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OCR for page 135
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
OCR for page 136
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.
OCR for page 137
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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Representative terms from entire chapter:
initial examinations
