Citation Nr: 21068643 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 15-01 637 DATE: November 12, 2021 REMANDED Entitlement to service connection for head and back trauma is remanded. REASONS FOR REMAND This matter was previously remanded in October 2018 for additional development, specifically verification of the Veteran's service periods, including each time period he served on active duty (AD), active duty for training (ACDUTRA), or inactive duty for training (INACDUTRA). Personnel records added to the claims file during the remand development include a certification of military service, specifically active duty for training from October 1984 to March 1985. The pertinent regulations, specifically 38 U.S.C. § 101(24) and 38 C.F.R. § 3.6, define active service to include any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty. Thus, for the purposes of the current claim, the service from October 1984 to March 1985 is sufficient to establish Veteran status. The Veteran asserted that he was injured while on ACDUTRA in February 1985. Specifically, he asserted in a May 2020 statement that on/about February 8, 1985, he was involved in a vehicle accident in Barstow, CA. Veteran reports that he sustained "7-inch laceration to the back of head, multiple abrasions to my back and severe sprain and contusions to my legs. As a result of the accident, I have permanent 7-inch scar, pain to my legs, frequent headaches, and back pain and problems." He noted that he attempted to obtain both the police report and medical records for treatment relating to this injury, but was unsuccessful. Service treatment records confirm that the Veteran sustained a head injury serious enough to require stitches. A February 1985 service treatment record noted that the Veteran reported to clinic for suture removal from the right side of his head after a motor vehicle accident and was treated in a civilian hospital. His February 1985 medical examination, on release from ACDUTRA, noted that he had a 3-inch scar on the right posterior side of his head. The Board cannot make a fully-informed decision on the issue of entitelment to service connection for head and back trauma because no VA examiner has opined whether the claimed disability is related to his miltiary service. VA treatment records reflect that the Veteran has been treated in the traumatic brain injury (TBI) clinic, and reported back pain and headaches. In McLendon v. Nicholson, the United States Court of Appeals for Veterans Claims ("CAVC") held that an examination is required when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing an "in-service event, injury or disease," or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the current disability may be related to the in-service event, but (4) insufficient evidence to decide the case. McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). The matter is REMANDED for the following action: Schedule the Veteran for a medical examination with an appropriate clinician to determine the nature and etiology of any head or back disability found on examination; this may require multiple VA examinations (e.g., spine, headaches, neurologic disorders, etc.). For each disability benefits questionnaire (DBQ), the examiner must opine as to whether any diagnosed disability is at least as likely as not is caused by an in-service injury, event, or disease, to include periods of ACDUTRA; had its inception during active duty service, to include periods of ACDUTRA; as aggravated beyond its natural progression during a period of ACDUTRA, if the disorder at least as likely as not preexisted that period of ACDUTRA; manifested during active duty service or within one year after discharge from service; or was noted during active duty service or within one year after discharge from such service such that the condition was not shown to be chronic at that time or a diagnosis of chronicity could be legitimately questioned, and there was a continuity of the same symptomatology since active duty service or the year following such service; or is proximately due to, or has been aggravated beyond its natural progression by, a service- connected disability, to include medication taken for the service-connected disability, or by any other disorder. Notify the examiner that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. A rationale is required for all opinions in the report. J. M. Kirby Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.N., Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.