PERSIAN GULF AND/OR AFGHANISTAN INFECTIOUS DISEASES (OTHER .
PERSIAN GULF AND/OR AFGHANISTAN INFECTIOUS DISEASES (OTHERTHAN TUBERCULOSIS) DISABILITY BENEFITS QUESTIONNAIREName of Claimant/VeteranClaimant/Veteran's Social Security NumberDate of ExaminationIMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OFCOMPLETING AND/OR SUBMITTING THIS FORM.Note - The Veteran is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire as partof their evaluation in processing the Veteran's claim. VA may obtain additional medical information, including an examination, if necessary, to complete VA's review of theveteran's application. VA reserves the right to confirm the authenticity of ALL Questionnaires completed by providers. It is intended that this questionnaire will becompleted by the Veteran's provider.Are you completing this Disability Benefits Questionnaire at the request of:Veteran/ClaimantOther, please describe:Are you a VA Healthcare provider?YesNoYesIs the Veteran regularly seen as a patient in your clinic?Was the Veteran examined in person?YesNoNoIf no, how was the examination conducted?EVIDENCE REVIEWEvidence reviewed:No records were reviewedRecords reviewedPlease identify the evidence reviewed (e.g. service treatment records, VA treatment records, private treatment records) and the date range.Note: This questionnaire is intended solely for claims based on 38 CFR 3.317(c) Presumptive service connection for infectious disease. Therefore, this questionnaire shouldonly be completed for Veterans who have or have had one or more of the following diseases/infections of the following agents: brucellosis, Campylobacter jejuni, Coxiellaburnetii (Q-fever), malaria, tuberculosis (Mycobacterium tuberculosis), nontyphoid Salmonella, Shigella, visceral leishmaniasis or West Nile virus.Persian Gulf and/or Afghanistan Infectious Diseases Disability Benefits QuestionnaireReleased March 2021Updated on March 31, 2020 v20 1Page of
SECTION I - DIAGNOSIS1A. Does the Veteran currently have or has the Veteran been diagnosed with any of the infectious diseases listed below?YesNoIf "Yes," complete item 1B1B.BrucellosisICD Code:Date of diagnosis:Campylobacter jejuniICD Code:Date of diagnosis:Coxiella burnetii (Q fever)ICD Code:Date of diagnosis:MalariaICD Code:Date of diagnosis:Nontyphoid salmonellaICD Code:Date of diagnosis:ShigellaICD Code:Date of diagnosis:Visceral leishmaniasisICD Code:Date of diagnosis:West Nile virusICD Code:Date of diagnosis:Mycobacterium tuberculosis (TB)*ICD Code:Date of diagnosis:*If mycobacterium tuberculosis is the only diagnosis checked, do not complete the rest of this questionnaire. Instead, complete the Tuberculosis Disability BenefitsQuestionnaire. If any other disease(s) have been checked along with mycobacterium tuberculosis, complete the Tuberculosis Disability Benefits Questionnaire and ALSOcomplete this questionnaire for all other non-tuberculosis related diseases checked above.SECTION II - MEDICAL HISTORY FOR DISEASE #12A. Name of disease #1:Describe history (including onset and course) of the Veteran's disease #1:2B. Status of disease #1:ActiveInactive/treated and resolvedDate of cessation of treatment for active disease:2C. If inactive, date disease became inactive/resolved:2D. If inactive/resolved, are there residuals due to the disease?YesNoIf yes, describe residuals:Note: If the Veteran has symptoms or residuals, also complete the appropriate questionnaire for each symptomatic or residual condition or disability. Potential residuals foreach infectious disease are listed in the evaluation criteria in 38 C.F.R. 4.88(b) and in 38 C.F.R. 3.317(d).SECTION III - MEDICAL HISTORY FOR DISEASE #23A. Name of disease #2:Describe history (including onset and course) of the Veteran's disease #2:3B. Status of disease #2:ActiveInactive/treated and resolvedDate of cessation of treatment for active disease:3C. If inactive, date disease became inactive/resolved:Persian Gulf and/or Afghanistan Infectious Diseases Disability Benefits QuestionnaireReleased March 2021Updated on March 31, 2020 v20 1Page of
SECTION III - MEDICAL HISTORY FOR DISEASE #2 (continued)3D. If inactive/resolved, are there residuals due to the disease?YesNoIf yes, describe residuals:Note: If the Veteran has symptoms or residuals, also complete the appropriate questionnaire for each symptomatic or residual condition or disability. Potential residuals foreach infectious disease are listed in the evaluation criteria in 38 C.F.R. 4.88(b) and in 38 C.F.R. 3.317(d).SECTION IV - MEDICAL HISTORY FOR DISEASE #34A. Name of disease #3:Describe history (including onset and course) of the Veteran's disease #3:Active4B. Status of disease #3:Inactive/treated and resolvedDate of cessation of treatment for active disease:4C. If inactive, date disease became inactive/resolved4D. If inactive/resolved, are there residuals due to the disease?YesNoIf yes, describe residuals:Note: If the Veteran has symptoms or residuals, also complete the appropriate questionnaire for each symptomatic or residual condition or disability. Potential residuals foreach infectious disease are listed in the evaluation criteria in 38 C.F.R. 4.88(b) and in 38 C.F.R. 3.317(d).SECTION V - ADDITIONAL PERSIAN GULF AND/OR AFGHANISTAN INFECTIOUS DISEASES5A. If the Veteran has had any additional Persian Gulf and/or Afghanistan infectious diseases, describe using above format:SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS6A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any of the conditions listed in thediagnosis section?YesNoIf yes, describe (brief summary):Persian Gulf and/or Afghanistan Infectious Diseases Disability Benefits QuestionnaireReleased March 2021Updated on March 31, 2020 v20 1Page of
SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (continued)6B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis section?YesNoIf yes, also complete appropriate dermatological questionnaire.6C. Comments, if any:SECTION VII - DIAGNOSTIC TESTINGNote: VA requires diagnostic confirmation for both the initial diagnosis and any relapse or recurrence. Certain Persian Gulf and/or Afghanistan infectious diseases requirespecific testing methods to confirm recurrence of active infection. If testing has been performed and reflects Veteran's current condition, repeat testing is not required. (For VApurposes, relapse is defined as a full return of a disease or the signs and symptoms of a disease after a period of improvement and recurrence refers to another separatedisease episode after a full recovery has been attained).7A. For brucellosis, please state if the initial diagnosis or recurrence of active infection is confirmed by:CultureSerologic testingPlease provide type of test or procedure, date and results (brief summary):7B. For malaria, please state if the initial diagnosis or relapse is confirmed by:Identification of the malarial parasites in blood smearsIdentification of the malarial parasites in other specific diagnostic laboratory tests such as antigen detection, immunologic (immunochromatographic) tests or moleculartesting such as polymerase chain reaction testsPlease provide type of test or procedure, date and results (brief summary):7C. For visceral leishmaniasis, please state if the recurrence of active infection is confirmed by:CultureHistopathologyOther diagnostic laboratory testingPlease provide type of test or procedure, date and results (brief summary):Persian Gulf and/or Afghanistan Infectious Diseases Disability Benefits QuestionnaireReleased March 2021Updated on March 31, 2020 v20 1Page of
SECTION VII - DIAGNOSTIC TESTING (continued)7D. For initial diagnosis, relapse, or recurrence of all other Persian Gulf or Afghanistan infectious diseases, please state the way in which active infection is or was confirmed:Please provide type of test or procedure, date and results (brief summary):SECTION VIII - FUNCTIONAL IMPACT8A. Does the Veteran's Persian Gulf and/or Afghanistan infectious disease(s) impact his or her ability to work?YesNoIf yes, describe impact of each of the Veteran's Persian Gulf and/or Afghanistan infectious diseases, providing one or more examples:SECTION IX - REMARKS9A. Remarks, if any:SECTION X - PHYSICIAN'S CERTIFICATION AND SIGNATURECertification - To the best of my knowledge, the information contained herein is accurate, complete and current.10A. Physician's signature10D. Physician's phone number10B. Physician's printed name10E. National Provider Identifier (NPI) number10C. Date signed10F. Medical license number and state10G. Physician's addressPersian Gulf and/or Afghanistan Infectious Diseases Disability Benefits QuestionnaireReleased March 2021Updated on March 31, 2020 v20 1Page of
Persian Gulf and/or Afghanistan Infectious Diseases Disability Benefits Questionnaire. PERSIAN GULF AND/OR AFGHANISTAN INFECTIOUS DISEASES (OTHER THAN TUBERCULOSIS) DISABILITY BENEFITS QUESTIONNAIRE. Note: This questionnaire is intended solely for claims based on 38 CFR 3.317(c) Presumptive service connection for infectious disease.
Afghanistan Horse Buzkashi – Afghanistan Horse Dawand – Afghanistan Horse Herati – Afghanistan Horse Kohband – Afghanistan Horse Mazari – Afghanistan Horse Qatgani – Afghanistan Horse Qazal – Afghanistan Horse Samand – Afghanistan Horse Tooraq – Afghanistan Horse Yargh
Persian Gulf States 72. Memorandum of Conversation1 Washington, March 11, 1969. SUBJECT US-UK Talks—Persian Gulf PARTICIPANTS (Morning Session) UK John Freeman—British Ambassador Geoffrey Arthur—Asst. Under Secretary, Foreign Office Sir Leslie Glass—Ambassador, Deputy Permanent Rep., UKUN Edward Tomkins—Minister, UK Embassy
About the Author Reza Nazari is a Persian author. He has published more than 50 Persian learning books including: Learn To Speak Persian Fast series, Farsi Grammar in Use series, Persia Club Dictionary Farsi - English, Essential Farsi Idioms, Farsi Verbs Dictionary Read and Write Persian Language in 7 Days Laugh and Learn Farsi: Mulla Nasreddin Tales For
vowels makes it imperative to learn to distinguish æ from a at an early stage. Furthermore, as we learn more about Persian, we realize that this distinction is essential for writing Persian as well. In Persian only the long vowels, in this case a, are written using a letter. æ is represented by a vowel sign (see "The Persian Writing System," for
COLOR KEY: RESOURCE CODE: FTT # COUNTRY PEOPLE GROUPS Population ROL LANGUAGE RELIGION WS OS J G R C B WN WC 1361 Afghanistan Arab 13,500 abh Arabic, Tajiki Islam - Sunni Y N 1 0 641 Afghanistan Deaf Afghan 119,000 und Undetermined Various N 2 0 5059 Afghanistan Jew, Judeo-Persian 12,500 jpr Dzhidi Judaism N 1 0 5060 Afghanistan Kowli Gypsy 10,500 rmt Domari Islam - Sunni NY 1 0
as Deputy Director of Gulf/2000, the largest research and documentation project on the Persian Gulf states, from 1994 to 2016. A graduate of Tufts College, he received an M.A. in Middle Eastern Studies from the School of Oriental and African Studies, University of London, and a Ph.D. in History from Columbia.
Poetries in Contact: Arabic, Persian, and Urdu 1. Introduction The Arabic method of metrical analysis devised by al-Khalīl Ibn Aḥmad of Basra (b. 718) came with Islam into Persian, and spread from there with the rest of Persian literary culture into Urd
NORTH LANARKSHIRE COUNCIL AGmA REPORT 1 1 I I 1 1 IFROM: QR8FSocWWoRK PERlQD Ollff109 - 16mm I I SoClAtWoRK DATE : 16 SEPTEMBER1896 Ref. : EMch I I 1 1. introduction This report compares actual expenditure and income against estimates both for the year to date and the prc@cted &-turn. Explanations are provided for the major &-turn variance.
