Disability Examination Worksheets
Social and Industrial Survey
Name: |
SSN: |
Date of Exam: |
C-number: |
Place of Exam: |
A. Demographic & Information and Sources
- Note the location of the interview/exam.
- List demographic data, including age, gender, marital status, and
other relevant data.
- List service connected disabilities.
- Discuss capacity to manage financial affairs (if an
issue).
- Verify accuracy of veteran's name, address, phone
number.
- List informants or sources of information, such as claims
folder, medical record, veteran, family members, employers, neighbors, friends,
physician, or other persons.
- If S&I Survey is done in the community, list the collaterals
residing in the home, their ages and relationship to the veteran, a brief
description at the household appearance and overall home environment.
B. Appearance & Response to Interview
- Appearance - Describe the veteran's size, build, general physical
appearance and dress, noting any distinguishing features or characteristics.
- Indicate if s/he was alone or interviewed with others.
- Make personal observations as to attitude, openness to
interview, reality testing, physical or mental difficulties in communicating.
Does s/he find the interview stressful or threatening? Is s/he cooperative and
friendly or guarded and withdrawn? Observe eye contact, facial expressions, and
attention span during interview.
C. Disabilities
- Include disabilities listed on Form 2507 for which the exam is
requested and any other complaints or conditions expressed by the veteran.
- List of current medications.
D. Brief Pre-Military Social History
Include where the veteran was born, his/her family configuration,
education, etc.
E. Military History
- Date the veteran entered military service and branch of
service.
- Where s/he completed basic training.
- Military occupation(s).
- Primary assignments and where stationed.
- Any special training received in military.
- Combat experiences.
- Sexual trauma while in military.
- Injuries or illness incurred while in military.
- If claim is for PTSD, include a detailed account of the
traumatic experience(s).
- Relationships with peers, superiors, subordinates, etc.
F. Prisoner of War (POW) Data (if applicable)
1. Capture Data
a. Injuries/wounds incurred when captured and any treatment
received. b. Captors - Date and place captured. c. Internment - List
names of camps where interred and dates of internment, psychological
conditions, physical conditions, methods used to control prisoners. d. Work
- Physical & psychological conditions of work. e. Diet - Daily meals,
including types of food, quantities, regularity of meals. f. Illnesses or
Injuries incurred when captured or while imprisoned and any treatment received.
2. Information from Veteran's Significant Other(s)
a. The significant other's relationship to the veteran. b.
Whether s/he knew veteran before or after capture. c. Any changes observed.
d. General comments on impact of POW experience.
G. Chronological History of Adjustment Prior to Service or
Stressor (if applicable)
- Evidence of disorder in infancy, childhood, or adolescence,
especially antisocial behavior (reference DSM-IV).
- Activity patterns: friendships and social relationships.
- Family: describe relationships.
- Significant issues in school, community, or work area.
- Pre-military traumatic events. Provide details, if possible.
H. Chronological History of Adjustment After Service or Stressor
- Changes in personality or interpersonal relationships.
- Work performance.
- Emotional difficulties: Describe onset and details, including
time, nature, and severity.
- Onset of any other type of symptoms, such as physical.
- Legal issues, such as involvement with authorities or
courts.
- Substance abuse history Describe use of drugs, alcohol,
prescription medications, and tobacco.
- Psychiatric treatment history.
I. Post-Military Social Adjustment
- Describe all marriages and divorces, loss of spouse or
significant other through death, and birth (and death if applicable) of all
children.
- Describe nature of friendships and social relationships,
including group memberships.
- Describe the veteran's living situation.
- Note any significant post-military adjustment problems,
including illness or injury.
J. Industrial Adjustment
- Veteran's occupation(s).
- All education and training.
- List all employers and positions, including:
- Earnings
- Dates of change(s) in employment
- Length of time with specific employers
- Periods of unemployment
- Relationship with co-workers, supervisors, and subordinates
- Highest paid position.
- Attitude toward employment.
- Is the veteran working at an occupation or position that is below
his/her education and training level?
- Is there evidence that the veteran's pre-traumatic level of
performance was above his/her post-traumatic level of performance? What is the
documentation of this?
- Is there evidence service connected disability(ies) impacted the
veteran's decision to retire? Discuss. (For example, did the veteran choose to
take an early retirement with financial loss in order to reduce the stress
experienced in the work environment because the stress was aggravating the
service connected disability(ies)?)
- Has an employer made official or unofficial accommodations to
handle veterans disabilities? Document any evidence of internal transfers,
re-assignments, etc.
K. Present Social Functioning
- Identify Stressors in any of the following categories:
- Primary support system or group
- Social environment
- Educational problems
- Occupational problems
- Housing problems
- Economic problems
- Problems accessing health care
- Legal system or criminal problems
- Other
- Appearance: Describe dress, speech, mannerisms, scars, facial
expressions, and body movements (assessment based on observation listed above).
- Relationships: Describe all relationships, including with whom
and duration of relationship. Describe physical intimacy, including frequency,
level of satisfaction, problems with intimacy, and any impact of medical or
psychiatric conditions on performance.
- Lifestyle: Describe how the veteran spends his/her time,
including interests, hobbies, employment, typical day and week, and eating and
sleeping patterns.
- Mental Status: Describe, including evidence of confusion, memory
problems, thought processes or disorders, and mood/affect. Describe the
veteran's functioning in the areas of cognitive, emotional (mood) and judgment.
- GAF Score (if available)
L. Capacity to manage financial affairs (if an
issue)
NOTE: Mental competency, for VA benefits purposes, refers only
to the ability of the veteran to manage VA benefit payments in his or her own
best interest, and not to any other subject. Mental incompetency, for VA
benefits purposes, means that the veteran, because of injury or disease, is not
capable of managing benefit payments in his or her best interest. In order to
assist raters in making a legal determination as to competency, please address
the following:
- What is the impact of injury or disease on the veteran's ability
to manage his or her financial affairs, including consideration of such things
as knowing the amount of his or her VA benefit payment, knowing the amounts and
types of bills owed monthly, and handling the payment prudently?
- Does the veteran handle the money and pay the bills himself or
herself?
- Based on your examination, do you believe that the veteran is
capable of managing his or her financial affairs? Please provide examples to
support your conclusion.
M. Summary & Conclusions
- Summarize the specific effect of disabilities and the impact on
employment.
- Summarize the specific effect of disabilities and the impact on
social functioning.
NOTE: Refer to medical, psychiatric and/or neuro-psychiatric
report(s), as appropriate.
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Date: |
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Reviewed/Updated Date:
April 30, 2007
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