Citation Nr: 1124877 Decision Date: 06/30/11 Archive Date: 07/06/11 DOCKET NO. 10-18 399A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder. 2. Entitlement to a total rating for compensation based upon individual unemployability due to service-connected disability. ATTORNEY FOR THE BOARD A. P. Simpson, Counsel INTRODUCTION The Veteran served on active duty from November 1965 to November 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating 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 the appellant if further action is required. REMAND The Board finds that additional development is warranted. Specifically, a social and industrial survey and a new VA examination are needed. Further, the RO/AMC should determine whether the Veteran is receiving Social Security Administration disability or retirement benefits. In reviewing the record, the Board finds inconsistencies. For example, a July 23, 2008, treatment records from the Goldsboro Psychiatric Clinic shows that the examiner checked off that the Veteran was depressed and felt hopeless 25 percent of the time. (This document lists symptoms and the frequency of the symptoms, which frequencies are never, 25%, 50%, 75% and always.) This record, prepared by a certified nurse assistant during a ten minute meeting, was completed in the morning. A VA treatment record, however, prepared by a physician that very afternoon, shows that the Veteran was asked, "Over the past two weeks, how often have you been bothered by the following problems? Feeling down, depressed, or hopeless." The response was, "Not at all." The physician wrote that the depression screening was negative. These facts are inconsistent, and that inconsistency must be resolved. At a May 2004 VA examination, the Veteran reported that he drove a local moving van for a living and had been working there for "16 years." This would mean that he had started working for this company in approximately 1988. However, in the VA Form 21-8940, Veteran's Application for Increased Compensation Based Upon Unemployability, received in March 2009, the Veteran stated he had been working for this company since 1995. This had to be the same company he was working for in 2004. If the appellant worked for another employer prior to 1995 he should so state. At the June 2009 VA examination the Veteran reported that over the prior year he had missed two to three weeks of work because of his increasing anxiety, difficulty getting along with others, hypervigilance, anger issues, difficulty with concentration, etc. He also reported stopping work in January 2009. In a VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, received in May 2009, however, the appellant's former employer wrote that the Veteran had missed no time during the 12 months preceding the last date of employment due to disability, and that he had been laid off in January 2009. The Veteran has claimed to VA that he had to quit his longtime job because of his increasing posttraumatic stress disorder symptoms. However, in a January 2009 record from the Goldsboro Psychiatric Clinic, the examiner wrote that the Veteran had "Retired" on January 7, 2009. At that time, the Veteran would have been 63 years old. In the VA Form 21-4192, the former employer wrote that the Veteran had been laid off. This discrepancy must be resolved. The most recent record from the Goldsboro Psychiatric Clinic is dated in January 2009. The Veteran claims he receives treatment from that facility every six months. Thus, VA should obtain the records dated since January 2009. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should obtain, with the Veteran's permission, the treatment records from the Goldsboro Psychiatric Clinic from January 2009 to the present. It should also request any relevant VA medical center records for the period since November 2009. 2. The RO/AMC should submit a request to the Social Security Administration to see if the Veteran is in receipt of Social Security Administration disability or retirement benefits. If he is in receipt of disability benefits, the records associated with that claim should be obtained and associated with the claims file. If the RO cannot locate such records, the RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 3. The RO/AMC should then schedule the Veteran for a social and industrial survey in order to identify the degree of social and occupational impairment attributable to posttraumatic stress disorder. The claims folder and a copy of this REMAND are to be made available for the examiner to review. All indicated special studies and tests should be accomplished. The Veteran is to be seen in his normal daily environment in order address how the posttraumatic stress disorder affects his daily activities, and any occupational or other gainful activities. The social worker should interview any available prior employer about the quality and reliability of the Veteran's work, and how the posttraumatic stress disorder affected his ability to work. The Board notes that there are inconsistent facts in the records, which have been laid out above. The social worker must address how the posttraumatic stress disorder alone limits the Veteran's employment opportunities, and whether it is at least as likely as not that the psychiatric disability alone, regardless of the appellant's age or other disorders, renders him unemployable. In doing so, the social worker must address the June 2009 VA medical opinion that, "It appears, at the time, that he would be having major issues in occupational reliability and productivity if he were to attempt to work at the present time. He might be employable in a situation that was extremely low stress, isolated and with little in the way of interpersonal demands. However, in most job settings[,] he would be, at least as likely as not, to be unemployable." A complete rationale must be provided for any opinion offered. 4. Thereafter, the Veteran should be afforded a VA examination by a psychiatrist or a psychologist. The claims folder, a copy of this REMAND, and a copy of the social and industrial survey are to be made available for the examiner to review. In accordance with the latest AMIE worksheet for rating psychiatric disorders, the examiner is to provide a detailed review of the Veteran's pertinent medical history, current complaints, and the nature and extent of the service-connected posttraumatic stress disorder. The Board notes that there are inconsistent facts in the records, which have been laid out above. Any necessary psychological testing must be accomplished, which may assist in the determination of the severity of the service-connected disability. To the extent possible, the examiner is to indicate the level of social and occupational impairment attributable to posttraumatic stress disorder alone. A complete rationale for any opinion expressed must be provided. The examiner must assign a global assessment of functioning score based on symptoms that are due to posttraumatic stress disorder. 5. After the development requested has been completed, the RO/AMC should review the social and industrial survey and examination report to ensure that they are in complete compliance with the directives of this REMAND. If any report is deficient in any manner, the RO must implement corrective procedures at once. 6. The Veteran is to be notified that it is his responsibility to report for the examinations and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2010). 7. Upon completion of the above-requested development and any additional development deemed appropriate, the RO/AMC should readjudicate the issues of entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder and entitlement to a total rating for compensation based upon individual unemployability due to service-connected disability. If any benefit sought on appeal remains denied, the appellant and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). __________________________________________ DEREK R. BROWN 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) (2010).