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1 Appendix I VA Persian Gulf Bi-Monthly Report INSTRUCTIONS AND SAMPLE FORMAT FOR COMPLETION OF BI-MONTHLY REPORT ON PERSIAN GULF WAR VETERANS REGISTRY EXAMINATIONS (RCS 10-0860) A bi-monthly report is required Tom all Department of Veterans Affairs (VA) facilities providing up-to-date statistical infonnation on Persian Gulf Registry (PGR) examinations. Instructions are provided below for the completion and submission of this report. 1. Date of Report. Each report should include the date the report was prepared and submitted to the following address: 2. Mailing Address. This report should be transmitted to the following address Nepal latent of Veterans Affairs Environmental Agents Service (131) ATTN: Persian Gulf Coordinator 810 Vermont Avenue, N.W. Washington, DC 20420 3. Mailing Date. This report should be sent to the above address NO LATER THAN 5 WORKING DAYS FOLLOWING THE END OF EACH BI- MONTHLY REPORTING PERIOD. 135

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136 ADEQUACY OF THE VA PERSIAN GULF REGISTRY AND UCAP 4. The following statistical information is required (see sample 2F-3 and 2F-4~. a. Initial Examination. (The first physical examination of the Persian Gulf veteran.) List the total number of completed initial examinations performed during the current 2-month reporting period. NOTE: A completed code sheet has already been sent to Austin Automation Center (AA C) which was completed for the purpose of entering a Persian Gulf veteran into the PGR. This count should be verif ed with the computerized or card f le records maintained at each facility (see par. 2. 04) describing the computerized or cardf le requirement. b. Cumulative Initial Examinations. The total number of cumulative initial examinations listed in the previous bi-monthly report. c. Cumulative Initial Examination. The total number of "first-time" examinations performed by the medical facility since the beginning of the PGR in 1992. This number should include the current month's initial examinations (par. 4a) plus the sum of the previous month's cumulative initial examinations (par. 4b). NOTE: Examinations performed by satellite outpatient clinics should be included in the total cumulative f gure for VA medical center of jurisdiction. Justif cation for exceptions to this requirement should be directed to EAS (131J, VHA Headquarters. Independent outpatient clinics should report in a manner similar to VA medical centers. d. Initial Incomplete Examinations (in process). The total number of incomplete (code sheeters) that has/have not been sent to AAC) initial examinations in process during the period of the current report. e. Follow-up Examinations. (A first-time examination subsequent to the initial examination- a completed initial examination code sheet has been sent to AAC). The total number of follow-up examinations during the period of the current report. f. Cumulative Follow-up Examinations. The total number of follow- up examinations performed by the medical facility since the beginning of the registry in 1992. This total should be the sum of the previous months' cumulative follow-up examination total and the current bi- monthly follow-up examinations.

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APPENDIXI 137 g. Follow-up Examinations in Process. The total number of follow-up examinations being processed (completed code sheeters) has/have not been sent to AAC). h. Pending Examination Appointments. The total number of initial Persian Gulf examinations for which appointments have been scheduled beyond the end of the bi-monthly report period. NOTE: This is not cumulative and applies to the current hi-monthly report. i. Next Appointment Date. Indicate the next available appointment date. j. Number of Veterans Failing to Keep an Initial Examination Appointment. The total number of veterans who failed to keep a scheduled appointment during the bi-monthly reporting report. NOTE: This is not cumulative and applies to reporting period only. k. Comments or Problems Regarding Pending Examination Appoint- ments. Problems or challenges should be documented with comments regarding examination workload. An explanation and action plan to alleviate delays should be provided in situations where a facility has 50 or more examinations pending, and/or the next available appointment is more than 30 days beyond the date of request. If statistics have been adjusted due to AAC acceptance of code sheets, the message "Cumulative statistics adjusted per transaction acceptance at AAC" need to be included in this paragraph. 1. Name and Telephone Number: The name and telephone number of the person preparing the report must be indicated.

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138 August 7, 1995 ADEQUACY OF THE VA PERSIAN GULFREGISTRYAND UCAP SAMPLE FORMAT FOR BI-MONTHLY REPORT ON PERSIAN GULF VETERANS (RCS-10-0860) DEPARTMENT OF VETERANS AFFAIRS Medical Center Anywhere, USA 85012 Department of Veterans Affairs Environmental Agents Service (131) AMEN: Persian Gulf Coordinator 810 Vermont Avenue, N.W. Washington, DC 20420 In Reply Refer to: SUBJECT: Bi-mon~ly Report of Persian Gulf War Veteran Registry Examinations, (RCS-10-0860 - Period Ending July 3 1, 1995 (Station #600) The subject report is submitted for the 2-month period ending July 31, 1995: a. Initial Examination (Current Bi-Monthly Reporting Period): List total number of completed initial examinations performed for 2-month period ending July 3 1, 1995 (i.e., total number of Persian Gulf Registry code sheets submitted to Austin Automation Center (AAC): b. Cumulative Initial Examinations Tom Previous Bi- Monthly Report: c. Cumulative Number of Completed Initial Examinations Perfonned Since Onset of Program (August, 1992~: Total of numbers listed in Paragraphs 1-a aIld 1-b Note: This should be the total number of all initial examination code sheets submitted to ARC since onset of program. If code sheets have not been sent to AA C, do not include in this total. 100 +450 550

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APPENDIXI d. Initial Incomplete Examinations (in process); Total number of initial (incomplete examinations in process: (code sheets have not been sent to AAC): e. Follow-Up Examinations (Code Sheets Sent to AAC): Total number of follow-up examinations performed for current reporting period (follow-up examinations are those performed subsequent to the initial examination where a completed code sheet for an initial examination has been sent to AAC): Cumulative Follow-up Examinations: Includes the total of follow-up examinations performed (this total includes the number listed in above (par. 1-e) and all follow-up examinations previously reported since August, 1992~. g. Follow-up Examinations in Process: Total number of follow-up examinations in process (code sheets have not been sent to AAC during this reporting period): h. Pending Examination Appointments: Total number of initial examinations for which appointments have been scheduled beyond the end of the bi-monthly report period: i. The Next Available Appointment Date: J Number of Veterans Failing to Keep an Initial Examina- tion Appointment: Total number of veterans who failed to keep a scheduled appointment during the current bi-monthly reporting period. This is not cumulative. k. Comments/problems regarding pending examinations: None 1. The name, address and telephone number of the person preparing this report: 139 75 15 75 12 20 8/10/95 Signature) John Doe Medical Center Director 10

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