February 25, 2005M21-1, Part III
_______________ 1. Environmental hazard or claim for an undiagnosed illness or medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) is of record.
_______________ 2. Service in SWA _______________ to _______________ is verified.
_______________ 3. Other service ____________ to ____________ is verified.
_______________ 4. Standard development letter has been sent. (See Exhibit A.3.)
_______________ 5. SMRs for all periods of service are of record, or documentation is of record that
they are not available.
_______________ 6. Adequate VA examination is of record.
a. All issues (including those raised on GW Registry exam) addressed.
b. Additional medical evidence obtained if shown on exam.
c. Additional lay evidence requested if shown on exam.
d. All recommended tests completed.
_______________ 7. GW Registry exam is in file (if conducted).
_______________ 8. Treatment records from VA have been received.
_______________ 9. Treatment records from private sources have been requested (with appropriate
_______________ 10. All lay evidence has been requested.
_______________ 11. Other conditions claimed have been fully developed (e.g., PTSD, exposure,
disability pension, etc.).
_______________ 12. Due process time (60 days) has been allowed and response has/has not been
received. [Circle one.]
_______________ 13. Date of claim _______________ [Enter date of receipt of claim for environmental
hazard or undiagnosed illness.]