September 2020 VFW Virtual Advanced Skill Level Training

Appeals Scenario

For this scenario, you will review a veteran’s rating decision along with supporting evidence then create

an appeal argument that adequately represents the veteran’s contentions based on the facts of the

case.

Your grade for this assignment will be based on the overall quality and accuracy of your argument,

grammar, and spelling. A total of 20 points are possible. Once you complete the end of conference test,

your score for this scenario will be added to your test score in order to create your final score.

Please create your appeal argument as a word document, DO NOT use a VA Form for this assignment.

When creating your argument include your name and department at the top of the page and limit your

arguments to 1-2 paragraphs per issue.

Once you are finished with your assignment email it as an attachment to Chris Macinkowicz, Assistant

Director for Training & Quality Assurance at CMacinkowicz@vfw.org.

All assignments must be submitted by 4:30PM Eastern Standard Time on Friday September 18, 2020

to receive full credit. Any late assignments will be penalized by 10% per day late.

Scenario:

Your next appointment is with John C. Layfield. John served as a radio operator in the US Army from

April 2001-May 2015. Mr. Layfield recently received a rating decision and would like your assistance

with filing an appeal as he is unhappy with his ratings.

Mr. Layfield believes that his back and depression ratings should be higher than what VA assigned. He

also stated that his obstructive sleep apnea (OSA) was diagnosed after separation but he believes that

the OSA is due to his service. He has no additional information or evidence to submit.

During your review of Mr. Layfield’s STRs, you confirmed that there were no complaints of or treatment

for OSA or its symptoms during service.

Below you will find all of the information needed to prepare your appeal argument.

Rating Decision Narrative & Codesheet

Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire

Sleep Apnea Disability Benefits Questionnaire

Dr. Letter from Jeffrey Harper MD

Mental Disorders (Other Than PTSD and Eating Disorders) Disability Benefits Questionnaire

DEPARTMENT OF VETERANS AFFAIRS Regional Office 100 N. Main ST

Springfield, USA

JOHN LAYFIELD

VA File Number 000 11 1133

Represented by: VETERANS OF FOREIGN WARS OF THE US

Rating Decision September 5, 2020

INTRODUCTION

The records reflect that you are a veteran of the Peacetime and Gulf War Eras. You served in the Army from April 10, 2001 to May 10, 2015. You filed a fully developed original disability claim that was received on August 20, 2019. Based on a review of the evidence listed below, we have made the following decision(s) on your claim.

DECISION

1. Service connection for major depressive disorder (Claimed as depression) is granted with an evaluation of 30 percent effective August 20, 2019.

2. Service connection for lumbosacral strain is granted with an evaluation of 10 percent effective August 20, 2019.

3. Service connection for obstructive sleep apnea is denied.

EVIDENCE

• VA Form 21-526EZ Veteran's Fully Developed Claim received August 20, 2019 • VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative

received August 20, 2019 • DD Form 214, Certificate of Release or Discharge from Active Duty received August 20, 2019 • Service Treatment Records, from April 10, 2010 through May 10, 2015 • DBQ Back (Thoracolumbar Spine) received on December 16, 2019 • DBQ Initial Post Traumatic Stress Disorder (PTSD) received on August 12, 2020 • DBQ Sleep Apnea received on December 16, 2019 • Statement from Dr. Jeffrey Harper MD dated October 4, 2019

REASONS FOR DECISION

1. Service connection for major depressive disorder (Claimed as depression)

Service connection for major depressive disorder has been established as directly related to military service.

An evaluation of 30 percent is assigned from August 20, 2019, the day we received your application for benefits.

We have assigned a 30 percent evaluation for your major depressive disorder based on:

Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks

Depressed Mood

Chronic sleep impairment

Mild memory loss, such as forgetting names, directions or recent events

Flattened Effect

Impaired judgment

Disturbances of motivation and mood

Difficulty in establishing and maintaining effective work and social relationships

Difficulty in adapting to stressful circumstances including work or a work like setting

Neglect of personal appearance and hygiene

The overall evidentiary record shows that the severity of your disability most closely approximates the criteria for a 30 percent disability evaluation.

A higher evaluation of 50 percent is not warranted unless there is evidence of 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired

judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.

The medical evidence shows that you are competent to manage your financial affairs.

2. Service Connection for lumbosacral strain

Service connection for lumbosacral strain has been established as directly related to military service.

An evaluation of 10 percent is assigned from August 20, 2019, the day we received your application for benefits.

We have assigned a 10 percent evaluation for your lumbosacral strain based on:

Forward Flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees

A higher evaluation of 20 % is not warranted unless there is evidence of:

Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis

3. Service connection for obstructive sleep apnea.

Service connection may be granted for a disability which began in military service or was caused by some event or experience in service.

Service connection for obstructive sleep apnea is denied since this condition neither occurred in nor was caused by service. We did not find a link between your medical condition and military service.

Favorable findings identified in this decision: i. The veteran’s diagnosis of obstructive sleep apnea was confirmed at the VA exam of 12/01/2019

REFERENCES:

Title 38 of the Code of Federal Regulations, Pensions, Bonuses and Veterans' Relief contains the regulations of the Department of Veterans Affairs which govern entitlement to all veteran benefits. For additional information regarding applicable laws and regulations, please consult your local library, or visit us at our web site, www.va.gov.

Rating Decision Regional Office VA Regional Office

Page 1 of 1 09/05/2020

Name of Veteran John C. Layfield

VA FILE NUMBER

000 11 1133 SSN

000 11 1133 POA

VFW COPY TO

VFW

ACTIVE DUTY

EOD RAD BRANCH CHARACTER OF DISCHARGE

04/10/2001 05/10/2015 Army Honorable

LEGACY CODES

ADD’L SVCCODE

COMBAT CODE

SPECIAL PROV CDE

FUTURE EXAM

DATE

1

JURISDICTION: Original Disability Claim 08/20/2019

ASSOCIATED CLAIM(s): 110; Initial; 08/20/2019

SUBJECT TO COMPENSATION (1.SC)

9434 MAJOR DEPRESSIVE DISORDER Service Connected, Gulf War, Incurred Static Disability

30% from 08/20/2019

5237 LOWER BACK SPRAIN Service Connected, Gulf War, Incurred Static Disability

10% from 08/20/2019

NOT SUBJECT TO COMPENSATION

6847 OBSTRUCTIVE SLEEP APNEA Not Service Connected

COMBINED EVALUATION FOR COMPENSATION:

40% from 08/20/2019

____________________________________

RVSR

LOCAL TITLE: COMP AND PEN NOTE

DATE OF NOTE: DEC 1, 2019@08:00 ENTRY DATE: 12/1/2019 12:47:32 AUTHOR: HIBBERT, JULIUS M. EXP COSIGNER:

URGENCY: NORMAL STATUS: COMPLETED

Back (Thoracolumbar Spine) Conditions

Disability Benefits Questionnaire

Name of patient/Veteran: Layfield, John

Indicate method used to obtain medical information to complete this document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process

because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination

will likely provide no additional relevant evidence.

[ ] Review of available records in conjunction with a telephone

interview

with the Veteran (without in-person or telehealth examination)

using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient

information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

Evidence review

- - - - - - - - - - - - - - -

Was the Veteran's VA claims file (hard copy paper C-file) reviewed?

[ ] Yes [X] No

If no, check all records reviewed:

[ ] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[ ] Department of Defense Form 214 Separation Documents

[ ] Veterans Health Administration medical records (VA treatment

records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who have

known the Veteran before and after military service)

[ ] No records were reviewed

[X] Other: VBMS

1. Diagnosis

------------

Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No

Thoracolumbar Common Diagnoses:

[ ] Ankylosing spondylitis

[X] Lumbosacral strain

[ ] Degenerative arthritis of the spine

[ ] Intervertebral disc syndrome

[ ] Sacroiliac injury

[ ] Sacroiliac weakness

[ ] Segmental instability

[ ] Spinal fusion

[ ] Spinal stenosis

[ ] Spondylolisthesis

[ ] Vertebral dislocation

[ ] Vertebral fracture

Diagnosis #1: lumbar strain

ICD code: 847

Date of diagnosis: 2019

2. Medical history

- - - - - - - - - - - - - - - - - -

a. Describe the history (including onset and course) of the Veteran's

thoracolumbar spine (back) condition (brief summary):

veteran stated that back pain began in service following a Humvee

rollover. There is no record of treatment in service following rollover. currently, veteran has back pain on daily basis. pain is

located in a band across the low back. pain is aching in nature. at baseline, pain is 4/10. by end of day, pain will be 5-6/10. no loss of bowel or bladder control.

back pain aggravated by sitting > 45-60 minutes; standing > 1-2 hours; also aggravated by lifting, bending, stooping; also aggravated by

running has not had debilitating flares of back condition in past 12 months; has not been prescribed bedrest. has been treating with OTC

meds.

b. Does the Veteran report flare-ups of the thoracolumbar spine (back)?

[ ] Yes [X] No

c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of

repetitive use)? [X] Yes [ ] No

If yes, document the Veteran's description of functional

loss or functional impairment in his or her own words. see above

3. Range of motion (ROM) and functional limitation

- - - - - - - - - - - - - - - - - - - - - - - -

a. Initial range of motion

[ ] All normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Forward Flexion (0 to 90): 0 to 70 degrees

Extension (0 to 30): 0 to 30 degrees

Right Lateral Flexion (0 to 30): 0 to 30 degrees

Left Lateral Flexion (0 to 30): 0 to 30 degrees

Right Lateral Rotation (0 to 30): 0 to 30 degrees

Left Lateral Rotation (0 to 30): 0 to 30 degrees

If abnormal, does the range of motion itself contribute to a

functional loss? [ ] Yes (please explain) [X] No

Description of pain (select best response):

Pain noted on exam with movement

If noted on exam, which ROM exhibited pain (select all that

apply)?

Forward Flexion

Is there evidence of pain with weight bearing? [ ] Yes [X] No

Is there objective evidence of localized tenderness or pain on

palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [ ] Yes [X] No

b. Observed repetitive use

Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No

Is there additional loss of function or range of motion after three

repetitions? [ ] Yes [X] No

c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time?

[ ] Yes [X] No

If the examination is not being conducted immediately after repetitive use over time:

[X] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over

time. [ ] The examination is medically inconsistent with the Veteran's

statements describing functional loss with repetitive use over time. Please explain.

[ ] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time.

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with repeated use over a period of time? [ ] Yes [X] No [ ] Unable to say w/o mere speculation

d. Flare-ups No response provided e. Guarding and muscle

spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spine

(back)? [ ] Yes [ X ] No

Muscle spasm: [X] None [ ] Resulting in abnormal gait or abnormal spinal contour

[ ] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below: Localized tenderness:

[X] None [ ] Resulting in abnormal gait or abnormal spinal contour

[ ] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below:

Guarding: [X] None

[ ] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal

contour [ ] Unable to evaluate, describe below:

f. Additional factors contributing to disability

In addition to those addressed above, are there additional Contributing factors of disability? Please select all that apply

and

describe: Interference with sitting

4. Muscle strength testing - - - - - - - - - - - - -

a. Rate strength according to the following scale: 0/5 No muscle movement

1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated

3/5 Active movement against gravity 4/5 Active movement against some resistance

5/5 Normal strength

Hip flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Knee

extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension:

Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5

b. Does the Veteran have muscle atrophy?

[ ] Yes [X] No

5. Reflex exam - - - - - - - - - - - - - -

Rate deep tendon reflexes (DTRs) according to the following scale:

0 Absent

1+ Hypoactive 2+ Normal

3+ Hyperactive without clonus 4+ Hyperactive with clonus

Knee: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

Ankle:

Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+

6. Sensory exam

- - - - - - - - - - - - - - - Provide results for sensation to light touch (dermatome) testing:

Upper anterior thigh (L2):

Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent

Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent Lower leg/ankle

(L4/L5/S1): Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

Foot/toes (L5): Right: [X] Normal [ ] Decreased [ ] Absent

Left: [X] Normal [ ] Decreased [ ] Absent

7. Straight leg raising test - - - - - - - - - - - - - - -

Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform

Left: [X] Negative [ ] Positive [ ] Unable to perform 8. Radiculopathy

- - - - - - - - - - - - - - - - Does the Veteran have radicular pain or any other signs or symptoms due to

radiculopathy? [ ] Yes [X]

No

a. Indicate symptoms' location and severity (check all that apply):

Constant pain (may be excruciating at times) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ]

Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Intermittent pain (usually dull)

Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Paresthesias and/or dysesthesias Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

Numbness Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe

b. Does the Veteran have any other signs or symptoms of radiculopathy?

[ ] Yes [X] No

c. Indicate nerve roots involved: (check all that apply)

[ ] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)

If checked, indicate: [ ] Right [ ] Left [ ]

Both

d. Indicate severity of radiculopathy and side affected:

Right: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe

Left: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe

9. Ankylosis

- - - - - Is there ankylosis of the spine? [ ] Yes [X] No

10. Other neurologic abnormalities - - - - - - - - - - - - - - - -

Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition

(such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No

11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - a. Does the Veteran have IVDS of the thoracolumbar spine?

[ ] Yes [X] No

12. Assistive devices

- - - - - - - - - a. Does the Veteran use any assistive device(s) as a normal mode

of locomotion, although occasional locomotion by other methods may be possible?

[ ] Yes [X] No

13. Remaining effective function of the extremities - - - - - - - - - - - - - - - - - - - - - - - - - -

Due to a thoracolumbar spine (back) condition, is there functional impairment of an extremity such that no effective function remains other than

that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.;

functions of the lower extremity include balance and propulsion, etc.) [ ]Yes [X] No

14. Other pertinent physical findings, complications, conditions, signs, symptoms and

scars - - - - - - - - - - - - - - - - - - - - - - - - - -

a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any

conditions listed in the Diagnosis Section above? [ ] Yes [X] No

b. Does the Veteran have any scars (surgical or otherwise) related to

any conditions or to the treatment of any conditions listed in the

Diagnosis Section above? [ ] Yes [X]

No

c. Comments, if any: No response provided

15. Diagnostic testing - - - - - - - - - - - - - - - - - - - - - -

a. Have imaging studies of the thoracolumbar spine been performed and are the results available?

[ ] Yes [X] No

b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No

c. Are there any other significant diagnostic test findings and/or

results? [ ] Yes [X] No

16. Functional impact

- - - - - - - - - - - Does the Veteran's thoracolumbar spine (back) condition

impact on his or her ability to work? [X] Yes [ ] No

If yes describe the impact of each of the Veteran's thoracolumbar

spine (back) conditions providing one or more examples:

limits sitting

17. Remarks, if any: - - - - - - - - - - -

none

/es/ Julius M. Hibbert, MD

Staff Physician Signed: 12/01/2019 12:47:32

LOCAL TITLE: COMP AND PEN NOTE DATE OF NOTE: December 1, 2019@08:30 ENTRY DATE: 12/01/2019 13:02:34

AUTHOR: Hibbert, Julius M EXP COSIGNER: URGENCY: Normal STATUS: COMPLETED

Sleep Apnea Disability Benefits Questionnaire

Name of patient/Veteran: Layfield, John C. Indicate method used to obtain medical information to complete this

document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process

because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely

provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented

with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no

additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination

Evidence review

- - - - - - - - - - - - - - - Was the Veteran's VA claims file reviewed?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the Veteran's VA claims file:

If no, check all records reviewed:

[ ] Military service treatment records [ ] Military service personnel records

[ ] Military enlistment examination [ ] Military separation examination

[ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment

records) [ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who Have known the Veteran before and after military service)

[ ] No records were reviewed [X] Other: VBMS

1. Diagnosis

- - - - - - - Does the Veteran have or has he/she ever had sleep apnea? [X] Yes [ ] No

[X] Obstructive

ICD code: 327 Date of diagnosis: 2019 [ ] Other sleep disorder, specify:

2. Medical history

- - - - - - - - - - - - - - - - - - a. Describe the history (including onset and course) of the Veteran's

sleep disorder condition (brief summary): sm was noted to have nighttime snoring and gasping. PSG was done in October 2019

and sm was noted to have moderate OSA. CPAP was recommended.

b. Is continuous medication required for control of a sleep disorder condition?

[ ] Yes [X] No

c. Does the veteran require the use of a breathing assistance device? [ ] Yes [X] No

d. Does the Veteran require the use of a continuous positive airway Pressure (CPAP) machine?

[X] Yes [ ] No

3. Findings, signs and symptoms - - - - - - - - - - - - - - -

Does the Veteran currently have any findings, signs or symptoms attributable to sleep apnea?

[X] Yes [ ] No

4. Other pertinent physical findings, complications, conditions, signs

and/or symptoms

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis

section above? [ ] Yes [X] No

b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions

listed in the Diagnosis section above? [ ] Yes [X] No

5. Diagnostic testing

- - - - - - - - - - - Has a sleep study been performed?

[X] Yes [ ] No

If yes, does the Veteran have documented sleep disorder breathing?

[X] Yes [ ] No

Date of sleep study: 10/26/19

Facility where sleep study performed, if known: Eastern Medical

Group

Results: Moderate OSA

a. Are there any other significant diagnostic test findings and/or results?

[ ] Yes [X] No

If yes, provide type of test or procedure, date and results (brief summary):

6. Functional impact

- - - - - - - - - - Does the Veteran's sleep apnea impact his or her ability to work?

[X] Yes [ ] No

7. Remarks, if any:

- - - - - - - - - - Veteran experienced significant weight gain after service which is

a common contributory factor to OSA. There were no complaints, treatment, or diagnosis in service therefore it is less likely than not related to military

service

/es/ Julius M. Hibbert, MD Staff Physician Signed: 12/01/2019 14:02:34

Jeffrey Harper, M.D.Eastern Medical Group

7489 Eastern BlvdSpringfield, USA 22153Office: (555) 555-1444Fax: (555) 555-1203

October 4, 2019

To Whom It May Concern:

Mr. John C. Layfield (DOB 12/26/1973) has been a patient of mine for 2 years. I have examined Mr. Layfield and have diagnosed him with Obstructive Sleep Apnea based on his sleep study that was conducted on 10/26/19. It is my professional opinion that the current disability that Mr. Layfield is suffering from is at least as likely as not incurred by or aggravated by injuries that occurred during active military service.

Further, I believe that the Obstructive Sleep Apnea diagnosis is related to the veteran's obesity and a reduced ability to exercise due to the previously diagnosed lumbar strain.

If you have any questions or concerns, please contact me at the above address.

Jeffrey Harper MD

Since

VA FORM

MAY 201821-0960P-2

MENTAL DISORDERS (OTHER THAN PTSD AND EATING DISORDERS) DISABILITY BENEFITS QUESTIONNAIRE

NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

If the veteran currently has one or more mental disorders that conform to DSM-IV criteria, provide all diagnoses:

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A MENTAL DISORDER(S)?

OMB Approved No. 2900-0779 Respondent Burden: 30 Minutes Expiration Date: 05/31/2021

NOTE: In order to conduct an INITIAL examination for mental disorders, the examiner must meet one of the following criteria: a board-certified or board-eligible

psychiatrist; a licensed doctorate-level psychologist; a doctorate-level mental health provider under the close supervision of a board-certified or board-eligible

psychiatrist or licensed doctorate-level psychologist; a psychiatry resident under close supervision of a board-certified or board-eligible psychiatrist or licensed

doctorate-level psychologist; or a clinical or counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under

close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist. In order to conduct a REVIEW examination for mental

disorders, the examiner must meet one of the criteria from above, OR be a licensed clinical social worker (LCSW), a nurse practitioner, a clinical nurse specialist, or a

physician assistant, under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist. This Questionnaire is to be

completed for both initial and review mental disorder(s) claims.

SECTION I: DIAGNOSIS

NOYES

NOTE: If the veteran experiences a mental health emergency during the interview, please terminate the interview and obtain help, using local resources as

appropriate. You may also contact the Veterans Crisis Line at 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the veteran to emergency care.

 IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE  PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION  BEFORE COMPLETING FORM.

DIAGNOSIS #1

DIAGNOSIS #3

ICD CODE: INDICATE THE AXIS CATEGORY:

ICD CODE:

AXIS I AXIS II

COMMENTS, IF ANY:

COMMENTS, IF ANY:

IF ADDITIONAL DIAGNOSES THAT PERTAIN TO MENTAL HEALTH DISORDERS, LIST USING ABOVE FORMAT:

COMMENTS, IF ANY:

AXIS IIAXIS IINDICATE THE AXIS CATEGORY:ICD CODE:

DIAGNOSIS #2

NOTE: If the veteran has a diagnosis of an eating disorder, complete VA Form 21-0960P-1, Eating Disorders Disability Benefits Questionnaire, in lieu of this questionnaire. NOTE: If the veteran has a diagnosis of PTSD, VA Form 21-0960P-4, Initial PTSD Disability Benefits Questionnaire, must be completed by a VHA staff or contract examiner in lieu of this questionnaire.

Page 1

ICD CODE: INDICATE THE AXIS CATEGORY: AXIS I AXIS II

COMMENTS, IF ANY:

PSYCHIATRIST/PSYCHOLOGIST/EXAMINER - Your patient is applying to the U. S. Department of Veterans Affairs (VA) for disability benefits.  VA will

consider the information you provide on this questionnaire as part of their evaluation in processing the veteran's claim. Please note that this questionnaire is for

disability evaluation, not for treatment purposes. VA reserves the right to confirm the authenticity of ALL DBQs completed by private health care providers.

1B. AXIS III - MEDICAL DIAGNOSES (TO INCLUDE TBI):

1C. AXIS IV - PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS (DESCRIBE, IF ANY):

1D. AXIS V - CURRENT GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCORE:

COMMENTS, IF ANY:

SUPERSEDES VA FORM 21-0960P-2, FEB 2015,

WHICH WILL NOT BE USED.

Depression

F33.0

J o h n L a y f i e l dC

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2. DIFFERENTIATION OF SYMPTOMS

Page 2

2A. DOES THE VETERAN HAVE MORE THAN ONE MENTAL DISORDER DIAGNOSED?

YES NO (If "Yes," complete Item 2B)

2B. IS IT POSSIBLE TO DIFFERENTIATE WHAT SYMPTOM(S) IS/ARE ATTRIBUTABLE TO EACH DIAGNOSIS?

YES NO

(If "No," provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis)

NOT APPLICABLE

(If "Yes," list which symptoms are attributable to each diagnosis)

2C. DOES THE VETERAN HAVE A DIAGNOSED TRAUMATIC BRAIN INJURY (TBI)?

YES NO (If "Yes," complete Item 2D)

2D. IS IT POSSIBLE TO DIFFERENTIATE WHAT SYMPTOM(S) IS/ARE ATTRIBUTABLE TO EACH DIAGNOSIS?

YES NO

(If "No," provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis)

NOT SHOWN IN RECORDS REVIEWED

Comments, if any:

NOT APPLICABLE

(If "Yes," list which symptoms are attributable to each diagnosis)

3. OCCUPATIONAL AND SOCIAL IMPAIRMENT

3A. WHICH OF THE FOLLOWING BEST SUMMARIZES THE VETERAN'S LEVEL OF OCCUPATIONAL AND SOCIAL IMPAIRMENT WITH REGARD TO ALL MENTAL

DIAGNOSES? (Check only one)

No mental disorder diagnosis

Total occupational and social impairment

Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood

Occupational and social impairment with reduced reliability and productivity

Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks,

although generally functioning satisfactorily, with normal routine behavior, self-care and conversation

Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks

only during periods of significant stress, or; symptoms controlled by medication

A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or

to require continuous medication

NO OTHER MENTAL DISORDER HAS BEEN DIAGNOSEDNOYES

3B. FOR THE INDICATED LEVEL OF OCCUPATIONAL AND SOCIAL IMPAIRMENT, IS IT POSSIBLE TO DIFFERENTIATE WHAT PORTION OF THE OCCUPATIONAL

AND SOCIAL IMPAIRMENT INDICATED IN ITEM 3A IS CAUSED BY EACH MENTAL DISORDER?

(If "Yes," list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis)

(If "No," provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis)

NO DIAGNOSIS OF TBINOYES

3C. IF A DIAGNOSIS OF TBI EXISTS, IS IT POSSIBLE TO DIFFERENTIATE WHAT PORTION OF THE OCCUPATIONAL AND SOCIAL IMPAIRMENT INDICATED IN

ITEM 3A IS CAUSED BY THE TBI?

(If "Yes," list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis)

(If "No," provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis)

VA FORM 21-0960P-2, MAY 2018

PATIENT/VETERAN'S SOCIAL SECURITY NO. 0 0 0 1 1 1 1 3 3

Page 3

SECTION II: CLINICAL FINDINGS:

2A. RELEVANT SOCIAL/MARITAL/FAMILY HISTORY (PRE-MILITARY, MILITARY, AND POST-MILITARY)

2B. RELEVANT OCCUPATIONAL AND EDUCATIONAL HISTORY (PRE-MILITARY, MILITARY, AND POST-MILITARY)

2C. RELEVANT MENTAL HEALTH HISTORY, TO INCLUDE PRESCRIBED MEDICATIONS AND FAMILY MENTAL HEALTH (PRE-MILITARY, MILITARY, AND POST-

MILITARY)

2D. RELEVANT LEGAL AND BEHAVIORAL HISTORY (PRE-MILITARY, MILITARY, AND POST-MILITARY)

2E. RELEVANT SUBSTANCE ABUSE HISTORY (PRE-MILITARY, MILITARY, AND POST-MILITARY)

2F. SENTINEL EVENT(S) (OTHER THAN STRESSORS)

2G. OTHER (If any)

2. HISTORY

1. EVIDENCE REVIEWIF ANY RECORDS (EVIDENCE) WERE REVIEWED, PLEASE LIST

NOTE: Initial examinations require pre-military, military, and post-military history. If this is a review examination only indicate any relevant

history since prior exam.

VA FORM 21-0960P-2, MAY 2018

PATIENT/VETERAN'S SOCIAL SECURITY NO.

Veteran reports that he is married with 2 children, he has a good relationship with hiswife and children. Childhood was relatively normal he had no siblings and participated inmany extracurricular activities in school. He currently participates in church functionsand is active in his local VFW Post but reports no close interpersonal relationships.

Veteran served in the Army from 2001-2015 as a Radio Operator and is currently working as aschool teacher which he began after leaving the Army. He has had no disciplinary issues atwork but reports stress and at times struggles with student and peer interaction. Herecently had to step down as the JROTC coordinator due to persistent memories of service.

Records show vet received treatment for depression during service. prior to service veteranhas no record of mental health treatment. There is no family history of mental health, heis currently self medicating with cannabis and reports that it helps him deal with stress.

None

Veteran drinks etoh 2x week mostly beer, he has noticed that he has been drinking moreregularly since leaving the service. Veteran has a state issued medical cannabis card whichhe uses daily after work.

Veteran has had no legal issues.

C-File, VBMS

Vet reports that he began suffering from depression during service when he was passed over forpromotion which led to the end of his military career. He sought treatment for which he wasprescribed anti-depressants but has since quit taking them as he feels the medicinal cannabisprovides greater relief of symptoms.

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4. DOES THE VETERAN HAVE ANY OTHER SYMPTOMS ATTRIBUTABLE TO MENTAL DISORDERS THAT ARE NOT LISTED ABOVE?

YES NO (If "Yes," describe)

Page 4

Disorientation to time or place

Neglect of personal appearance and hygiene

Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene

Persistent danger of hurting self or others

Persistent delusions or hallucinations

Grossly inappropriate behavior

Impaired impulse control, such as unprovoked irritability with periods of violence

Spatial disorientation

Suicidal ideation

Obsessional rituals which interfere with routine activities

Difficulty adapting to stressful circumstances, including work or a work like setting

Inability to establish and maintain effective relationships

Difficulty in establishing and maintaining effective work and social relationships

Disturbances of motivation and mood

Gross impairment in thought processes or communication

Impaired judgment

Impaired abstract thinking

3. FOR VA RATING PURPOSES, CHECK ALL SYMPTOMS THAT APPLY TO THE VETERAN'S DIAGNOSES

Memory loss for names of close relatives, own occupation, or own name

Impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks

Mild memory loss, such as forgetting names, directions or recent events

Depressed mood

Anxiety

Suspiciousness

Panic attacks that occur weekly or less often

Chronic sleep impairment

Flattened affect

Circumstantial, circumlocutory or stereotyped speech

Panic attacks more than once a week

Difficulty in understanding complex commands

Speech intermittently illogical, obscure, or irrelevant

Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively

VA FORM 21-0960P-2, MAY 2018

SECTION III: SYMPTOMS

SECTION IV: OTHER SYMPTOMS

PATIENT/VETERAN'S SOCIAL SECURITY NO. 0 0 0 1 1 1 1 3 3

7C. DATE SIGNED

7E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER 7F. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER/ ADDRESS

7B. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER PRINTED NAME

(VA Regional Office FAX No.)

7A. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER SIGNATURE & TITLE (Sign in ink)

  CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current. 

NOTE - A list of VA Regional Office FAX Numbers can be found at www.benefits.va.gov/disabilityexams or obtained by calling 1-800-827-1000.

  IMPORTANT - Psychiatrist/psychologist please fax the completed form to

7D. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER PHONE AND FAX NUMBER

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN:  We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

YES NO

5. IS THE VETERAN CAPABLE OF MANAGING HIS OR HER FINANCIAL AFFAIRS?

6. REMARKS (If any)

Page 5

(If "No," explain)

VA FORM 21-0960P-2, MAY 2018

SECTION V: COMPETENCY

SECTION VI: REMARKS

SECTION VII: PSYCHIATRIST/PSYCHOLOGIST/EXAMINER CERTIFICATION AND SIGNATURE

PATIENT/VETERAN'S SOCIAL SECURITY NO.

Terry Hogan, Psy.D

08/12/2020 111-111-1122

98765434365 Evergreen Terrace, Springfield USA

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