Citation Nr: 21069499 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 18-01 003 DATE: November 18, 2021 REMANDED Entitlement to service connection for encephalomyelitis claimed as a result of in-service batteries of immunizations and boosters is remanded. REASONS FOR REMAND The Veteran had active service from March 1999 to August 1999, with subsequent service in the National Guard. This matter is before the Board of Veterans' Appeals (Board) on appeal of the November 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. Entitlement to service connection for encephalomyelitis claimed as a result of batteries of immunizations and boosters in service. The Veteran contends that his encephalomyelitis disability is a result of receiving three complete batteries of immunizations and boosters in preparation for possible deployment to the Middle East. In July 2021, the Veteran testified at a Board hearing. The Veteran testified he received a first round of vaccinations when he signed up for the military, during basic training. Then a few years later, during the Iraq war, when his unit was preparing to deploy, his medical records were missing, so they forced him to get a second set of vaccines. The Veteran testified that he tried to decline them, but they threatened him with military prison. The Veteran testified that six months after that, the exact same thing happened again because the new shot record was misplaced. Six months after that they found his original records, but made him have a booster shot, even though he was already vaccinated. The Veteran reported that they did not offer to titer his blood which would have potentially demonstrated that he already had the vaccinations required. The Veteran testified that at the time of discharge, I had no idea that this was service connected. I didn't understand that A plus B plus C equaled D. So, I did not ask for that. They just said you obviously can't be in, in the unit. You can't do anything. So, we're going to get you out. I said okay. And that was the end of the discussion and a few months later, I was out. If I had known what I knew as time went on that this was absolutely connected to my service, I would've begged please do this the right way. But I didn't know, so I didn't put up a fight. I just said okay. The Veteran indicated that he last received treatment in June of this year. The records are not associated with the file, and thus a remand is required to secure these records and any other relevant outstanding records. In addition, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, at 83. The Board finds that the threshold has been met, and a remand is necessary prior to adjudicating this claim, to secure an examination and medical opinion. The matter is REMANDED for the following action: 1. Obtain all outstanding VA treatment records including any separately stored National Guard records and associate them with the evidence of record before the Board. 2. With any necessary assistance from the Veteran, obtain any relevant outstanding private treatment records. 3. Then, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the claimed encephalomyelitis disability. The examiner must review the claims file, including this remand. The examiner must note and address the Veteran's relevant lay testimony. 4. The examiner is asked to provide a response to the following: Provide a diagnosis of any current neurological/psychiatric disability. Determine if it is at least as likely as not (50 percent or greater probability) that the claimed encephalomyelitis disability (if present) or any other diagnosed disorder had its onset during or is otherwise etiologically related to the Veteran's active service, to include the Veteran's contention that he received three complete batteries of immunizations and boosters in preparation to be deployed to the Middle East, and he was discharged from the military due to his medical condition. The examiner should consider all service medical records (to include an April 2004 record noting abdominal discomfort, nausea and fatigue), all post service records, and the Veteran's testimony and statements. The examiner should also consider a history of a reported nonservice-connected skull fracture in 2000 noted in an April 14, 2005 VA mental health intake record. Similarly, a service medical record dated in May 2002 presumably refers to the same incident as it notes a past history of being struck in the head with a pistol which required surgical repair. 5. A complete rationale must be provided for any opinion or conclusion expressed. The clinician must note that a lack of contemporaneous medical evidence does not, in and of itself, render lay evidence not credible. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). If the examiner is unable to provide any requested opinion, he or she must provide a thorough explanation. (Continued on the next page) 6. After completing the above, and conducting any further development deemed necessary, readjudicate the claim. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative must be provided a Supplemental Statement of the Case and be given an adequate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Quist 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.