Environmental Hazard Registry Worksheet - VA Form

To submit the Environmental Hazard Registry Worksheet, ensure you have completed all sections accurately. You can submit the form via email at veteransupport@va.gov or fax it to (555) 123-4567. Alternatively, physical submissions can be mailed to the Department of Veterans Affairs, Registry Operations, 123 Main St., Anytown, USA, 12345. Make sure to keep a copy for your records.

Important dates for the Environmental Hazard Registry include the expiration date of the current form, which is 08/31/2024. Be aware of any updates or changes in regulation that may come into effect after this date. Keeping track of submission dates ensures compliance and access to benefits.

The purpose of the Environmental Hazard Registry Worksheet is to collect essential health data from Veterans who may have been exposed to environmental hazards during their service. This information helps inform healthcare providers and officials about the potential impacts of such exposures on Veterans' health. Accurate completion of this form is critical to ensuring that eligible Veterans are entered into the registry and can access necessary benefits.

• 1. Last Name: Veteran's last name.
• 2. First Name: Veteran's first name.
• 3. Middle Name: Veteran's middle name.
• 4. Social Security Number: Veteran's social security number.
• 5. Date of Birth: Veteran's date of birth.
• 6. Address: Residential address of the Veteran.
• 7. City: City of residence.
• 8. State: State of residence.
• 9. County: County of residence.
• 10. Zip Code: Postal code of the residence.
• 11. Birth Sex: Gender of the Veteran.
• 12. Marital Status: Current marital status.
• 13. Race: Racial identification.
• 14. Ethnicity: Ethnic identification.
• 15. Periods of Service: Service timeframes of the Veteran.
• 16. Military Related Exposures: Details about military exposures.

Failure to submit the Environmental Hazard Registry Worksheet can lead to a lack of documented exposure for Veterans, potentially affecting their eligibility for benefits. Without this critical health data, the VA may be unable to offer the necessary medical evaluations or support services. Thus, timely submission is crucial for accessing health care and benefits.

• Loss of Registry Entry: If the form is not submitted, the Veteran may not be entered into the registry.
• Delayed Benefits: Failure to document exposure may delay access to necessary health care benefits.
• Impact on Health Evaluations: Incomplete information can hinder proper health evaluations related to service.

• 1. Exposure Documentation: To document any environmental exposures experienced during military service.
• 2. Health Evaluations: To assist healthcare providers in evaluating health concerns related to military exposure.
• 3. Benefits Claims: To support claims for health benefits related to environmental hazards.