Social and Industrial Survey

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Demographic & Information and Sources

1. Note the location of the interview/exam.
   
2. List demographic data, including age, gender, marital status, and other relevant data.
   
3. List service connected disabilities.
   
4. Discuss capacity to manage financial affairs (if an issue).
   
5. Verify accuracy of veteran's name, address, phone number.
   
6. List informants or sources of information, such as claims folder, medical record, veteran, family members, employers, neighbors, friends, physician, or other persons.
   
7. 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

1. Appearance - Describe the veteran's size, build, general physical appearance and dress, noting any distinguishing features or characteristics.
   
2. Indicate if s/he was alone or interviewed with others.
   
3. 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 Is s/he cooperative and friendly or guarded and withdrawn?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

1. Include disabilities listed on Form 2507 for which the exam is requested and any other complaints or conditions expressed by the veteran.
   
2. 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

1. Date the veteran entered military service and branch of service.
   
2. Where s/he completed basic training.
   
3. Military occupation(s).
   
4. Primary assignments and where stationed.
   
5. Any special training received in military.
   
6. Combat experiences.
   
7. Sexual trauma while in military.
   
8. Injuries or illness incurred while in military.
   
9. If claim is for PTSD, include a detailed account of the traumatic experience(s).
   
10. 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)

1. Evidence of disorder in infancy, childhood, or adolescence, especially antisocial behavior (reference DSM-IV).
   
2. Activity patterns: friendships and social relationships.
   
3. Family: describe relationships.
   
4. Significant issues in school, community, or work area.
   
5. Pre-military traumatic events. Provide details, if possible.

H. Chronological History of Adjustment After Service or Stressor

1. Changes in personality or interpersonal relationships.
   
2. Work performance.
   
3. Emotional difficulties: Describe onset and details, including time, nature, and severity.
   
4. Onset of any other type of symptoms, such as physical.
   
5. Legal issues, such as involvement with authorities or courts.
   
6. Substance abuse history Describe use of drugs, alcohol, prescription medications, and tobacco.
   
7. Psychiatric treatment history.

I. Post-Military Social Adjustment

1. Describe all marriages and divorces, loss of spouse or significant other through death, and birth (and death if applicable) of all children.
   
2. Describe nature of friendships and social relationships, including group memberships.
   
3. Describe the veteran's living situation.
   
4. Note any significant post-military adjustment problems, including illness or injury.

J. Industrial Adjustment

1. Veteran's occupation(s).
   
2. All education and training.
   
3. List all employers and positions, including:
   
   1. Earnings
   2. Dates of change(s) in employment
   3. Length of time with specific employers
   4. Periods of unemployment
   5. Relationship with co-workers, supervisors, and subordinates
4. Highest paid position.
   
5. Attitude toward employment.
   
6. Is the veteran working at an occupation or position that is below his/her education and training level?
   
7. 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?
   
8. 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)?)
   
9. 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

1. Identify Stressors in any of the following categories:
   
   
   1. Primary support system or group
   2. Social environment
   3. Educational problems
   4. Occupational problems
   5. Housing problems
   6. Economic problems
   7. Problems accessing health care
   8. Legal system or criminal problems
   9. Other
   
   
2. Appearance: Describe dress, speech, mannerisms, scars, facial expressions, and body movements (assessment based on observation listed above).
   
3. 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.
   
4. Lifestyle: Describe how the veteran spends his/her time, including interests, hobbies, employment, typical day and week, and eating and sleeping patterns.
   
5. 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.
   
6. 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:

1. 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?
   
2. Does the veteran handle the money and pay the bills himself or herself?
   
3. 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

1. Summarize the specific effect of disabilities and the impact on employment.
   
2. 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.

Signature:

Date: