item D Number

°4966

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RBDOrt/ArtlGlB TitlB Typescript: Veterans Administration Agent Orange
Registry -- An Overview

Journal/Book Title
Year

000

°

Month/Day
Color

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^'so includes VA Form IO-9009 Agent Orange Registry Code
Sheet.

Friday, February 22, 2002

Page 4966 of 5115

 VETERANS ADMINISTRATION
AGENT ORANGE REGISTRY — AN OVERVIEW

History:
The Agent Orange Registry was initiated by the Veterans
Administration in mid-1978 in response to concerns expressed
by Vietnam veterans who were increasingly worried that they
may have been exposed to chemical herbicides which might be
causing a variety of ill effects. VA Circular 10-78-219,
dated September 14, 1978, established the framework of the
Registry.
The circular also created a card file to record each examined
veteran's name and address. This component of the Registry
has changed as experience has dictated. Initially, a special
summary was created to contain selected information and was
retained in the medical record. In 1979, the procedure was
changed so that the summary was submitted to the VA Central
Office for encoding. The coded data was then entered into a
computerized data base.
A special Data Analysis Task Force was formed in June 1980
when it became obvious that the Registry's data input
procedures needed improvement. The Task Force recommended
a number of changes during 1981 and, in August 1982, Circular
10-82-154 ordered an updating of the names and addresses for
the veterans listed in the Registry. This was followed by
Circular 10-83-38 that completely revised the reporting
process in order to improve the coding of demographic and
medical information, thereby permitting easier data
retrieval.
Registry records consist of two components: the medical
record maintained at the VA Medical Center where the veteran
was examined and a computerized extract from that record.
The veteran's medical record includes the full medical
history, physical examination, laboratory reports and other
clinical findings. The computerized extract, better called
the "register," includes the veteran's name, address, the
examining medical center, some information about the
veteran's military service, an estimate of herbicide exposure
and elements of the findings at the time of the physical
examination. The computerized register constitutes an index
to this nationwide set of medical records. A copy of the
currently used code sheet is attached.

 Purpose
The principal purpose for which the Agent Orange Registry
program was designed remains unchanged to the present time.
It is a process which serves all veterans who are worried
about the possible adverse health effects of their exposure
to herbicides while serving in Vietnam. It provides the
veteran an opportunity to receive a complete health
evaluation and answers to questions concerning the current
state of knowledge regarding the relationship between
herbicide exposure and subsequent health problems.
Following completion of the examination the veteran is given
the results of the physical exam and laboratory studies.
This information is provided to the veteran by both a
face-to-face discussion with a physician familiar with the
health aspects of the Agent Orange issue as well as a
follow-up letter summarizing the results of the examination.
The Registry serves an important second purpose in that it
enables the VA to provide veterans current information as it
develops regarding their concerns. In addition it would
permit the VA to contact veterans for further testing in the
event that continuing research efforts should make this
action advisable. The Registry serves yet another purpose,
namely, to provide a means of detecting clues or suggestions
that specific health problems or unexpected health trends are
showing up in this group of veterans. Such clues would then
form the basis for the design and conduct of specific
epidemiological studies.
Limitations
Because of the self-selected nature of the Registry
participants, this group of veterans cannot, with any
scientific validity be viewed as being representational of
Vietnam veterans as a whole. Therefore the health-related
information contained in the data base cannot be used
directly as an epidemiological tool. The information can,
however, be used to detect suggested health trends, as noted
above, and can provide some descriptors as to the
characteristics of the group itself. For example, it is
possible to show the numbers in each branch of military
service, the period(s) of service in Vietnam, the kinds of
symptoms the veterans are experiencing and some of the
results of the physical examinations. However, since
participation in the Registry program is entirely voluntary,
one cannot make statistically valid comparisons with other
groups of veterans or non-veterans.
Summary
The Agent Orange Registry remains the most effective means of
identifying concerned Vietnam veterans. Any eligible Vietnam
veteran expressing a concern relating to exposure to

 herbicides is encouraged to participate in the Registry,
which includes a thorough medical examination. During the
examination, the veteran is asked demographic and identifying
information, military information including branch of service
and dates of service in Vietnam, and how he perceives his
exposure to Agent Orange. A complete past medical history is
obtained and documented. The veteran is then provided a
physical examination which includes several base-line
laboratory studies. Additional tests/consultations may be
ordered depending on the veteran's physical condition or past
medical history.
As of December 31, 1983, the VA had completed 130,220 initial
Agent Orange Registry examinations of which approximately
13,600 have utilized the new code sheet. In addition, 31,471
follow-up examinations have been performed.

 UMB NO. ZVUO-USTti

Veterans Administration
SUFFIX

FACILITY NO.

TT

1. UsePTF
Number Onlv

AGENT ORANGE REGISTRY CODE SHEET

(2)

(3)

(4)

(5)

(6)

(7)

PART!
The information the veteran supplies may be disclosed outside the VA to Federal, State and local government agencies and National Health Organizations to assist in the development
of programs for research purposes and other uses as stated in the "Notice of Systems of VA Records" published in the Federal Register in accordance with the Privacy Act of 1974.

INSTRUCTIONS: Please print. Use only one letter or number per block. If possible use black ballpoint or felt-tip pen. Shaded areas for VA use only.
(DO NOT USE BLUE INK)
. LAST NAME (8-33)

4. MIDDLE NAME (49-58)

. FIRST NAME (34-48)

1

7. S E R V I C E S E R I A L N U M B E R (Begin at left. Leave unused blocks 8. DATE OF B I R T H (Complete all blanks)
blank. If service number is unknown, enter "U,") (7(1-79)
MO. (80-81) DAY(82-83) YR (84-85)

6. SOCIAL SECURITY NUMBER (60-69)
(60)

\9. ADDRESS-Street Name and Apartment Number, If Applicable (8(>-lll)

CITY OR TOWN (112-137)

COUNTY

STATE

10. RACE/ETHNITICITY (Enter one code at right)
1 = American Indian or Alaskan Native
2 = Asian or Pacific Islander
12. StX (Enter one
code at right)
1-Male

154

2=Fernale

152

3 = Black, Mot of Hispanic Origin
4 = White, Not of Hispanic Origin

1 = Inpatient
2 = Outpatient

11. M A R I T A L STATUS (Knter one code at right)

G - Hispanic

1, Married
2. Divorced

155

13. C U R R E N T STATUS (Knter one code at right)

(ISO.
COUNTY (147-149) STATE
1611

(M9)

ZIP CODE (138-142)

3. Incarcerated
4 = Active Duty

3. Separated
4. Widowed

14. B R A N C H OF S E R V I C E (If more than one, enter latest
Vietnam Service)
l=Atmy
3 = Navy
5 = Coast Guard
2 = Air Force
4 = Mai inn Corps
6 - Other

WO{ 158-59)

YR (ifio-61)

YR(164-65)

T

o

B. NEXT-TOLAST
PERIOD

756

157

15. DID VETERAN HAVE MILITARY SERVICE IN VIETNAM?
1 = No
2 • Yes (If yes, list below the dates of veteran's last two periods of service in Vietnam.)
A. LAST
PERIOD

153

.

5. Single, Never
Married

M0( 166-67)

R
O
M

MO(170-7I)

VR/172-7J)

T
O

16. IN WHAT CORPS OR AREA DID VETERAN SERVE? (Enter one code at right) I 74 17. LIST MILITARY UNITS IN WHICH VETERAN SERVED PLEASE SPECIFY COMPLETE UNABBREVIATED TITLE. (Company, battalion, etc.)
1 " I Corps
4 - IV Corps
7 = Other (specify)
2 = II Corps

5 = Sea Duty

3 = III Corps

6 = More than one

8 - Don't know

,

18. ENTER THE DATES OF LAST TWO P E R I O D S OF S E R V I C E (Wlk'ilii'r in Vietnam or not)
A. LAST
PERIOD

MOfl 75-76; YRC/77-7SJ

M0(l 79-80)

T
O

B. NEXT-TOLAST
PERIOD

F
R
O

MQ( 187-88)

MO(l8.'l-84)

T
O

M

19. VETERAN'S EXPOSURE TO AGENT ORANGE:
(Knter a number in each of the following blocks using these coda)
1 - Definitely yes

3 = Not sure

2 = Probably yes

b. I was not directly sprayed but was in a recently
sprayed area.

a. I was .involved in handling or sprayiny
Agent Orange.

d. I was directly sprayed with Agent Orange.

194

4 - Definitely no
c. I was exposed to herbicides other than
Agent Orange.

e. I atf! food or drink that could have been
contaminated.

196

20. ENTER ONE CODE AT THE RIGHT WHICH DESCRIBES HOW VETERAN'S HEALTH HAS G E N E R A L L Y BEEN
1 = Very good

VAFORM in.gnnq
DEC.

1982

"-* "«"»

2 = Good

193

3 ~ All right

4 - Poor

SUPERSEDES VA FORM 109009 SEP 1981, ANn
VA FORM 10-20681INH), AUG 1979. WHICH W I L L NOT RF: USED

5 = Very poor

 PART II •— To be completed by Examining Physician
22. VETERANS COMPLAINT(S) (MAS coders, enter ICD9-CM code at right)
21. DATE OF EXAM

203

204

7

8

208

209

7

8

273

274

7

8

205

206

207

210

211

272

215

216

277

a.
MONTH

DAY

YEAR

(199-200)

(201-202)

'

b.

(197-198)

:

C.

, 23. Does veteran attribute chief complaint
f
to Agent Orange exposure?
1 = Yes

218

25. Is there evidence of birth
defects among veteran's
children?

2 • No

220

(Code 5 or more as "B")

223

c. Psychiatry

3 Workup/consultation done. Diagnosis established.

4 Yes, both before and
after Vietnam Service

222

b. Neurology

2 Workup/consultation done. Diagnosis doubtful.

3 Yes, conceived before
Vietnam Service

219

227

a. Dermatology

1 No workup. No consultation
clone.

1 No

2 Yes, conceived after
Vietnam Service
24. Number of veteran's complaints?

2 6. Diagnostic workup/consultation
(use the following codes):

d. Infertility/
Genetic
Problem

4 Workup/consultation done.
No diannosis.

224

27. SPECIFY ANY ADDITIONAL WORKUPS/CONSULTATIONS PERFORMED WHICH WERE NOT LISTED IN ITEM 26.

28. LIST UP TO THREE DEFINITE DIAGNOSES (MAS coders enter 1CD9-CM Codes at right I
(225) (226)

(227)

(228)

(229.

(230)

(231)

(232)

(233)

(234,

(235)

(236, (237)

(238)

(239,

(243)

(244)

(245)

251

252

a.
b.

e.

(240) (241) (242)

29. EVIDENCE OF NEOPLASIA (Specify diagnosis) ENTER "1" FOR YES AND "2" FOR NO IN BLOCK 240.

;

30. If no disease is found, enter "1" in block
at right, otherwise, leave blank.

1 32. DISPOSITION (Enter one i:ode in each block)

246

31. Enter year of onset for each diagnosis is ted
above, if unknown, leave blank.

1 = Yes

254

b.

256

d. Referred for VA outpat ent
care
267

e. Referred to private physician,
non-VA clinic or non-VA hospital.

Hospitalized at the VAMC
for further tests

i
36. SIGNATURE OF EXAMINER

VA FPRM i^j anna
DEC 1982 IU-8UUS

250

2ND
DX

3RD
DX

If veteran was referred for VA
outpatient care, indicate two digit
code for the clinic at nght. (See
clinic codes listed on VAl; 10-2875-1.)
f.

Biopsy

255

c.

Hospitalized at the VAMC
for treatment

f

CLINIC

CLINIC

CLINIC
I

™ " " r !ir
208

toAFIP

33. REMARKS

I 34. NAME OF EXAMINER (/'lease print)

249

248

-'

2 = No (Code Hem d separately according to instructions)

253

a. Exam completed

247
1ST
DX

35. TITLE OF EXAMINER

CLINIC
{:?«.'>')

C'li-l)

CLINIC
(2IO~')

(26G)
269