Form VA Form 10-9009 VA Form 10-9009 Agent Orange Registry Code Sheet

OMB Number 2900-0376
Estimated burden: 20 min.

AGENT ORANGE REGISTRY CODE SHEET
#5

TT

Facility Number (Use PTF No. only) (2 - 4)

Suffix (5 - 7)

This information is collected in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this
collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Respondents should be aware that notwithstanding any other provision of law, no
person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. This collection of
information is to collect data for research on exposure to Agent Orange. Response to this survey is voluntary and failure to participate will have no adverse effect on benefits
to which you might otherwise be entitled. The information the veteran supplies may be disclosed outside the VA to Federal, State and local government agencies and National
Health Organizations to assist in the development of programs for research purposes and other uses as stated in the Notice of Systems of VA Records (19VA136)
"Patient Medical Record-VA" published in the Federal Register in accordance with the Privacy Act of 1974.

INSTRUCTIONS: Registry Physicians and Coordinators: Please print. If possible use black ballpoint or felt-tip pen.
PART 1 - OBTAIN THIS INFORMATION FROM PATIENT' S CHART ONLY.
2. LAST NAME (8-33)

6.
(60)

5. TYPE
(59)

4. MIDDLE NAME (49-58)

3. FIRST NAME (34-48)

SOCIAL SECURITY NUMBER (60 - 69) 7. SERVICE SERIAL NO (70 - 79) (Begin at
(Begin entering SSN in Block 61. If SSN left, leave unused blocks blank. Enter " U" if
is pseudo number, enter " P" in Block 60. service number is unknow n.)

8. DATE OF BIRTH (80 - 87)
(mm/dd/yyyy)

9. ADDRESS (Street Name and Apartment Number, if applicable)

CITY OR TOWN (114-139)

COUNTY

STATE

10. Race/Ethnicity (Enter one code in Block
2 = Asian or Pacific Islander;
1 = American Indian or Alaskan Native;
5 = Hispanic;
4 = White, Not Hispanic Origin;
11. Marital Status (Enter one code in Block 155)
1 = Married;

2 = Divorced;

PLUS 4

ZIP CODE (140-144)

3 = Separated;

(Optional)(145-148)

COUNTY
(149-151)

STATE
(152-153

(154)

3 = Black, Not Hispanic Origin;
6 = Unknow n
(155)

4 = Widow ed;

5 = Single, Never Married

(157)
12. Sex (Enter one code in Block 156) (156) 13. Current Status (enter code in Block 157.)
1 = Inpatient;
2 = Outpatient;
3 = Incarcerated;
F = Female
M = Male
4 = Active Duty, Inpatient; 5 = Active Duty, Outpatient
(158)
14. Branch of Service (If more than 1, enter latest Branch of Service in Block 158.)
1 = Army;
2 = Air Force;
3 = Navy;
4 = Marines;
6 = Other
5 = Coast Guard;
(159)
15. Does veteran have military service in Vietnam, Korea or other locations w here Agent Orange or other herbicides w ere
tested, transported or sprayed for military purposes? (Enter one of the follow ing codes in Block 159):
1 = Vietnam
2 = Korea (1968 or 1969)
If served in other locations, but neither Vietnam nor Korea, use " Code 4" and describe under Item 33.
3 = Both
If served in either Vietnam or Korea, list appropriate dates in Blocks 160-183.
4 = Neither (Other locations)
FROM (160-165)

15A.
Last
Period
of
Service

(mm/yyyy)

TO (166-171)
(mm/yyyy)

15B.
Next
to Last
Period of
Service

16. Did you serve in any of the follow ing:
Enter Y= Yes,
N= No, or " U" = Unknow n in Blocks 184-189.
If " Other," (Block 189) describe in Item 33, " Remarks."

FROM (172-177)

TO (178-183)

(mm/yyyy)

(mm/yyyy)

(184)
I Corps

(185)
II Corps

(186)
III Corps

(187)
IV Corps

(188)
Sea Duty

(189)
Other

17. List military units in w hich veteran served. Specify complete unabbreviated title (Company, Battalion)

VA FORM
MAR 2004 (R)

10-9009

Existing stock of VA Form 10-9009, MAY 2001 may be used.

Page 1 of 4

AGENT ORANGE REGISTRY CODE SHEET (CONTINUED)
NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

18.

ENTER THE DATES OF THE LAST TWO PERIODS OF SERVICE, IF OTHER THAN VIETNAM OR KOREA.
FROM (190-195)
TO (196-201)
FROM (202-207)
18A.
(mm/yyyy)
(mm/yyyy)
(mm/yyyy)
18B.
Last
Next to Last
Period
Period of
of
Service
Service

19.

TO (208-213)
(mm/yyyy)

VETERAN'S EXPOSURE TO AGENT ORANGE: (Enter the appropriate number in Blocks (214-219) using the following codes:

2= Not Sure;

1= Definitely Yes;

3= Definitely No
(214)

19A. I was involved in handling or spraying Agent Orange.
(215)

19B. I was not directly sprayed but was in a recently sprayed area.
(216)

19C. I was exposed to herbicides other than Agent Orange.
(217)

19D. I was directly sprayed with Agent Orange.
(218)

19E. I ate food or drink that could have been sprayed with Agent Orange.
20. Veteran's assessment of own health. (Enter one of the following codes in Block 219.)
1= Very Good;
3= Fair;
4= Poor;
2= Good;

(219)

5= Very Poor

PART II - REGISTRY PHYSICIAN, COORDINATOR AND CODING STAFF SHOULD COMPLETE THIS SECTION.

Date (mm/dd/yyyy) (220-227)

21. Date of Registry Examination:
(Enter Month, Day and Year in Blocks 220-227)

22. Veteran's Complaint(s). VA Coders, enter ICD-9 in Blocks 228-242. (If more than 3 complaints/symptoms, list under Item 22D.)
(Left justify all codes - If there are no complaints/symptoms, enter 78000 in Blocks 228-232.)
22A.

(228-232)

22B.

(233-237)

22C.

(238-242)

22D. Additional Complaints:

ENTER APPROPRIATE CODES IN BLOCKS IN COLUMN AT RIGHT

23. Does veteran attribute chief complaint to Agent Orange exposure?

Y = Yes;

N = No;

or U =Unknown

24. Enter total number of veteran's complaints in Blocks 244-245. (Describe any complaint over 3 in Item 22D)
(e.g.; If veteran has 2 complaints, enter slash zero in Block 244 and 2 in Block 245. If none, enter slash zeros in
Blocks 244 and 245 and go to Item 25.)

(243)
(244-245)

25. Evidence of Birth Defects among Vietnam veteran's children. Enter numbers in listed blocks.
25A. How many children does veteran have? (Enter number in Blocks 246-247.)
(e.g.; If veteran has 2 children, enter slash zero in Block 246 and 2 in Block 247. If none, enter slash zeros in
Blocks 246 and 247 and go to Item 26.)

(246-247)

NOTE: Items 25B through 25K are to be completed by Vietnam veterans only. If veteran served outside Vietnam, skip to item 26.
25B. How many children were born before veteran's military service in the Republic of Vietnam?
(Enter number in Blocks 248-249. (If none, enter slash zeros in Blocks 248 and 249 and go to Item 25G)
VA FORM
MAR 2004 (R)

10-9009

Existing stock of VA Form 10-9009, MAY 2001 may be used.

(248-249)

Page 2 of 4

AGENT ORANGE REGISTRY CODE SHEET (CONTINUED)
NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

How many of the children born before the veteran's military service in the Republic of Vietnam showed evidence of spina

(250-251)

25C. bifida?

(Enter number of children in Blocks 250 and 251. If none, enter slash zeros and go to Item 25E.)

Mother's age at conception of first child conceived before the veteran's military service in the Republic of Vietnam showing

(252-253)

25D. evidence of spina bifida.

(Enter age in Blocks 252 and 253.)

How many of the children born before the veteran's military service in the Republic of Vietnam showed evidence of other birth

(254-255)

25E. defects?

(Enter number in Blocks 254 and 255. If none, enter slash zeros and go to Item 25G.)

Mother's age at conception of first child conceived before the veteran's military service in the Republic of Vietnam showing
25F. evidence of other birth defects.
(Enter age in Blocks 256 and 257.)
How many children were born during or after the veteran's military service in the Republic of Vietnam?

25G.

(256-257)

(258-259)

(Enter number in Blocks 258 and 259. If none, go to Item 26.)

How many of the children born during or after the veteran's military service in the Republic of Vietnam showed evidence of
25H. spina bifida?
(Enter number in Blocks 260 and 261. If none enter slash zeros and go to Item 25J.

(260-261)

Mother's age at conception of first child conceived during or after the veteran's military service in the Republic of Vietnam
25I. showing evidence of spina bifida.
(Enter age in Blocks 262 and 263.)

(262-263)

How many of the children born during or after the veteran's military service in the Republic of Vietnam showed evidence of
25J. other birth defects?
(Enter number in Blocks 264 and 265. If none, enter slash zeros and go to Item 26.)

(264-265)

Mother's age at conception of first child conceived during or after the veteran's military service in the Republic of Vietnam
25K. showing evidence of other birth defects.
(Enter age in Blocks 266 and 267.)

(266-267)

26. Diagnostic Workup/Consultations. (Use one of the follow ing codes in Blocks 268-275):
1 = No w orkup done.
2 = Workup/consultation done. Diagnosis undetermined (veteran w ith symptoms but diagnosis cannot be determined).
3 = Workup/consultation done. Diagnosis established.
4 = Workup/consultation done. No diagnosis (veteran w ithout symptoms and no evidence of illness).
5 = Workup/consultation in process. Results pending.
6 = Workup/consultation scheduled - veteran w as a " no show "
(268)

26A. Dermatology

(Enter code in Block 268.)

26B. Pulmonary

(Enter code in Block 269.)

26C. Reproductive Health

(Enter code in Block 270.)

(269)
(270)
(271)

26D. Hematology/Oncology. (Enter code in Block 271.)
(272)

26E. Urology.

(Enter code in Block 272.)

26F. Neurology

(Enter code in Block 273.)

26G. ENT

(Enter code in Block 274.)

26H. Other

(Enter Y= Yes or N= No in Block 275.)

26I. Hepatitis C
(With veteran' s

(In Block 276, enter: P= Positive or N= Negative or X= No testing done.)

(273)
(274)
(275)

VA FORM
MAR 2004 (R)

10-9009

(276)

Existing stock of VA Form 10-9009, MAY 2001 may be used.

Page 3 of 4

AGENT ORANGE REGISTRY CODE SHEET (CONTINUED)
NAME (Last, First, Middle initial)

SOCIAL SECURITY NUMBER

27. Specify any additional w orkups not listed in Item 26 on the follow ing lines

28. Diagnoses. Examiner w ill list up to three definite medical diagnoses on lines 28A-C. Coders w ill enter corresponding ICD9
codes in Blocks 277-291. If there are more than three diagnoses, list these under Item 33 - " Remarks." Do not duplicate
A

(277-281)

B

(282-286)

C

(287-291)

29. Evidence of neoplasia. Enter Code Y= Yes or N= No in Block 292.

(292)

(293-297)

If " Yes," describe below and enter ICD9 code in Blocks 293-297. If " No," leave blank. Use
Items A through C above if there is evidence of more than one case of neoplasia.

(298)

30. If no disease/diagnosis is found enter a Code " 1" in Block 298.
31. Enter year of onset
for each diagnosis listed
in Blocks 277-291 and
293-297. Leave blank if
unknow n.

1st Diagnosis (299-302)

2nd Diagnosis (303-306)

3rd Diagnosis (307-310)

4th Dx (Neoplasia 311-314)

32. Disposition (Enter one of the follow ing codes in each Block: Y= Yes or N= No.) All Blocks must be completed. If veteran has
no diagnosis and you have answ ered " YES" in Blocks 317 - 319, explain w hy under remarks (Item 33.)
(315)

A. Exam Completed?

B. Hospitalized at VAMC
for further tests?

(316)

C. Hospitalized at
VAMC for treatment?

(319)

E. Referred to private physician;
non-VA clinic or Non-VA hospital?

(317)

(320)

F. Biopsy?

D. Referred for VA
Outpatient Treatment
G. Specimens to be
Sent to AFIP?

(318)

(321)

(322)

33. Remarks (Please indicate w hether you have made any remarks by entering a Y for Yes or N for No in Block 322.)

34. PRINT FULL NAME OF EXAMINER/REGISTRY PHYSICIAN

35. FULL TITLE OF EXAMINER

36. SIGNATURE OF EXAMINER

37. SIGNATURE OF REGISTRY PHYSICIAN

VA FORM
MAR 2004 (R)

10-9009

Existing stock of VA Form 10-9009, MAY 2001 may be used.

Page 4 of 4