Agent Orange Registry Code Sheet 10-9009
ADVERTISEMENT
1
2
3
4OMB Number 2900-0376
Estimated burden: 20 min.
Expiration Date: 3/31/2004
AGENT ORANGE REGISTRY CODE SHEET
#5
Facility Number (Use PTF No. only) (2 - 4)
TT
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" published in the Federal
Register in accordance with the Privacy Act of 1974.
INSTRUCTIONS: Registry Physicians and Coordinators:
Please print. Use only one letter or number per block. If possible use black ballpoint or felt-tip pen.
PART 1 OBTAIN THIS INFORMATION FROM PATIENT'S CHART ONLY.
2. LAST NAME (8-33)
4. MIDDLE NAME (49-58)
3. FIRST NAME (34-48)
5. TYPE
(59)
SOCIAL SECURITY NUMBER (60 69)
6.
7. SERVICE SERIAL NO (70 - 79) (Begin at
8. DATE OF BIRTH (80 87)
(Begin entering SSN in Block 61. If SSN
left, leave unused blocks blank. Enter "U" if
is pseudo number, enter "P" in Block 60.
Date
Year
Month
service number is unknown.)
(60)
9. ADDRESS (Street Name and Apartment Number, if applicable)
CITY OR TOWN (114-139)
COUNTY
STATE
ZIP CODE (140-144)
PLUS 4
COUNTY
STATE
(149-151)
(152-153
(Optional)(145-148)
(154)
10. Race/Ethnicity (Enter one code in Block 154)
2
3
1
= Asian or Pacific Islander;
= Black, Not Hispanic Origin;
= American Indian or Alaskan Native;
5
6
4
= Hispanic;
= Unknown
= White, Not Hispanic Origin;
(155)
11. Marital Status (Enter one code in Block 155)
1
2
3
4
5
= Married;
= Divorced;
= Separated;
= Widowed;
= Single, Never Married
(157)
12. Sex (Enter one code in Block 156)
(156) 13. Current Status (enter code in Block 157.)
1
2
3
= Inpatient;
= Outpatient;
= Incarcerated;
M
F
= Male
= Female
4
5
= Active Duty, Inpatient;
= Active Duty, Outpatient
(158)
14. Branch of Service (If more than 1, enter latest Branch of Service in Block 158.)
1
2
3
4
5
6
= Army;
=Air Force;
=Navy;
=Marines;
= Coast Guard;
= Other
(159)
15. Does veteran have military service in Vietnam, Korea or other locations where Agent Orange or other herbicides were
tested, transported or sprayed for military purposes? (Enter one of the following 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
TO
FROM
TO
15B.
15A.
Month
Year
Month
Year
Month
Year
Month
Year
Last
Next
(160-161)
(162-165)
(166-167)
(168-171)
(172-173)
(174-177)
(178-179)
(180-183)
to Last
Period
of
Period of
Service
Service
16. Did you serve in any of the following:
(184)
(185)
(186)
(187)
(188)
(189)
III Corps
IV Corps
Sea Duty
Other
I Corps
II Corps
Enter Y=Yes,
N=No, or "U" = Unknown in Blocks 184-189.
If "Other," (Block 189) describe in Item 33, "Remarks."
17. List military units in which veteran served. Specify complete unabbreviated title (Company, Battalion)
10-9009
VA FORM
Page 1 of 4
Existing stock of VA Form 10-9009, JUL 2000, will not be used.
MAY 2001 (RS)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal