Blank TERA Memorandum

Department of Veterans Affairs Memorandum Claimant Name: File Number: Date: SUBJ: Toxic Exposure Risk Activity (TERA) Memorandum Question 1. Does the Veteran qualify for a presumption of exposure(s) for one or more of the following hazards during military service? (If Yes, provide details below.) No Yes, the Veteran was exposed to the following (select all that apply): Herbicide Agent - 2,3,7,8 - Tetrachlorodibenzodioxin (TCDD) Radiation - Ionizing Mustard Gas - Nitrogen, Sulfur Mustard or Lewisite Camp Lejeune Water Contamination - Perchloroethylene (PCE), trichloroethylene (TCE), vinyl chloride, benzene Evidence of exposure (include the subject and date of receipt of the cited documents): Question 2A. Is there an Individual Longitudinal Exposure Record (ILER) entry for the Veteran? (If Yes, answer 2B and ensure that the Individual Exposure Summary is uploaded into VBMS.) No Yes Question 2B. Is there any evidence of exposure over permissible limits in the ILER report? (If Yes, ensure that pertinent evidence is bookmarked or annotated in VBMS.) No Yes Question 3A. Does the Veteran's VBMS eFolder contain the Persian Gulf War Service - Sec. 1117 flash and 1117 memo? (If No, answer 3B as well.) No Yes Question 3B. Is there evidence of record verifying that the Veteran served in a 38 C.F.R. § 3.317(e)(2) and/or Sec. 1117 location? (If Yes, provide details below.) No Yes Evidence of service in a 38 C.F.R. § 3.317(e)(2) and/or Sec. 1117 location (include the subject and date of receipt of the cited documents): TERA Memorandum Page 1 of 2

Question 4A. Does the Veteran's VBMS eFolder contain the Toxic Exposure - Sec. 1119 Covered Veteran flash and 1119 memo? (If No, answer 4B as well.) No Yes Question 4B. Is there evidence of record verifying that the Veteran served in a 38 C.F.R. § 3.320 and/or Sec. 1119 location? (If Yes, provide details below.) No Yes Evidence of service in a 38 C.F.R. § 3.320 and/or Sec. 1119 location (include the subject and date of receipt of the cited documents): Question 5A. Is there evidence of other deployment related exposure in the eFolder and/or ILER (not already depicted in the questions above) which is consistent with the circumstances of the Veteran's service? (If Yes, provide details below and answer 5B as well.) No Yes Evidence and details about deployment related exposure (include the subject and date of receipt of the cited documents): Question 5B. Where in the eFolder does the deployment information exist (e.g., ILER, VIS, military personnel record? (Ensure that the pertinent evidence is bookmarked or annotated in VBMS.) Question 6. Is there evidence of non-deployment related exposure in the eFolder and/or ILER which is consistent with the circumstances of the Veteran's service? (If Yes, provide details below.) No Yes Evidence and details about non-deployment related exposure (such as Military Occupational Specialty; other military duties; garrison exposures; any relevant location, dates, and length of each exposure, etc.): CONCLUSION. Did the Veteran participate in a TERA during active military service? (If Yes was answered to any of the above questions, then "Yes, the Veteran participated in a TERA" should be selected.) Yes, the Veteran participated in a TERA No, the Veteran did not participate in a TERA Employee signature TERA Memorandum Page 2 of 2