Attachment A_Screenings_Updated.pdf

Updated 4/28/2023

Toxic Exposure Screening

VHA Clinical Reminder for Toxic Exposures Version 1.4

As required by the Honoring our PACT Act (Public Law 117-168), VA is screening all enrolled Veterans to help address potential toxic exposures while serving in the Armed Forces. This screening will occur at least once every 5 years and the Veteran is offered the Toxic Exposure Screening information.

Possible exposures include:

Open Burn Pits/Airborne Hazards Gulf War related exposures Agent Orange Radiation Camp Lejeune contaminated water exposure Other exposures

++ ALL STAFF, EXCEPT CLINICANS: Read the following to Veteran/caregiver ++

- Participation in this survey is voluntary

- If you choose not to answer, it will not change your benefits

- It should take less than 5 minutes to complete

- All information is confidential as required by law

- This survey follows the rules of the Paperwork Reduction Act

- Our Office of Management and Budget number: 2900-0913, esp. 03/31/23

- Comments about the length of the survey should be sent to

VHAPACTACT603ToxicExposureScreening@va.gov

Do you believe you experienced any toxic exposure(s), such as Open Burn Pits/Airborne Hazards, Gulf War related exposures, Agent Orange, Radiation, contaminated water at Camp Lejeune or other such exposures, while serving in the Armed Force?

Yes (NOTE: If selected, generates the Toxic Exposure Screening Follow-up) Your concerns about military exposures are important. It’s important to us that your concerns are addressed and your needs are met. We want to be sure you get the care you deserve.

* Do you believe you were exposed to any of the following while serving in the Armed Forces?

Open Burn Pits/Airborne Hazards:

* Veteran/caregiver was made aware of educational resources that includes information on the Registry Program, presumptive conditions and how to file a claim. Printed information was offered and provided if desired.

Toxic Exposures Screening Information Presumptive Conditions Associated with Open Burn Pits/Airborne Hazards

Gulf War related exposures:

* Veteran/caregiver was made aware of educational resources that includes information on the Registry Program, presumptive conditions and how to file a claim. Printed information was offered and provided if desired.

Toxic Exposures Screening Information Presumptive Conditions Associated with Open Burn Pits/Airborne Hazards

Other Presumptive Conditions Associated with Gulf War Exposures Agent Orange:

* Veteran/caregiver was made aware of educational resources that includes information on the Registry Program, presumptive conditions and how to file a claim. Printed information was offered and provided if desired.

Toxic Exposures Screening Information

Presumptive Conditions Associated with Agent Orange Radiation:

* Veteran/caregiver was made aware of educational resources that includes information on the Registry Program, presumptive conditions and how to file a claim. Printed information was offered and provided if desired.

Toxic Exposures Screening Information

Presumptive Conditions Associated with Radiation Exposure Camp Lejeune contaminated water exposure:

* Veteran/caregiver was made aware of educational resources that includes information on the Registry Program, presumptive conditions and how to file a claim. Printed information was offered and provided if desired.

Toxic Exposures Screening Information

Presumptive Conditions Associated with Camp Lejeune Other exposures: Comment: ________________________________________

* Veteran/caregiver was made aware of educational resources and printed information was offered and provided if desired.

Toxic Exposures Screening Information

* Ask the Veteran/caregiver if they have follow-up questions:

Health/Medical Questions All patients who report a health/medical concern will receive follow-up from a clinician in the next 14 days. For urgent or emergent concerns, follow local facility policy.

Benefits/Claims Questions Inform Veteran/caregiver of local point of contact.

VA Healthcare Enrollment and Eligibility Questions Inform Veteran/caregiver of local point of contact.

Registry Questions Inform Veteran/caregiver of local point of contact.

Veteran/caregiver does not have questions at this time Inform Veteran/caregiver of local point of contact.

Contact information for local resources:

Benefits/Claim Questions: 800-827-1000 VA Healthcare Enrollment: 877-222-VETS (8387) Registry: 1-800-MyVA411, Option #8

++ ONLY Primary Care Provider/Toxic Exposure Screening (TES) navigator may complete below section ++

++ NOTE: ADD exposure concern to the problem list using the ICD-10 code included in the encounter. ++

* Veteran/caregiver reported a health/medical concern:

No Yes Concern: ______________________________________________________ Additional comment if needed (NOTE: Opens up text box)

* Veteran/caregiver has the following connections given:

Provided contact information for the Environmental Registry Program Consult/Referral to TES Navigator (NOTE: This auto-generates a consult to TES) Consult/Referral to Social Work (NOTE: This auto-generates a consult to Social Work) Veterans Benefits Administration (VBA) for Benefits/claims: 1-800-827-1000 Veteran Service Officer (VSO) VSO CONTACT INFORMATION None

No (screening ends) We will continue to ask this screening question every 5 years. Please contact your provider/healthcare team if you have concerns about exposures and would like to be screened sooner.

Printed information was offered and provided if desired. Toxic Exposures Screening Information

Don’t Know (NOTE: If selected, generates the Toxic Exposure Screening Follow-up)

Printed information was offered and contact information for local resources were provided if requested.

Toxic Exposures Screening Information

*Ask the Veteran/caregiver if they have follow-up questions:

Health/Medical Questions All patients who report a health/medical concern will receive follow-up from a clinician in the next 14 days. For urgent or emergent concerns, follow local facility policy.

Benefits/Claims Questions Inform Veteran/caregiver of local point of contact.

VA Healthcare Enrollment and Eligibility Questions Inform Veteran/caregiver of local point of contact.

Registry Questions Inform Veteran/caregiver of local point of contact.

Veteran/caregiver does not have questions at this time Inform Veteran/caregiver of local point of contact.

Contact information for local resources:

Benefits/Claim Questions: 800-827-1000 VA Healthcare Enrollment: 877-222-VETS (8387) Registry: 1-800-MyVA411, Option #8

Declines Screening (screening ends)

Reason: _______________________________

If you should change your mind and would like to be screened in the future, contact your provider/healthcare team.

Printed information was offered and provided if desired. Toxic Exposures Screening Information