February 25, 2005M21-1, Part III
If the evidence established that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s testimony alone establishes the occurrence of the claimed in-service stressor. (38 CFR 3.304(f) and 38 U.S.C. 1154(b))
(2) Non-Combat Stressors. PTSD may result from a non-combat stressor, such as a plane crash, ship sinking, explosion, rape or assault, duty on a burn ward or in a graves registration unit.
(3) POW Status. If the evidence establishes that the veteran was a prisoner-of-war under the provisions of 38 CFR 3.1(y) and the claimed stressor is related to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s testimony alone establishes the occurrence of the claimed in-service stressor. (38 CFR 3.304(f) and 38 U.S.C. 1154(b))
(1) If the veteran indicates pertinent treatment in a VA facility, Vet Center, or elsewhere, request
hospital report(s) and clinical records.
(2) If the evidence does not establish that the veteran was engaged in combat with the enemy, or the evidence does establish this but the claimed stressor is not related to that combat, then credible supporting evidence is required to establish that a stressor occurred. (38 CFR 3.304(f)) In cases where available records do not contain this, develop for this evidence as follows:
(a) Request specific details of the in-service stressful incident(s): date(s), place(s), unit of assignment at the time of the event(s), description of the event(s), medal(s) or citation(s) received as a result of the event(s), and, if appropriate, name(s) and other identifying information concerning any other individuals involved in the event(s). At a minimum, the claim must indicate the location and approximate time (a 2-month specific date range) of the stressful event(s) in question, and the unit of assignment at the time the stressful event occurred. Inform the veteran that this information is necessary to obtain supportive evidence of the stressful event(s) and that failure to respond or an incomplete response may result in denial of the claim.
Note: Do not ask the veteran for specific details in any case in which there is credible supporting evidence that the claimed in-service stressor occurred.
(b) Use only one of these codes at a time in PIES. Use O19 for simple PTSD claims and O18 for personal trauma. Do not use the free text and list all of the information mentioned in the manual. The response team at NPRC knows which pages to send for simple PTSD cases. In personal trauma cases, they will send copies of everything. There should be no occasion where both O18 and O19 are used. If the claim is for both personal trauma and PTSD, the use of code O18 will include pages that would have been sent in response to code O19. In either event, no additional instructions need to be added to the PIES request.
ARMY: “Personnel Qualification Record,” DA Form 2-1. The form is used for both Officers and Enlisted personnel, and first came into use in January 1973. Prior to that, DA Form 20 and DA Form 66 were used.
NAVY: Enlisted record of "Transfer and Receipts" (p 12), pages 32 and 33. Enlisted record of "Administrative Remarks" (p. 4-9, 13), page 34. Officer record, NAVPERS 1301/51, "Officer Data Card," page 35. DD214 and enlistment contracts are usually included.