Free VA Form 10-9009d - Depleted Uranium (DU) Questionnaire - Federal

Depleted Uranium Worksheet
Name SSN

DEMOGRAPHICS LAST NAME FIRST NAME MIDDLE NAME

SOCIAL SECURITY NUMBER

DATE OF BIRTH

ADDRESS

CITY

COUNTY

STATE

ZIP CODE

PLUS FOUR

PHONE NUMBER (DAYTIME)

PHONE NUMBER (EVENING)

SEX

F=FEMALE M=MALE

MARITAL STATUS

1=MARRIED 2= DIVORCED 3= SEPERATED 4= WIDOWED 5= SINGLE, NEVER MARRIED

RACE RACE CODE
1 = AMERICAN INDIAN OR ALASKAN NATIVE 2 = ASIAN 3 = BLACK OR AFRICAN AMERICAN 4 = NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 5 = WHITE 6 = DECLINED TO ANSWER 7 = UNKNOWN BY PATIENT

COLLECTION METHOD
1 = OBSERVER 2 = PROXY 3 = SELF-IDENTIFICATION 4 = UNKNOWN

ETHNICITY ETHNICITY CODE
1 = HISPANIC OR LATINO 2 = NOT HISPANIC OR LATINO 3 = DECLINED TO ANSWER 4 = UNKNOWN BY PATIENT

COLLECTION METHOD
1 = OBSERVER 2 = PROXY 3 = SELF-IDENTIFICATION 4 = UNKNOWN

BRANCH OF SERVICE
1 = ARMY 2 = AIR FORCE 3 = NAVY 4 = MARINES 5 = COAST GUARD 6 = OTHER

START DATE

PERIODS OF SERVICE END DATE

REMARKS

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Depleted Uranium Worksheet
Name SSN

GENERAL FACILITY NUMBER FACILITY SUFFIX DATE OF EXAM

EXAMINER NAME

EXAMINER TITLE

REMARKS

CURRENT STATUS BRANCH OF SERVICE

1 = INPATIENT 2 = OUTPATIENT 3 = INCARCERATED 1 = ARMY 2 = AIR FORCE 3 = NAVY

4 = ACTIVE DUTY (INPATIENT) 5 = ACTIVE DUTY (OUTPATIENT) 4 = MARINES 5 = COAST GUARD 6 = OTHER

MILITARY BRANCH OF SERVICE
8 = PERSIAN GULF AREA 4 = OTHER

LOCATION DESCRIPTION

START DATE

END DATE

REFERRED BY 9. Who referred veteran to VA Medical Center for evaluation?
A = Force Health Protection & Readiness Programs of DoD B = Another Department of Defense office C = Department of Veteran's Affairs D = Self referred E = Other sources

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Depleted Uranium Worksheet
Name SSN

AREAS 10. Where did the veteran serve? KUWAIT SAUDI ARABIA IRAQ ONLY ON A SHIP (NOT ASHORE) OTHER IF YES, DESCRIBE OTHER AREA 11. Was the veteran a Logistics Assistance Representative (LAR) who inspected depleted uranium contaminated systems to determine repairability? 12. Was the veteran a member of the battle damage assessment team (BDAT) who examined U. S. combat vehicles known, or suspected to be, damaged or destroyed by DU?
13. If the veteran served prior to Operation Iraqi Freedom, was he/she a member of the 144th Service and Supply Company who processed damaged equipment, including some with DU contamination during Operation Desert Storm/ Desert Shield?
Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO

14. Was the veteran a member of a radiation control (RADCON), or other radiation survey team deployed in the Persian Gulf? 15. Was the veteran involved in the examination or recovery of damaged or destroyed enemy vehicles? 16. Was the veteran involved in the downloading of equipment or munitions from vehicles known or suspected to be contaminated by DU? 17. Was the veteran a member of a unit maintenance team performing maintenance on or in systems know or suspected to be contaminated by DU? 18. If the veteran served prior to Operation Iraqi Freedom, was he/ she at Doha on July 11, 1991, at the time of the fire? Was the veteran directly involved in clean-up operations following the Doha explosion and fire? If yes Was the veteran exposed to smoke from burning Doha rounds?

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Depleted Uranium Worksheet
Name SSN

ENEMY FIRE 19. Was the veteran in or on a vehicle hit by enemy fire at the time it was hit? What type of vehicle? Abrams battle tank Bradley fighting vehicle If Yes Other If yes, identify other
Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO Y = YES N = NO U = UNKNOWN

Don't know Was the vehicle hit by DU munitions? 20. Did the veteran enter an Abrams battle tank to perform rescue operations immediately after it was struck by enemy fire? 21. Did the veteran enter an Abrams battle tank to retrieve sensitive items immediately after it was struck by enemy fire? 22. Did the veteran enter a Bradley fighting vehicle to perform rescue operations immediately after it was struck by enemy fire? 23. Did the veteran enter a Bradley fighting vehicle to retrieve sensitive items immediately after it was struck by enemy fire? FRIENDLY FIRE 24. Was the veteran in or on a vehicle hit by friendly fire at the time it was hit? What type of vehicle? Abrams battle tank Bradley fighting vehicle If Yes Other If yes, identify other

Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

Don't know Was the vehicle hit by DU munitions? 25. Did the veteran enter an Abrams battle tank to perform rescue operations immediately after it was struck by friendly fire? 26. Did the veteran enter an Abrams battle tank to retrieve sensitive items immediately after it was struck by friendly fire? 27. Did the veteran enter a Bradley fighting vehicle to perform rescue operations immediately after it was struck by friendly fire? 28. Did the veteran enter a Bradley fighting vehicle to retrieve sensitive items immediately after it was struck by friendly fire?

Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

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Depleted Uranium Worksheet
Name SSN

FRIENDLY FIRE (continued) 29. Did the veteran enter any enemy vehicle to perform rescue operations immediately after it was struck by our fire? What type of vehicle? Tank Other tracked vehicle If yes, identify other
Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

Truck If Yes Other wheeled vehicle If yes, identify other

Other type of vehicle If yes, identify other

Y = YES N = NO U = UNKNOWN

Don't know 30. Did the veteran enter any enemy vehicle to retrieve sensitive items or intelligence material immediately after it was struck by our fire? What type of vehicle? Tank Other tracked vehicle If yes, identify other

Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

Truck If Yes Other wheeled vehicle If yes, identify other

Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

Other type of vehicle If yes, identify other

Y = YES N = NO U = UNKNOWN

Don't know

Y = YES N = NO U = UNKNOWN

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Depleted Uranium Worksheet
Name SSN

EQUIPMENT 31. Was the veteran exposed to smoke from any enemy equipment by DU rounds? 32. Did the veteran remove equipment or other items from a damaged or destroyed U.S. or enemy vehicle? Description If Yes Does the veteran still have equipment or other items removed from a damaged or destroyed U.S. or enemy vehicle? NEAR 33. Was the veteran within 50 meters (45.72 yards) of a vehicle when it was hit (not including vehicles the veteran was in or on that were hit)? What type of vehicle? Abrams battle tank Bradley fighting vehicle If Yes Other If yes, identify other
Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

Don't know Was the vehicle hit by DU munitions? 34. Did the veteran breath smoke or dust from vehicles hit by enemy or friendly fire? What type of vehicle? Abrams battle tank Bradley fighting vehicle If Yes Other If yes, identify other

Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

Don't know Was the vehicle hit by DU munitions?

Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

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Depleted Uranium Worksheet
Name SSN

POST 35. Did the veteran climb on or enter vehicles hit by enemy or friendly fire sometime after the immediate post-impact rescue period? What type of vehicle? Abrams battle tank Bradley fighting vehicle Other If yes, identify other
Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

Don't know How many times? 1 time 2 times If Yes 3-10 times More than 10 times Don't know How long (in total was the veteran aboard the vehicle(s)? Less than 5 minutes 5-15 minutes 16-30 minutes More than 30 minutes Don't know Was the vehicle hit/contaminated by DU munitions? 36. Did the veteran pass within 50 meters (45.72 yards) of a damaged or destroyed vehicle? How long (in total) after the destructive event? Less than 12 hours 12- 24 hours More than 24 hours Don't know What type of vehicle? If Yes Abrams battle tank Bradley fighting vehicle Other If yes, identify other

Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

Don't know Was the vehicle burning?

Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

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Depleted Uranium Worksheet
Name SSN

WOUND 37. Was the veteran wounded as a result of being in, on, or within 50 meters (45.72 yards) of the damaged vehicle at the time it was hit? Where was the veteran wounded? leg/foot arm/hand If Yes face/head neck body Does the veteran have retained fragments or shrapnel in his/her body? OTHER EXPOSURE 38. Did the veteran fire DU rounds? 39. Did the veteran handle bare/damaged DU penetrator rounds? If Yes Did the veteran handle the rounds with gloves? Did the veteran handle the rounds with shielding?
Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN Y = YES N = NO U = UNKNOWN

40. Did the veteran have exposure to DU that is not captured by this questionnaire? If yes, describe

41. Did the veteran have other exposures and experiences to discuss with the provider? If yes, describe

Y = YES N = NO U = UNKNOWN

URINE URANIUM 42. Is the 24-hour urine collection for Uranium being performed? Explain If no or unknown
Y = YES N = NO U = UNKNOWN

Corrected urine uranium (expressed per mcg per g creatinine) 3 digits to the left and 3 digits to the right of the decimal (999.999) Repeat urine uranium Remarks

Note:

-Baltimore DU Follow-up group will enter urine uranium results in EAS registry database; -VA facility EH Coordinators are responsible for entering all other data in EAS registry database

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