Citation Nr: 0811389 Decision Date: 04/07/08 Archive Date: 04/23/08 DOCKET NO. 05-21 680 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUE Entitlement to an initial evaluation in excess of 30 percent disabling for post-traumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Jennifer R. White, Law Clerk INTRODUCTION The veteran served on active duty from August 1967 to August 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2004 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The appeal is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. VA will notify you if further action is required on your part. REMAND The Board finds that additional development is needed prior to consideration of this claim. The veteran was last afforded a VA examination in July 2004. He has recently submitted a private medical report from Goldsboro Psychiatric Clinic in September 2006. The private medical report dated September 2006 provides a picture of the veteran's symptoms which is somewhat inconsistent with other indications in the record of the veteran's current disability level. Thus, the Board finds that a current VA examination is necessary. Ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA treatment records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). In addition, the Board observes that further development is required under the Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C.A. §§ 5103, 5103A (West 2002), and implemented at 38 C.F.R. § 3.159 (2007). During the pendency of this appeal, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. In the present appeal, he was not provided with notice of the type of evidence necessary to establish a disability rating or effective date for the disability on appeal. Thus, corrective notice can be provided on remand. The notice should also advise the veteran that to substantiate a claim for a higher rating, he 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). The notice should 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. Accordingly, the case is REMANDED for the following action: 1. Send the veteran and his representative a corrective VCAA notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) that includes an explanation of the information and evidence needed to establish a disability rating and an effective date for the disability on appeal, as outlined by the Court in Dingess/Hartman. The notice should also advise the veteran that to substantiate a claim for a higher rating, he 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 his employment and daily life. The notice should 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. Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008). 2. Obtain current treatment records from the Durham VA Medical Center dating since March 2005. 3. Schedule a VA mental disorders examination to determine the current severity of the veteran's PTSD. The claims folder must be made available to and reviewed by the examiner in conjunction with the examination. All symptomatology should be described in detail. The examiner should also provide a Global Assessment of Functioning score for the PTSD. 4. After the development requested above has been completed to the extent possible, review the record. If the benefit sought on appeal remains denied, the veteran and representative, if any, should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). _________________________________________________ K.A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2007).