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SCORE-Bench

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Naranjana Trehan
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36. Address (Include ZIP Code) Arlington 210 Quincy St VA 22203
37. Date (Mo., day, year) ___
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If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or modifications, please contact OWCP. See Instructions for additional details.
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Form CA-5b (Rev. 10-2020)
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APPLICATION FOR HEALTH BENEFITS
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Continued
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VETERAN'S NAME (Last, First, Middle)
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Eckersley Robert James
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SOCIAL SECURITY NO.
(999-99-9999)
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781-56-6366
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SECTION II - MILITARY SERVICE INFORMATION (Continued)
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3. MILITARY EXPOSURE INFORMATION (Check yes or no) YES NO YES NO
A. DID YOU SERVE IN AN IONIZING RADIATION LOCATION AND PARTICIPATE IN ANY NUCLEAR TESTING TREATMENTS, OR CLEAN UP? (Hiroshima and Nagasaki cleanup or Enewetak Atoll, cleanup of Air Force B-52 bomber carrying nuclear weapons off the coast of Palomares, Spain, response to the fire onboard an Air Force B-52 bomber carrying nuclear weapons near Thule Air Force Base in Greenland.)
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D. DID YOU SERVE IN ANY OF THE FOLLOWING HERBICIDE (e.g. Agent Orange) LOCATIONS? (Republic of Vietnam to include 12 nautical mile territorial waters; Thailand at any United States or Royal Thai base; Laos; Cambodia at Mimot or Krek; Kampong Cham Province; Guam or American Samoa; or in the territorial waters thereof; Johnston Atoll or a ship that called at Johnston Atoll; Korean demilitarized zone; aboard (to include repeated operations and maintenance with) a c-123 aircraft known to have been used to spray an herbicide agent (during service in the Air Force and Air Force Reserves.)
WHEN DID YOU SERVE IN THESE LOCATIONS?
NOTE: Please provide an approximate time-frame (MM/YYYY)
FROM:
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09/1972
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TO:
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12/1972
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[x]
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B. DID YOU SERVE IN ANY OF THE FOLLOWING GULF WAR HAZARD LOCATIONS? (Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, Yemen, Lebanon, Somalia, Afghanistan, Israel, Egypt, Turkey, Syria, Jordan, Djibouti, Uzbekistan, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, and the Red Sea.)
WHEN DID YOU SERVE IN THESE LOCATIONS?
NOTE: Please provide an approximate time-frame (MM/YYYY)
FROM: ___TO: ___
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E. HAVE YOU BEEN EXPOSED TO ANY OF THE FOLLOWING? (Check all that apply)
Veterans can locate additional military exposure categories on VA’s Public Health website at: https://www.publichealth.va.gov/exposures/
[] AIR POLLUTANTS (burn pits, sand, oil well/sulfur fires)
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[x]
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CHEMICALS (pesticides, herbicides, contaminated water)
[] CONTAMINATED WATER AT CAMP LEJEUNE
[] RADIATION [] SHAD (Shipboard Hazard and Defense)
[] OCCUPATIONAL HAZARDS (jet fuel, industrial solvents, lead, firefighting foams)
[] ASBESTOS [] MUSTARD GAS
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[x]
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WARFARE AGENTS (nerve agents, chemical and biological weapons)
[] OTHER (Specify):
WHEN WERE YOU EXPOSED?
NOTE: Please provide an approximate time-frame (MM/YYYY)
FROM:
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09/1972
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TO:
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12/1972
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C. WERE YOU DEPLOYED IN SUPPORT OF ANY OF THE FOLLOWING OPERATIONS? (Enduring Freedom, Freedom's Sentinel, Iraqi Freedom, New Dawn, Inherent Resolve, and Resolute Support Mission)
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SECTION III - INSURANCE INFORMATION (Use a separate sheet for additional information)
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