner described the veteran's PTSD as "mild", clearly providing evidence against this claim. Both subsequent examination reports state that his PTSD had not worsened since the first examination, providing more evidence against this claim. GAF scores of 72 were assigned following the April 2003 and June 2004 examinations and a GAF score of 65 was assigned following the February 2005 examination. VA outpatient treatment records do not present a significantly different picture from depicted by the examination reports. An August 2003 note assigned a GAF score of 55. May 2006 VA outpatient indicate that the veteran's affect was irritable and dysphoric, consistent with content. January 2007 notes contain a report that the veteran was concerned about recent medical problems as well as legal problems resulting from a driving while intoxicated charge. February 2007 VA outpatient notes contain a report that the veteran exhibited hesitant speech but he had coherent thought processes. At that time he endorsed feelings of hopelessness, had depressed mood but without suicidal plan or intent, his affect was anxious and dysphoric. The attending physician stated that the veteran wanted to return to work but there was some doubt as to his capabilities given the severity of his anxiety and depressive symptoms. That physician described his condition as "continued serious PTSD symptoms." The VA examinations and outpatient treatment records are found to provide, overall, evidence against assigning a rating higher than 30 percent for the veteran's PTSD. The extent of his social impairment amounts to irritability, with difficulty controlling his temper. The Board is aware that his recent driving while intoxicated charge can reasonably be construed as social impairment. However, the veteran has reported a continual relationship with a significant other and that he has a number of friends with whom he engages in social interaction. The evidence shows that he does not have difficulty in maintaining social relationships, providing evidence against this claim. As to any occupational impairment, the evidence shows that the veteran actively works as an electrician including as a supervisor. Although he reported three jobs in a relatively short period of time, one of these ended for reasons completely unrelated to his PTSD; the termination of a contract. During the January 2006 DRO hearing, the veteran theorized that his layoffs from jobs "would probably be the anger which is related to the PTSD." DRO hearing transcript at 12 - 13. He also testified that he does not get along with coworkers. Id. at 5 - 6. The veteran's theory as to a possible reason for his layoffs is pure speculation. He has been able to maintain employment and there is no concrete evidence that any job changes were indeed due to his PTSD. In fact, the Board finds that the statements of the veteran regarding this issue provide evidence against this claim. Although he may have difficulties with his coworkers, the preponderance of the evidence shows that he does not have difficulty in maintaining and establishing effective work relationships. Overall, the Board finds no evidence of record shows the veteran to have reduced reliability and productivity in his social or occupational functioning or that any of the representative symptoms listed under the criteria for ratings higher than 30 percent present. His speech, at worst, was described as hesitant, but has never been describes as circumstantial, circumlocutory or stereotyped. He has never been found to have difficulty in understanding complex commands, to have any impairment of memory, or to suffer from panic attacks. There is no evidence of disturbance in motivation, impaired thinking or impaired judgment. While he has been found to be dysphoric, this disturbance in mood is not shown to have caused impairment either socially or occupationally. Significantly, the GAF scores assigned over the course of this appeal indicate mild symptoms, with the exception of the most recent score of 55, indicative of moderate symptoms. However, even given that score and taking all the other evidence at the time that score was assigned, a rating of 30 percent is the most appropriate. Also considered by the Board is the description of his PTSD symptoms as "severe" by the attending physician in February 2007. Giving this statement due probative value, the Board finds that the rest of the record, which indicates mild symptoms of PTSD, and nearly no social or occupational impairment, outweighs the statement by the attending physician. In short, the veteran's PTSD does not warrant a schedular rating higher than that already assigned. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2007). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. The Court of Appeals for Veterans Claims (Court) has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The RO considered an extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b)(1) and determined referral for extraschedular consideration was not warranted in this case. The Board agrees. The veteran has not required any periods of hospitalization for his PTSD. Although he has expressed concern over his employment and indicated some changes in jobs, he has nearly always been employed over the course of this appeal. Furthermore, no objective evidence of record, including the most recent VA treatment records, shows that his PTSD has caused marked interference with employment. To the extent that his PTSD interferes at all with his employment, such interference is minimal and already contemplated by the schedular rating assigned. See 38 C.F.R. § 4.1. In the absence of evidence presenting exceptional circumstances, the claim is not referred for consideration of an extraschedular rating; the veteran's disability is appropriately rated under the schedular criteria. The Board does not find evidence that rating for the veteran's PTSD should be increased for any other separate period, or referred for extraschedular consideration, based on the facts found during the whole appeal period. The evidence of record from the day the veteran filed the claim to the present supports the conclusion that the veteran is not entitled to additional increased compensation during any time within the appeal period. Based on the above, the preponderance of the evidence is against assigning a rating higher than 30 percent for the veteran's PTSD. Therefore, the claim must be denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2007). Duties to notify and assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, upon receipt of an application for a service- connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. For an increased-compensation claim, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Further, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Vazquez-Flores, at 43-44. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Id. As to the issues withdrawn by the veteran, since the Board has no jurisdiction to decide those issues, the VCAA is inapplicable. With regard to the veteran's claim for entitlement to service connection for tinnitus, the Board is granting in full the benefit sought. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. As to the remaining issues decided above, those involving the veteran's PTSD and hearing loss, the VCAA duty to notify was satisfied by way of a letters sent to the veteran in February 2003, February 2004, and March 2006, that fully addressed all four notice elements. Here, the duty to notify was not completely satisfied prior to the initial unfavorable decision on these claims by the AOJ. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ) see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case (SOC) or supplemental statement of the case (SSOC), is sufficient to cure a timing defect). In this case, the VCAA duty to notify was satisfied subsequent to the initial AOJ decision by way of the letters described above, that fully addressed all four notice elements. The February 2003 letter informed the veteran of what evidence was required to substantiate his claim for entitlement to service connection for PTSD and of the veteran's and VA's respective duties for obtaining evidence. The veteran was also asked to submit evidence and/or information, which would include that in his possession, to the AOJ. That letter was sent prior to the initial adjudication of his claim by the AOJ. The February 2004 letter provided the veteran with VCAA notice as to his claim for an increased rating for hearing loss and as to the requirements for establishing a higher initial rating for PTSD. He was given examples of the types of evidence needed to substantiate his claims, including medical evidence and that he could submit statements from other individuals as to the manner in which disabilities had worsened in severity. Additionally, he was told that the evidence should completely describe his symptoms, their frequency and severity, and other involvement, extension and additional disablement caused by his disability. This notice was sufficiently broad as to reasonably encompass the effect of his PTSD and hearing loss on his employment and daily life. Finally, he was again apprised of his and VA's respective duties for obtaining evidence and asked to submit evidence and/or information in her or his possession, to the AOJ. Although the notice letter was not sent before the initial AOJ decision in this matter, the Board finds that this error was not prejudicial to the veteran because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the veteran been afforded a meaningful opportunity to participate effectively in the processing of her or his claim and given ample time to respond, but the AOJ also readjudicated his claims since that notice. Notably, the RO readjudicated his claim regarding PTSD by way of an SOC issued in October 2004, and SSOC's issued in March 2005, October 2005, and April 2006. Similarly, the RO readjudicated his claim regarding hearing loss by way of an SOC issued in October 2005 and an SSOC, issued in March 2006. In March 2006, the veteran was sent a letter informing him as to how VA assigns effective dates and disability ratings. However, no subsequent adjudication followed that letter so the Board does not find that the notice defect as to effective dates was "cured." However, the Board does find that the error as to this notice is harmless error. In Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), the Court stated that in determining whether the essential fairness of the adjudication had been affected by defects in notice, consideration should be given to the notice that was provided and the extent to which the extensive administrative process had provided an opportunity to develop the case. Here, the veteran's claims, adjudicated in this decision, have been subject to a lengthy and extensive administrative process, including a hearing before the undersigned, following issuance of the March 2006 letter. The Board thus finds that the veteran has had a meaningful opportunity to participate in the development of this case and has not been prejudiced by this defect in notice. Is sum, the Board finds that the notice provided in the February 2003, February 2004, and March 2006 letters, coupled with the extensive administrative process, has sufficiently satisfied VA's duty to notify and, to the extent that any error remains, at this point the error is harmless. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. VA has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA outpatient treatment records. The veteran private treatment records from Mercy Hospital of Tiffin, and treatise evidence, which the Board has reviewed. An opportunity was provided for the veteran to set forth his contentions during the hearing before the undersigned Veterans Law Judge. VA medical examinations were afforded the veteran with regard to his PTSD in April 2003, June 2004, and February 2005, and with regard to his hearing loss disability and in June 2004 and February 2005. In November 2004, the veteran requested that VA assist him in obtaining evidence pertinent to his PTSD from Cleveland State University Department of Psychology. VA requested this evidence and received a reply in April 2005 that the evidence was not available. In the October 2005 SSOC, the RO informed the veteran of this development. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the veteran is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER The appeal with regard to entitlement to service connection for shell fragment wounds of the back, jungle rot, emersion foot, loss of teeth, residuals of vampire bat bite, residuals of rabies shot, a concussion, and with regard to whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for malaria, is dismissed. Service connection for tinnitus is granted. A compensable evaluation for bilateral hearing loss is denied. An evaluation in excess of 30 percent disabling for PTSD is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs