M21-1, Part III February 25, 2005
In both cases, the finding should establish that all the procedures have been properly followed; evidence
of written and telephonic efforts to obtain the records are in the file; all efforts to obtain the needed information have been exhausted; further efforts are futile; and that based on these facts, the information required to verify the stressful events is unavailable. The finding should detail the actions taken to obtain the required information. Prepare the findings on a separate page to be filed in the claims folder. (See Exhibit B-11 of this chapter) Final approval rests with the Veterans Service Center Manager (VSCM) or his/her designee.
(7) After the finding is signed, the veteran will be contacted telephonically. Fully advise the claimant of the determination and give the claimant 10 days to furnish the evidence. The veteran should be advised of the lack of evidence required to verify the stressful events and the requirement that he/she submit any relevant documents/evidence in his/her possession. Further advise the claimant that a decision will be made based on the evidence of record if the requested evidence is not received within 10 days from the date of the conversation. Document the results of the telephone contact on VA Form 119. If telephone contact cannot be made, provide written notification of this information to the claimant. The 10-day time limit for reply will be based on the date of this letter.
d. PTSD Claims Based on Personal Assault
(1) Veterans claiming service connection for disability due to an in-service personal assault face unique problems documenting their claims. Personal assault is an event of human design that threatens or inflicts harm. Examples of this are rape, physical assault, domestic battering, robbery, mugging, and stalking. Although these incidents are most often thought of as involving female veterans, male veterans may also be involved. Care must be taken to tailor development for a male or female veteran. These incidents are often violent and may lead to the development of PTSD secondary to personal assault.
(2) Because assault is an extremely personal and sensitive issue, many incidents of personal assault are not officially reported, and victims of this type of in-service trauma may find it difficult to produce evidence to support the occurrence of the stressor. Therefore, alternative evidence must be sought.
(3) To service connect PTSD, there must be credible evidence to support the veteran’s assertion that the stressful event occurred. This does not mean that the evidence actually proves that the incident occurred, rather that there be at least an approximate balance of positive and negative evidence that it occurred.
(4) Review the claim and all attached documents. Develop for SMRs and MPRJ information as needed.
(a) Service records not normally requested may be needed to develop this type of claim. Responses to the development letter requesting details concerning the personal assault may identify additional information sources. These include:
A rape crisis center or center for domestic abuse,
A counseling facility,
A health clinic,
Family members or roommates,
A faculty member,
Civilian police reports,
Medical reports from civilian physicians or caregivers who may have treated the veteran either immediately following the incident or sometime later,
A chaplain or clergy,
Fellow service persons, or
Personal diaries or journals.