Department of Defense

INSTRUCTION

NUMBER 1332.38

November 14, 1996

ASD(FMP)

SUBJECT:  Physical Disability Evaluation 

References:  (a)  DoD Directive 1332.18, "Separation
or Retirement for Physical Disability,” November 4,
1996 

(b)  Title 10, United States Code

(c)  Sections 3502, 5532, 6303, and l8332 of title 5,
United States Code

(d)  Sections 206 and 502 of title 37, United States
Code

(e)  through (k), see enclosure 1

1.  PURPOSE 

This Instruction implements policy, assigns responsibilities,
and prescribes procedures under references (a) and (b)
for:

1.1.  Retiring or separating Service members because
of physical disability.

1.2.  Making administrative determinations under references
(c) and (d) for Service members with Service-incurred
or Service aggravated conditions.

1.3.  Authorizing a fitness determination for members
of the Ready Reserve who are ineligible for benefits
under reference (b) because the condition is unrelated
to military status and duty.

2.  APPLICABILITY 

This Instruction applies to the Office of the Secretary
of Defense (OSD), the Military Departments (including
the Coast Guard when it is operating as a Military Service
in the Navy), the Chairman of the Joint Chiefs of Staff,
and the Combatant Commands (hereafter referred to collectively
as “the DoD Components”).   The term “Military Services,”
as used herein, refers to the Army, the Navy, the Air
Force and the Marine Corps.

3.  DEFINITIONS 

Terms used in this Instruction are defined at enclosure
2.

4.  POLICY 

It is DoD policy under reference (a) that:

4.1.  The DoD Disability Evaluation System (DES) shall
be established to conduct physical disability evaluation
in a consistent and timely manner.

4.2.  Members of the Reserve components who are not
on a call to active duty of more than 30 days and who
are medically disqualified for impairments unrelated
to the member’s military status and performance of duty
shall be referred into the DES solely for a fitness
determination upon the request of the member or when
directed by the Secretary concerned.

4.3.  The applicable standards for all determinations
related to physical disability evaluation shall be consistently
and equitably applied, in accordance with 10 U.S.C.
(reference (b)), to Active component and Ready Reserve
members.

5.  RESPONSIBILITIES 

5.1.  The Under Secretary of Defense for Personnel and
Readiness shall:

5.1.1.  Exercise cognizance and oversight of the DoD
DES.

5.1.2.  Make the final decision on requests from the
Military Departments for exceptions to the standards
of this Instruction.

5.2.  The Assistant Secretary of Defense for Force Management
Policy, under the Under Secretary of Defense for Personnel
and Readiness, shall:

5.2.1.  Exercise cognizance of laws, policies, and regulations
that effect the DES.

5.2.2.  Issue guidance, as required, to further interpret,
implement, and govern the policy and procedures for
the four elements of the DES.

5.2.3.  Establish necessary reporting requirements to
monitor and assess the performance of the DES and compliance
of the Military Departments with this Instruction and
DoD Directive 1332.18 (reference (a)).

5.2.4.  Coordinate with the Assistant Secretary of Defense
for Reserve Affairs concerning the impact of laws and
DoD policy on Reserve members who have conditions that
are cause for medical disqualification.

5.2.5.  Coordinate with the Assistant Secretary of Defense
for Health Affairs in developing procedures for medical
issues pertaining to physical disability evaluation.

5.2.6.  Review substantive changes proposed by the Military
Departments to Departmental policies and procedures
for physical disability evaluation that affect the uniformity
of standards for separation or retirement for unfitness
because of physical disability or separation of Ready
Reserve members for medical disqualification.

5.2.7.  Develop quality assurance procedures to ensure
that policies are applied in a fair and consistent manner.

5.3.  The Assistant Secretary of Defense for Health
Affairs, under the Under Secretary of Defense for Personnel
and Readiness, shall:

5.3.1.  Make recommendations for a final decision by
the Secretary of Defense on the unfit findings on all
officers in pay grade 0-7 or higher and medical officers
in any grade who are pending nondisability retirement
for age or length of service at the time of their referral
into the DES.

5.3.2.  Review substantive changes proposed by the Military
Departments in their supplemental medical standards
to enclosure 4 of this Instruction concerning medical
conditions that are cause for referral of a member into
the DES.

5.4.  The Assistant Secretary of Defense for Reserve
Affairs, under the Under Secretary of Defense for Personnel
and Readiness, shall coordinate as necessary to ensure
that procedures for the DES apply consistently and uniformly
to members of the Reserve components.

5.5.  The Secretaries of the Military Departments shall:

5.5.1.  Ensure that members with conditions that may
be cause for referral into the DES are counseled at
appropriate stages on the DES process and the member’s
rights, entitlements, and benefits.

5.5.2.  Establish a quality assurance process to ensure
that policies and procedures established by DoD Directive
1332.18 (reference (a)) and this Instruction are interpreted
uniformly.

5.5.3.  Make determinations on unfitness because of
medical disqualification or physical disability; entitlement
to assignment of percentage of disability at the time
of retirement or separation because of physical disability;
and, except as limited by 10 U.S.C. 1216(d) (reference
(b)), entitlement to and payment of disability retired
and severance pay.

5.5.4.  Ensure that the record of proceedings for physical
disability cases supports the findings and recommendations
made.

5.5.5.  Ensure the Temporary Disability Retired List
(TDRL) is managed to meet the requirements of 10 U.S.C.
1210 (reference (b)) for timely periodic physical examinations,
suspension of retired pay, and removal from the TDRL.

5.5.6.  Designate a Military Department representative
to serve as the Department representative for the Disability
Evaluation System.

5.5.7.  Ensure all matters raising issues of fraud on
the DES by members are investigated and resolved as
appropriate.

6.  PROCEDURES 

See enclosure 3.

7.  EFFECTIVE DATE 

This Instruction is effective for all MEBs 120 days
after the date of this Instruction.

Enclosures - 5 

1.   References

2.   Definitions

3.   Procedures

4.   Guidelines Regarding Medical Conditions and Physical
Defects That Are Cause for Referral into the Disability
Evaluation System

5.   Conditions Not Constituting a Physical Disability

E1.  ENCLOSURE 1

REFERENCES, continued

(e)  DoD Directive 6130.3, “Physical Standards for Appointment,
Enlistment, Induction”, May 2, 1994

(f)  Section 104 of title 26, United States Code

(g)  DoD Directive 1332.27, “Survivor Benefit Plan”,
January 4, 1974

(h)  DoD Directive 1332.35, “Transition Assistance for
Military Personnel,” December 9, 1993

(i)  DoD Instruction 1332.39, “Application of the Veterans
Administration Schedule for Rating Disabilities,” November
14, 1996 

(j)  Sections 801-940 of title 10, United States Code,
“Uniform Code of Military Justice”

(k)  Sections 101 and 302 of title 38, United States
Code

E2.  ENCLOSURE 2

DEFINITIONS, continued

E2.1.1.  Accepted Medical Principles.    Fundamental
deductions, consistent with medical facts that are so
reasonable and logical as to create a virtual certainty
that they are correct.

E2.1.2.  Accession Standards.    Physical standards
or guidelines that establish the minimum medical conditions
and physical defects acceptable for an individual to
be considered eligible for appointment, enlistment or
induction into the Military Services under DoD Directive
6130.3 (reference (e)).

E2.1.3.  Active Duty.    Full-time duty in the active
Military Service of the United States.   It includes:

E2.1.3.1.  Full-time National Guard Duty.

E2.1.3.2.  Annual training.

E2.1.3.3.  Attendance while in active Military Service
at a school designated as a Service school by law or
by the Secretary of the Military Department concerned.

E2.1.3.4.  Service by a member of a Reserve component
ordered to active duty (with or without his or her consent),
or active duty for training (with his or her consent),
with or without pay under competent orders.

E2.1.4.  Active Duty for a Period of More than 30 Days.
   Active duty or full-time National Guard Duty under
a call or order that does not specify a period of 30
days or less.

E2.1.5.  Active Reserve Status.    Status of all Reserves
who are not on an active-duty list maintained under
Section 574 or 620 of 10 U.S.C. (reference (b)), except
those in the inactive National Guard, on an inactive
status list or in the Retired Reserve.   Reservists
in an active status may train with or without pay, earn
retirement points, and may earn credit for and be considered
for promotion.   In accordance with the Reserve Officer
Personnel Management Act (ROPMA), a member in an Active
Reserve status must be on the Reserve Active-Status
List (RASL) (10 U.S.C. 14002 (reference b)).

E2.1.6.  Active Service.    Service on active duty or
full-time National Guard duty.

E2.1.7.  Compensable Disability.    A medical condition
determined to be unfitting by reason of physical disability
and which meets the statutory criteria under Chapter
61 of reference (b) for entitlement to disability retired
or severance pay.

E2.1.8.  Competency Board.    A board consisting of
at least three medical officers or physicians (including
one psychiatrist) convened to determine whether a member
is competent (capable of making a rational decision
regarding his or her personal and financial affairs).

E2.1.9.  Death.    A determination of death must be
made in accordance with accepted medical standards and
the laws of the State where the member is located or
the military medical standards in effect at an overseas
location.

E2.1.10.  Deployability.    A determination that the
member is free of a medical condition(s) that prevents
positioning the member individually or as part of a
unit, with or without prior notification to a location
outside the Continental United States for an unspecified
period of time.

E2.1.11.  Duty Related Impairments.    Impairments which,
in the case of a member on active duty for 30 days or
less, are the proximate result of, or were incurred
in line of duty after September 23, 1996, as a result
of:

E2.1.11.1.  Performing active duty or inactive duty
training;

E2.1.11.2.  Traveling directly to or from the place
at which such duty is performed; or

E2.1.11.3.  After September 23, 1996, an injury, illness,
or disease incurred or aggravated while remaining overnight,
between successive periods for purposes of IDT, at or
in the vicinity of the site of the IDT, if the site
is outside reasonable commuting distance of the member’s
residence.

E2.1.12.  Extended Active Duty.    Active duty under
orders specifying a period of more than 30 days.

E2.1.13.  Final Reviewing Authority.    The final approving
authority for the findings and recommendations of the
PEB.

E2.1.14.  Full and Fair Hearing.    A hearing held by
a board, before which the Service member has the right
to make a personal appearance with the assistance of
counsel and to present evidence in his or her behalf.

E2.1.15.  Impairment of Function.    Any disease or
residual of an injury that results in a lessening or
weakening of the capacity of the body or its parts to
perform normally, according to accepted medical principles.

E2.1.16.  Inactive Duty Training (IDT). Duty prescribed
for Reservists, other than active duty or full-time
National Guard Duty, under 37 U.S.C. 206 (reference
(d)) or other provision of law.   It does not include
work or study in connection with a correspondence course
of a Uniformed Service.

E2.1.17.  Instrumentality of War.    A vehicle, vessel,
or device designed primarily for Military Service and
intended for use in such Service at the time of the
occurrence of the injury.   It may also be a vehicle,
vessel, or device not designed primarily for Military
Service if use of or occurrence involving such a vehicle,
vessel, or device subjects the individual to a hazard
peculiar to Military Service.   This use or occurrence
differs from the use or occurrence under similar circumstances
in civilian pursuits.    There must be a direct causal
relationship between the use of the instrumentality
of war and the disability, and the disability must be
incurred incident to a hazard or risk of the service.

E2.1.18.  Line of Duty Investigation.    An inquiry
used to determine whether an injury or disease of a
member performing military duty was incurred in a duty
status; if not in a duty status, whether it was aggravated
by military duty; and whether incurrence or aggravation
was due to the member's intentional misconduct or willful
negligence.

E2.1.19.  Natural Progression.    The worsening of a
pre-Service impairment that would have occurred within
the same timeframe regardless of Military Service.

E2.1.20.  Nonduty Related Impairments.    Impairments
of members of the Reserve components that were neither
incurred nor aggravated while the member was performing
duty, to include no incident of manifestation while
performing duty which raises the question of aggravation.
  Members with nonduty related impairments are eligible
to be referred to the PEB for solely a fitness determination
but not a determination of eligibility for disability
benefits.

E2.1.21.  Office, Grade, Rank, or Rating. 

E2.1.21.1.  Office.    A position of duty, trust, authority
to which an individual is appointed.

E2.1.21.2.  Grade.    A step or degree in a graduated
scale of office or military rank that is established
and designated as a grade by law or regulation.

E2.1.21.3.  Rank.    The order of precedence among members
of the Armed Forces.

E2.1.21.4.  Rating.    The name (such as "Boatswain's
Mate") prescribed for members of an Armed Force in an
occupational field.

E2.1.22.  Optimum Hospital and Medical Treatment Benefits.
   The point of hospitalization or treatment when a
member's progress appears to be stabilized; or when,
following administration of essential initial medical
treatment, the patient's medical prognosis for being
capable of performing further duty can be determined.

E2.1.23.  Performing Military Duty of 30 days or less.
   A term used to inclusively cover the categories of
duty pertaining to 10 U.S.C. 1204 - 1206 (reference
(b)) (active duty, IDT, and travel directly to and from
active duty or IDT).

E2.1.24.  Permanent Limited Duty.    The continuation
on active duty or in the Ready Reserve in a limited
duty capacity of a Service member determined unfit as
a result of physical disability evaluation or medical
disqualification.

E2.1.25.  Physical Disability.    Any impairment due
to disease or injury, regardless of degree, that reduces
or prevents an individual's actual or presumed ability
to engage in gainful employment or normal activity.
  The term "physical disability" includes mental disease,
but not such inherent defects as behavioral disorders,
adjustment disorders, personality disorders, and primary
mental deficiencies.   A medical impairment or physical
defect standing alone does not constitute a physical
disability.   To constitute a physical disability, the
medical impairment or physical defect must be of such
a nature and degree of severity as to interfere with
the member’s ability to adequately perform his or her
duties.

E2.1.26.  Preponderance of Evidence.    That evidence
that tends to prove one side of a disputed fact by outweighing
the evidence on the other side (that is, more than 50
percent).   Preponderance does not necessarily mean
a greater number of witnesses or a greater mass of evidence;
rather, preponderance means a superiority of evidence
on one side or the other of a disputed fact.   It is
a term that refers to the quality, rather than the quantity
of the evidence.

E2.1.27.  Presumption.    An inference of the truth
of a proposition or fact, reached through a process
of reasoning and based on the existence of other facts.
  Matters that are presumed need no proof to support
them, but may be rebutted by evidence to the contrary.

E2.1.28.  Presumption Period.    The designated time
frame that requires application of the Presumption of
Fitness Rule to a member's physical disability evaluation.

E2.1.29.  Proximate Result.    A permanent disability
the result of, arising from, or connected with active
duty, annual training, active duty for training, or
inactive duty training (IDT), (etc.) to include travel
to and from such duty or remaining overnight between
successive periods of inactive duty training.   Proximate
result is a statutory criteria for entitlement to disability
compensation under Chapter 61 of reference (b) applicable
to Reserve component members who incur or aggravate
a disability while performing an ordered period of military
duty of 30 days or less.

E2.1.30.  Ready Reserve.    Units and individual reservists
liable for active duty as outlined in Sections 12301
(Full Mobilization) and 12302 (Partial Mobilization)
of 10 U.S.C. (reference (b)).  This includes members
of units, members of the Active Guard Reserve Program,
Individual Mobilization Augmentees, Individual Ready
Reserve, and the Inactive National Guard.

E2.1.31.  Retention Standards.    Physical standards
or guidelines which establish those medical conditions
or physical defects that may render a Service member
unfit for further Military Service and are therefore
cause for referral of the member into the DES.30.

E2.1.32.  Service Aggravation. The permanent worsening
of a pre-Service medical condition over and above the
natural progression of the condition caused by trauma
or the nature of Military Service.

E3.  ENCLOSURE 3

PROCEDURES

TABLE OF CONTENTS

PART 1.    OPERATIONAL STANDARDS FOR THE DESPage

E3.P1.1.    Overview of the DES16

E3.P1.2.    Medical Evaluation16

        E3.P1.2.1.    Purpose16

        E3.P1.2.2.    Type of Evaluation 16

        E3.P1.2.3.    Content17

        E3.P1.2.4.    Competency17

        E3.P1.2.5.    TDRL Periodic Examinations17

        E3.P1.2.6.    Physician’s Guide18

        E3.P1.2.7.    Nonmedical Documentation18

        E3.P1.2.8.    Ready Reserve Nonduty-Related
Impairments18

E3.P1.3.    Physical Disability Evaluation18

        E3.P1.3.1.    Purpose18

        E3.P1.3.2.    Informal PEB19

        E3.P1.3.3.    Formal PEB19

            E3.P1.3.3.1.    Eligibility19

            E3.P1.3.3.2.    Directed Formal19

            E3.P1.3.3.3.    Issues19

            E3.P1.3.3.4.    Submission of Informal PEB
Rebuttal19

            E3.P1.3.3.5.    Hearing Rights20

        E3.P1.3.4.    Record of Proceedings21

            E3.P1.3.4.1.    Duty-Related Impairments21

            E3.P1.3.4.2.    Nonduty-Related Conditions22

            E3.P1.3.4.3.    Rationales22

        E3.P1.3.5.    Quality Assurance22

E3.P1.4.    Counseling22

        E3.P1.4.1.    Purpose22

        E3.P1.4.2.    Topics22

        E3.P1.4.3.    Ready Reserve Members23

        E3.P1.4.4.    Incompetent Members23

        E3.P1.4.5.    Pre-separation Counseling23

E3.P1.5.    Personnel23

        E3.P1.5.1.    Purpose23

        E3.P1.5.2.    Functions23

E3.P1.6.    Time Standards for Case Processing24

        E3.P1.6.1.    Referral Time Frame24

        E3.P1.6.2.    Medical24

            E3.P1.6.2.1.    Duty Related24

            E3.P1.6.2.2.    Nonduty-Related24

        E3.P1.6.3.    PEB24

        E3.P1.6.4.    Imminent Death Processing24

TABLE OF CONTENTS, continued

E3.P1.7.    Training and Education25

PART 2.    ELEGIBILITY FOR REFERRAL26

E3.P2.1.    Criteria for Referral26

E3.P2.2.    Duty-Related Impairments26

E3.P2.3.    Nonduty-Related Impairments27

E3.P2.4.    Ineligibility for Referral27

E3.P2.5.    Members with a Nonwaivered Pre-Existing
Condition28

E3.P2.6.    Members with Medical Waivers28

E3.P2.7.    Waiver of MEB/PEB Evaluation29

PART 3.    STANDARDS FOR DETERMINING UNFITNESS DUE TO
PHYSICAL

                 DISABILITY OR MEDICAL DISQUALIFICATION30

E3.P3.1.    Uniformity of Standards30

E3.P3.2.    General Criteria for Making Unfitness Determinations31

E3.P3.3.    Relevant Evidence30

        E3.P3.3.1.    Referral Following Illness or
Injury30

        E3.P3.3.2.    Referral for Chronic Impairment31

        E3.P3.3.3.    Adequate Performance Until Referral31

        E3.P3.3.4.    Cause and Effect Relationship31

E3.P3.4.    Reasonable Performance of Duties31

        E3.P3.4.1.    Considerations31

            E3.P3.4.1.1.    Common Military Tasks31

            E3.P3.4.1.2.    Physical Fitness Test31

            E3.P3.4.1.3.    Deployability32

            E3.P3.4.1.4.    Special Qualifications32

        E3.P3.4.2.    General, Flag, and Medical Officers32

        E3.P3.4.3.    Members on Permanent Limited Duty32

        E3.P3.4.4.    Overall Effect32

E3.P.3.5.    Presumption of Fitness32

        E3.P3.5.1.    Application32

        E3.P3.5.2.    Presumptive Period33

        E3.P3.5.3.    Overcoming the Presumption33

E3.P.3.6.    Evidentiary Standards for Determining Unfitness

                 Because of Physical Disability34

        E3.P3.6.1.    Factual Finding34

        E3.P3.6.2.    Preponderance of Evidence34

PART 4.    STANDARDS FOR DETERMINING COMPENSABLE DISABILITIES35

E3.P4.1.    Overview of Compensable Criteria35

E3.P4.2.    Proximate Result36

E3.P4.3.    Applicable Statute for Reserve Component
Members36

TABLE OF CONTENTS, continued

E3.P4.4.    Line of Duty Requirements36

        E3.P4.4.1.    Uses37

        E3.P4.4.2.    Relationship of Line of Duty Findings
to DES Determinations37

        E3.P4.4.3.    Referral Requirement38

        E3.P4.4.4.    Presumptive Determinations38

        E3.P4.4.5.    Required Determinations38

E3.P4.5.    Evidentiary Standards for Determining

                Compensability of Unfitting Conditions39

        E3.P4.5.1.    Misconduct and Negligence39

        E3.P4.5.2.    Presumptions for Members on Ordered
Active Duty of More Than 30 Days39

            E3.P4.5.2.1.    At Time of Entry39

            E3.P4.5.2.2.    After Entry39

                E3.P4.5.2.2.1.    Presumption39

                E3.P4.5.2.2.2.    Hereditary and/or
Genetic Diseases39

            E3.P4.5.2.3.    Presumption of Aggravation39

        E3.P4.5.3.    Prior-Service Impairments40

        E3.P4.5.4.    Conditions Presumed To Be Pre-existing40

        E3.P4.5.5.    Medical Waivers40

        E3.P4.5.6.    Treatment of Pre-Existing Conditions41

E3.P4.6.    Rating Disabilities41

PART 5.    ADMINISTRATIVE DETERMINATIONS42

E3.P5.1.    Administrative Determinations for Purposes
of Employment

                  under Federal Civil Service42

        E3.P5.1.1.    Incurred in Combat with an Enemy
of the 

                            United States (5 U.S.C.
8332) (Reference (c))42

        E3.P5.1.2.    Armed Confllict (5 U.S.C. 3502,
5532, 6303)

                            (Reference (c))42

        E3.P5.1.3.    Instrumentality of War during
a Period of War (5 U.S.C. 3502,

                            5532, 6303) (Reference (c))42

            E3.P5.1.3.1.    World War II43

            E3.P5.1.3.2.    Korea 43

            E3.P5.1.3.3.    Vietnam43

            E3.P5.1.3.4.    Persian Gulf War43

E3.P5.2.    Determinations for Federal Tax Benefits
43

        E3.P5.2.1.    Status43

        E3.P5.2.2.    Combat Related44

TABLE OF CONTENTS, continued

PART 6.    TDRL Management45

E3.P6.1.    Placement on the TDRL45

E3.P6.2.    TDRL Reevaluation 45

        E3.P6.2.1.    Administrative Finality 45

        E3.P6.2.2.    New Diagnoses45

        E3.P6.2.3.    Member Medical Records45

        E3.P6.2.4.    Compensability of New Diagnoses46

        E3.P6.2.5.    Current Physical Examination46

        E3.P6.2.6.    Refusal or Failure to Report46

        E3.P6.2.7.    Priority46

        E3.P6.2.8.    Reports from non MTFs46

        E3.P6.2.9.    Incarcerated Members47

PART 7.    FINAL DISPOSITION48

E3.P7.1.    Final Decision Authority48

        E3.P7.1.1.    Secretary of Defense (or Secretary
of Transportation)48

        E3.P7.1.2.    Secretary of the Military Department
48

E3.P7.2.    General Rules Regarding Disposition48

        E3.P7.2.1.    Retirement48

        E3.P7.2.2.    Fit Off the TDRL49

            E3.P7.2.2.1.    Appointment and/or Enlistment49

            E3.P7.2.2.2.    Recall to Active Duty49

                E3.P7.2.2.2.1.    Regular Component
Members 49

                E3.P7.2.2.2.2.    Reserve Component49

            E3.P7.2.2.3.    Separation49

            E3.P7.2.2.4.    Termination of TDRL49

E3.P7.3.    Continuance of Unfit Members on Active Duty
or in the Ready Reserve50

E3.P7.4.    Transition Benefits50

E3.P7.5.    Dispositions for Unfit Members50

        E3.P7.5.1.    Permanent Disability Retirement50

        E3.P7.5.2.    Placement on the TDRL50

        E3.P7.5.3.    Separation with Disability Severance
Pay50

            E3.P7.5.3.1.    Criteria50

            E3.P7.5.3.2.    Active Service51

            E3.P7.5.3.3.    Transfer to Retired Reserve51

            E3.P7.5.3.4.    Ready Reserve Early Qualification
for Retired Pay51

        E3.P7.5.4.    Separation under Chapter 61 of
10 U.S.C. (Reference (b)) 

                            without Entitlement to Benefits51

        E3.P7.5.5.    Discharge under other than Chapter
61 of 10 U.S.C. (Reference (b))51

        E3.P7.5.6.    Revert with Disability Benefits52

E3.P1.  ENCLOSURE 3 PART 1

OPERATIONAL STANDARDS FOR THE DES

E3.P1.1.  Overview of the DES. 

Under the supervision of the Secretary concerned, each
DES shall consist of four elements:

E3.P1.1.1.  Medical evaluation by Medical Evaluation
Boards (MEBs), Ready Reserve physical examinations,
and TDRL periodic physical examinations.

E3.P1.1.2.  Physical disability evaluation by Physical
Evaluation Board (PEBs), to include appellate review.

E3.P1.1.3.  Service member counseling.

E3.P1.1.4.  Final disposition by appropriate personnel
authorities.

E3.P1.2.  Medical Evaluation 

E3.P1.2.1.  Purpose.    The medical evaluation element
of the DES shall document under departmental regulations
the medical status and duty limitations of Service members
referred into the DES.

E3.P1.2.2.  Type of Evaluation.    Medical evaluation
is required for personnel undergoing a Medical Evaluation
Board when:

E3.P1.2.2.1.  The Service member is on active duty under
orders specifying a period of more than 30 days.

 E3.P1.2.2.2.  The Service member is a Reserve component
member referred for a duty related impairment.

 E3.P1.2.2.3.  The member is on the TDRL and due for
a periodic physical examination.

   

Either a physical examination or a MEB is required when
a Reserve component member is referred for impairments
unrelated to the member’s military status and performance
of duty (see definition for nonduty-related impairments).
   Before submission to the PEB, physical examinations
accomplished by other than a medical treatment facility
(MTF) shall be forwarded through command channels to
the medical approving authority designated by the respective
Service for review and approval.

E3.P1.2.3.  Content.    MEBs, TDRL physical examinations,
and Reserve component physical examinations shall document
the full clinical information of all medical conditions
the Service member has and state whether each condition
is cause for referral into the DES.   (See enclosure
4 of this Instruction.)   Clinical information shall
include a medical history, appropriate physical examination,
medical tests and their results, medical and surgical
consultations as necessary or indicated, diagnoses,
treatment, and prognosis.   MEBs shall not state a conclusion
of unfitness because of physical disability, assignment
of disability percentage rating, or the appropriate
disposition under Chapter 61 of 10 U.S.C. (reference
(b)).

E3.P1.2.4.  Competency.    MEBs and TDRL periodic examinations
shall include the results of a competency board when
the member has a functional or organic disorder that
makes questionable the member's ability to handle his
or her personal affairs and to understand and cooperate
in MEB and PEB proceedings.

E3.P1.2.5.  TDRL Periodic Examinations.    In addition
to the requirements specified above, TDRL periodic examinations
shall address:

E3.P1.2.5.1.  An estimate of change since the previous
examination.

E3.P1.2.5.2.  Etiology of all medical impairments diagnosed
since the member was placed on the TDRL, to include:

E3.P1.2.5.2.1.  Whether the new diagnosis was caused
either by the condition for which the member was placed
on the TDRL or the treatment received for such a condition.

E3.P1.2.5.2.2.  If not caused by the condition for which
the member was placed on the TDRL, whether the member's
medical records document incurrence or aggravation of
the condition while the member was in a military duty
status; and if so, whether the condition was cause for
referral into the DES at the time the member was placed
on the TDRL.

E3.P1.2.5.3.  The stability of the condition.   If the
condition remains unstable, the report of examination
shall address the progress of the disability and a suggested
time frame (not to exceed 18 months) for the next examination.

E3.P1.2.5.4.  A detailed occupational history and an
indication of pertinent social and recreational activities,
and activities of daily living.

 E3.P1.2.6.  Physician’s Guide.    Physicians who prepare
MEBs and TDRL periodic physical examinations for referral
for physical disability evaluation are encouraged to
use the DVA’s Physician’s Guide for Disability Evaluation
Examinations to describe the nature and degree of severity
of the member’s condition.

 E3.P1.2.7.  Nonmedical Documentation.    For cases
of members with duty-related impairments, the MTF shall
forward to the PEB with the MEB documentation, the documents
listed in paragraphs E3.P1.2.7.1. through E2.P1.2.7.4.,
below.

E3.P1.2.7.1.  A copy of the line of duty determination
under subsection E3.P4.4.3. of Part 4.

E3.P1.2.7.2.  Except in situations of critical illness
or injury in which return to duty is not expected, a
statement from the member's immediate commanding officer
describing the impact of the member's medical condition
on the member's ability to perform his or her normal
military duties and to deploy or mobilize, as applicable.
  When the member has been reassigned for medical purposes
(for example, to a medical holding unit) the MTF will
obtain this statement from the member's former unit
commander.

E3.P1.2.7.3.  Pertinent personnel records, as required
by the member’s Service, to establish the member's military
history.

E3.P1.2.7.4.  Official document identifying the next-of-kin,
court appointed guardian, or trustee when a Service
member is determined incompetent.   (See subsection
E3.P1.2.4. of Part 1.)

E3.P1.2.8.  Ready Reserve Nonduty-Related Impairments.
   Cases of Ready Reserve members with nonduty-related
impairments (see definition) will be referred to the
PEB in accordance with Service regulations.

E3.P1.3.  Physical Disability Evaluation 

E3.P1.3.1.  Purpose.    The physical disability evaluation
element of the DES shall determine the fitness of Service
members with medical impairments to perform their military
duties; and for members determined unfit for duty-related
impairments, their entitlement to benefits under Chapter
61 of 10 U.S.C. (reference (b)).   Physical disability
evaluation shall be conducted by PEBs and include the
elements in subsections E3.P1.3.2. through E3.P1.3.5.,
below.

E3.P1.3.2.  Informal PEB.    The informal PEB will conduct
a documentary review without the presence of the Service
member for providing initial findings and recommendations.

E3.P1.3.3.  Formal PEB.    Eligible Service members
shall be provided a minimum of one opportunity for a
formal PEB to fulfill the statutory requirement of Section
1214 of reference (b) for a full and fair hearing when
requested by a Service member being separated or retired
for physical disability under Chapter 61 of reference
(b).   The Service member’s declination of a formal
PEB will be documented by the Physical Evaluation Board
Liaison Officer (PEBLO) counselor.   Appearance before
a formal PEB may be in person, through a designated
representative, or via video teleconferencing media.

E3.P1.3.3.1.  Eligibility 

E3.P1.3.3.1.1.  Service members determined unfit by
the informal PEB shall be granted a formal PEB upon
request.

E3.P1.3.3.1.2.  Active duty and Ready Reserve members
determined fit do not have an entitlement to a formal
PEB since a finding of fit does not cause involuntary
separation for physical disability.

E3.P1.3.3.1.3.  TDRL members determined fit shall be
entitled to a formal PEB since removal from the TDRL
represents a change in military status.

E3.P1.3.3.2.  Directed Formal.    A formal PEB may be
directed by the final reviewing authority or appropriate
designated Military Department authority without regard
to the member’s election concerning the informal PEB’s
findings.

E3.P1.3.3.3.  Issues.    At the formal hearing, the
member shall be entitled to address any issue that affects
the member's benefits under Chapter 61 of 10 U.S.C.
(reference (b)); 5 U.S.C. 3502, 5532, 6303, and 8332
(reference (c)); and 26 U.S.C. 104 (reference (f)).
  Final determination of these issues shall be in accordance
with Military Department regulations.

E3.P1.3.3.4.  Submission of Informal PEB Rebuttal. 
  Service members requesting a formal PEB should be
encouraged to submit a rebuttal identifying the issues
of disagreement with the informal PEB's findings and
recommendations.

E3.P1.3.3.5.  Hearing Rights.    Service members shall
have, at a minimum, the following rights before the
formal PEB:

E3.P1.3.3.5.1.  The right to personally appear at the
formal hearing, which may include video teleconferencing,
unless such appearance proves impracticable because
the member cannot travel (e.g., the member is incarcerated
or incapacitated).

E3.P1.3.3.5.1.1.  If the member’s conduct or statements
create a potential security risk to board members and/or
other personnel, local security police shall be alerted
and appropriate security precautions shall be taken.

E3.P1.3.3.5.1.2.  Unless the formal hearing is directed
by the Military Department concerned, members of the
Ready Reserve with nonduty-related impairments are responsible
for their personal travel and other expenses.

E3.P1.3.3.5.2.  The right to the assistance of a detailed
military counsel provided at no expense to the member
or a personal representative provided at no expense
to the Service.   This right extends to Reserve component
members who request a formal hearing pending separation
for medical disqualification.

E3.P1.3.3.5.3.  The right to make a sworn statement
or an unsworn statement.

E3.P1.3.3.5.4.  The right to remain silent.   When the
member exercises this right, the member may not selectively
respond, but must remain silent throughout the hearing.

E3.P1.3.3.5.5.  The right to introduce witnesses, depositions,
documents, sworn or unsworn statements (affidavits)
or other evidence in their behalf and to question all
witnesses who testify at the hearing.   Witnesses who
are not members or employees of the Department of Defense
and members of the Department of Defense who are not
deemed essential witnesses as determined by the PEB
attend formal hearings at no expense to the Government.

 E3.P1.3.3.5.6.  The right of access to all records
and information received by the PEB before, during,
and after the formal hearing which may affect the findings
of the PEB or appellate review authority.

E3.P1.3.3.5.7.  The right to a written rationale explaining
the findings and recommendations of the formal PEB.

E3.P1.3.3.5.8.  The right, upon written request, to
a record of the hearing.   The respective Service shall
determine the format of the record (audio, video, or
written transcript).

E3.P1.3.3.5.9.  The right to appeal the findings and
recommendations of the formal PEB.

E3.P1.3.4.  Record of Proceedings.    A record of proceedings
will be prepared to document the findings and recommendations
of the PEB.

E3.P1.3.4.1.  Duty-Related Impairments.    The record
of proceedings for active duty members and Ready Reserve
members referred for duty-related impairments shall
document at a minimum:

E3.P1.3.4.1.1.  The determination of fit or unfit. 
If determined fit, a determination of whether the Service
member is deployable may be included if Service regulations
require such a determination and deployability is defined
and uniformly applied to the office, grade, rank, or
rating in both the Active and Reserve components of
that Service.

 E3.P1.3.4.1.2.  The code and percentage rating assigned
an unfitting physical disability in accordance with
the VASRD.

E3.P1.3.4.1.3.  The reason an unfitting condition is
not compensable.

E3.P1.3.4.1.3.1.  For all cases with a finding of pre-existing
condition without aggravation, the specific accepted
medical principle for overcoming the presumption of
Service aggravation shall be cited and explained.

 E3.P1.3.4.1.3.2.  For all cases of Reserve component
members performing duty of 30 days of less with a finding
of not the proximate result of performing duty, the
justification shall be documented.

E3.P1.3.4.1.4.  For members being placed on the TDRL
or permanently retired, a statement concerning the stability
and permanent nature of the physical disability.

E3.P1.3.4.1.5.  Administrative determinations under
sections A. and B. of Part 5 of this Instruction.

E3.P1.3.4.2.  Nonduty-Related Conditions.    For members
of the Ready Reserve referred for nonduty-related conditions,
the record of proceedings shall document only:

E3.P1.3.4.2.1.  The fitness determination.

E3.P1.3.4.2.2.  For members determined fit, a determination
of whether the member is deployable if Service regulations
require such a determination and deployability is defined
and applied to the office, grade, rank, or rating in
both the Active and Reserve components of that Service.

E3.P1.3.4.3.  Rationales.    The record of all proceedings
for PEB evaluation and changes made as a result of review
by subsequent reviewing authority shall include a written
rationale (explanation) in support of the findings and
recommendations made.

E3.P1.3.5.  Quality Assurance.    Quality assurance
review shall be conducted as necessary to ensure compliance
with the laws, directives, and regulations governing
physical disability evaluation.

E3.P1.4.  Counseling 

E3.P1.4.1.  Purpose.    The counseling element of DES
shall afford Service members undergoing evaluation by
the DES the opportunity to be advised of the significance
and consequences of the determinations made and the
associated rights, benefits, and entitlements.

E3.P1.4.2.  Topics.    Counselors shall counsel on such
matters as:

E3.P1.4.2.1.  The sequence and nature of the steps in
processing.

E3.P1.4.2.2. Statutory and regulatory rights.

E3.P1.4.2.3. Effect of findings and recommendations.

E3.P1.4.2.4. Recourse to rebuttals.

E3.P1.4.2.5. Estimated retired or severance pay based
upon the PEB's findings and recommendations.

E3.P1.4.2.6. Probable retired grade.

E3.P1.4.2.7. Potential veterans benefits.

E3.P1.4.2.8. Post-retirement insurance programs and
the Survivor Benefit Plan in accordance with DoD Directive
1332.27 (reference (g)) if appropriate.

E3.P1.4.2.9. Applicable transition benefits under DoD
Directive 1332.35 (reference (h)).

E3.P1.4.2.10.  Prior to acting on a Service member’s
request for a formal PEB, review with the member the
applicable standard detailed in the VASRD or DoD Instruction
1332.39 (reference (i)), which would have to be recognized
in order to increase the percentage of disability.

E3.P1.4.3.  Ready Reserve Members.    Ready Reserve
members pending separation for physical disability should
be counseled by the MTF Physical Evaluation Board Liaison
Officer concerning their rights under the DES as established
by section E3.P1.3. of Part 1 and section E3.P2.1. of
Part 2.

E3.P1.4.4.  Incompetent Members.    When a Service member
has been determined incompetent, his or her primary
next of kin, or court appointed guardian shall be counseled
and afforded the opportunity to assert the rights granted
to the Service member, unless prohibited by law.

E3.P1.4.5.  Pre-Separation Counseling.    Service members
on a call to active duty of more than 30 days shall
not be separated or retired because of physical disability
prior to completion of pre-separation counseling under
reference (h).   Though counseling is normally accomplished
90 days before separation, the date of separation or
retirement of members determined unfit need not be extended
to provide a minimum of 90 days between counseling and
separation or retirement.

E3.P1.5.  Personnel 

E3.P1.5.1.  Purpose.    The personnel element of DES
shall accomplish disposition of the Service member's
case.   Specifically, appropriate personnel authorities
shall accomplish the functions listed in subsection
E3.P1.5.2., below.

E3.P1.5.2.  Functions.    The personnel element shall:

E3.P1.5.2.1.  Issue orders and instructions to implement
the determination of the respective Service's final
reviewing authority.

E3.P1.5.2.2.  Serve as approving authority for requests
by Service members determined unfit to continue on active
duty or in the Ready Reserve in a permanent limited
duty status.

E3.P1.5.2.3.  Manage the TDRL under section E3.P6.2.
of Part 6.

E3.P1.6.  Time Standards for Case Processing 

E3.P1.6.1.  Referral Time Frame.    It is not within
the mission of the Military Departments to retain members
on active duty or in the Ready Reserve to provide prolonged,
definitive medical care when it is unlikely the member
will return to full military duty.   Service members
shall be referred into the DES as soon as the probability
that they will be unable to return to full duty is ascertained
and optimal medical treatment benefits have been attained
(see Enclosure 2, Page 9, Paragraph E2.1.20).   All
members shall be referred for evaluation within one
year of the diagnosis of their medical condition if
they are unable to return to military duty.

E3.P1.6.2.  Medical 

 E3.P1.6.2.1.  Duty-Related.    When a physician initiates
a MEB, the processing time should normally not exceed
30 days from the date the MEB report is dictated to
the date it is received by the PEB.

E3.P1.6.2.2.  Nonduty-Related.    For cases of Reserve
component members referred for solely a fitness determination
on a nonduty-related condition, processing time for
conduct of MEB or physical examination shall not exceed
90 calendar days.

E3.P1.6.3.  PEB.    Upon receipt of the MEB or physical
examination report by the PEB, the processing time to
the date of the determination of the final reviewing
authority as prescribed by the Secretary of the Military
Department should normally be no more than 40 days.

 E3.P1.6.4.  Imminent Death Processing.    When competent
medical authority determines that a Service member's
death is expected within 72 hours, the member may be
referred expeditiously into the DES.   To protect the
interests of the Government and the Service member,
disposition shall be placement on the TDRL provided
all requirements under statute, law, and regulation
are met.   In no case shall a Service member be retired
after his or her death or before completion of a required
line of duty determination.   Determination of death
shall be made under the laws of the state where the
member is assigned, or under military medical standards
when the member is outside the United States.

 E3.P1.7.  Training and Education. 

Those Service members designated by the Secretary concerned
as primary participants in the DES shall be trained
and educated in a timely and continuing manner concerning
the policies and procedures of this Instruction.   Primary
participants in the DES include, but are not limited
to, medical officers who prepare MEBs, patient administration
officers, disability counselors, PEB and appellate review
members, and judge advocates.



E3.P2.  ENCLOSURE 3 PART 2

ELIGIBILITY FOR REFERRAL

E3.P2.1.  Criteria for Referral. 

Service members on active duty or in the Ready Reserve
shall be eligible for referral into the DES when the
member:

E3.P2.1.1.  Has a medical condition that is cause for
referral into the DES as established by enclosure 4
of this Instruction or by the respective Service’s supplemental
medical standards, and the member has received optimal
medical treatment benefits; or

E3.P2.1.2.  Will be unable to return to full military
duty within one year of diagnosis of the medical condition;
or

E3.P2.1.3.  Was previously determined unfit, continued
in a permanent limited duty status, and the period of
continuation has expired; and

E3.P2.1.4.  Is not disqualified under section E3.P2.4.
of Part 2.

E3.P2.1.5.  Is a member of the regular component of
the Armed Forces entitled to basic pay; or any other
member of the Armed Forces entitled to basic pay who
has been called or ordered to active duty for more than
30 days; or any other member of the Armed Forces, after
September 23, 1996, who is on active duty but is not
entitled to basic pay under 37 U.S.C. 502(b) (reference
(d)) due to authorized absence to participate in an
educational program, or for an emergency purpose, as
determined by the Secretary concerned.

E3.P2.2.  Duty-Related Impairments 

E3.P2.2.1.  Service members described in section E3.P2.1.,
above, who have impairments which, in the case of a
member on active duty for 30 days or less, are the proximate
result of, or were incurred in line of duty after September
23, 1996, as a result of:

E3.P2.2.1.1.  Performing active duty or inactive duty
training;

E3.P2.2.1.2.  Traveling directly to or from the place
at which such duty is performed; or

E3.P2.2.1.3.  After September 23, 1996, an injury, illness,
or disease incurred or aggravated while remaining overnight,
between successive periods for purposes of IDT, at or
in the vicinity of the site of the IDT, if the site
is outside reasonable commuting distance of the member’s
residence.

   

shall be referred into the DES except as provided in
sections E3.P2.4. and E3.P2.7., below.

E3.P2.2.2.  Members with duty related impairments as
described in paragraphs E3.P2.2.1.1. through E3.P2.2.1.3.,
above, shall be referred into the DES for a determination
of fitness, and if found unfit, a determination of entitlement
to separation or retirement for disability with benefits
under Chapter 61 of 10 U.S.C.(reference (b)).   The
fact that a Service member is unfit for disabilities
incurred during the periods designated in paragraphs
E3.P2.2.1.1.  through E3.P2.2.1.4., above, does not
constitute entitlement to disability benefits.   (See
Part 4 for compensation entitlement criteria.)

E3.P2.3.  Nonduty-Related Impairments. 

Members of the Ready Reserve with nonduty-related impairments,
and who are otherwise eligible, will be referred into
the DES upon the request of the member or when directed
under Service regulations.   Referral will be solely
for a determination of fitness for duty.

E3.P2.4.  Ineligibility for Referral. 

Service members are ineligible for physical disability
evaluation, when:

E3.P2.4.1.  The member's defect is a developmental or
constitutional disorder not constituting a physical
disability.    (See enclosure 5 for a comprehensive
listing.)

E3.P2.4.2.  Except as provided under Service regulations,
the member is pending an approved, unsuspended, punitive
discharge or dismissal.

E3.P2.4.3.  Except as provided under Service regulations,
the member is pending separation under provisions that
authorize a characterization of service of Under Other
Than Honorable (UOTH).   This restriction is based on
the provisions under which the member is being separated
and not on the actual characterization the member receives.
  For example, because separation for misconduct authorizes
a UOTH, a member who is being separated for misconduct
with a general characterization is ineligible for referral
into the DES except as provided under the regulations
of the respective Service.

E3.P2.4.4.  Service regulations should normally provide
for referral to the DES of those members designated
in subsections E3.P2.4.2. and E3.P2.4.3., above, when
the medical impairment or extenuating circumstances
may be the cause of the conduct.

E3.P2.5.  Members with a Nonwaivered Pre-Existing Condition.


Service members who are identified with nonwaivered
medical conditions or physical defects that existed
prior to service may be administratively separated without
referral into the DES when the medical condition meets
all the criteria listed in subsections E3.P2.5.1. through
E3.P2.5.4., below:

E3.P2.5.1.  The medical impairment is identified prior
to or within 180 days of the member's initial entry
on active duty or active duty for training or full-time
National Guard duty.

E3.P2.5.2.  The medical impairment does not meet accession
standards under DoD Directive 6130.3 (reference (e)).

E3.P2.5.3.  The impairment is not a condition that is
cause for referral to the PEB under enclosure 4 or Service
supplemental medical standards.

E3.P2.5.4.  Service aggravation of the impairment has
not occurred.   If the Service member contests the “not
Service aggravated” determination by the physician recommending
separation, the member may request the MEB be forwarded
to the PEB for review.

E3.P2.6.  Members with Medical Waivers. 

Provided no aggravation has occurred, Service members
who enter the military with a medical waiver may be
separated without physical disability evaluation when
the responsible medical authority designated by Service
regulations determines within 180 days of the member's
entry into active service that the waivered condition
represents a risk to the member or prejudices the best
interests of the Government.   Once 180 days have elapsed
or the condition is one which causes referral into the
DES, the member shall be referred for physical disability
evaluation, if otherwise qualified.

E3.P2.7.  Waiver of MEB/PEB Evaluation. 

In certain circumstances, Service members may waive
referral to the PEB with the approval of the Secretary
of the Military Department.   The member must be counseled
on the DES process; his or her right to a PEB; and the
potential benefits of remaining in an active duty or
Active Reserve status for purposes of completing evaluation
by the DES.   The member must request a waiver in writing,
and such request, or an affidavit, must attest that
the member has received the counseling described above
and declines referral to the PEB.   Waiver requests
are authorized when either:

E3.P2.7.1.  The MEB reflects that the member's medical
condition existed prior to service and was not aggravated
by service.

E3.P2.7.2.  Physical disability evaluation requires
extension past the date of the member's Service agreement
or an approved retirement date, and the member does
not consent to retention.

 E3.P2.7.2.1.  Members of a Reserve component on active
duty under a call to duty of more than 30 days may continue
disability evaluation upon release from active duty
provided they maintain a Ready Reserve status.   However,
they must sign a waiver declining retention on active
duty.

E3.P2.7.2.2.  Members approved for separation under
any program which incurs a Reserve obligation and who
have conditions which are cause for referral into the
DES are prohibited from waiving physical disability
evaluation.

 E3.P2.7.3.  A Service member reaches the end of active
obligated Service and has no remaining Service obligations.



E3.P3.  ENCLOSURE 3 PART 3

STANDARDS FOR DETERMINING UNFITNESS DUE TO PHYSICAL
DISABILITY OR MEDICAL DISQUALIFICATION

E3.P3.1.  Uniformity of Standards. 

The standards listed within this instruction for determining
unfitness due to physical disability shall be strictly
adhered to, unless exceptions are approved by the Under
Secretary of Defense for Personnel and Readiness based
upon the unique needs of the respective Military Department.

E3.P3.2.  General Criteria for Making Unfitness Determinations


E3.P3.2.1.  A Service member shall be considered unfit
when the evidence establishes that the member, due to
physical disability, is unable to reasonably perform
the duties of his or her office, grade, rank, or rating
(hereafter called duties) to include duties during a
remaining period of Reserve obligation.

E3.P3.2.2.  In making a determination of a member’s
ability to so perform his/her duties, the following
criteria may be included in the assessment:

E3.P3.2.2.1.  The medical condition represents a decided
medical risk to the health of the member or to the welfare
of other members were the member to continue on active
duty or in an Active Reserve status.

E3.P3.2.2.2.  The medical condition imposes unreasonable
requirements on the military to maintain or protect
the member.

E3.P3.2.2.3.  The Service member’s established duties
during any remaining period of reserve obligation.

E3.P3.3.  Relevant Evidence. 

All relevant evidence will be considered in assessing
Service member fitness, including the circumstances
of referral.   To reach a finding of unfit, the PEB
must be satisfied that the information it has before
it supports a finding of unfitness.

E3.P3.3.1.  Referral Following Illness or Injury.  
 When referral for physical disability evaluation immediately
follows acute, grave illness or injury, the medical
evaluation may stand alone, particularly if medical
evidence establishes that continued service would be
deleterious to the Service member’s health or is not
in the best interests of the respective Service.

 E3.P3.3.2.  Referral For Chronic Impairment.    When
a Service member is referred for physical disability
evaluation under circumstances other than as described
in subsection E3.P3.3.1., above, evaluation of the member’s
performance of duty by supervisors as indicated, for
example, by letters, efficiency reports, credential
reports, status of physician medical privileges, or
personal testimony may provide better evidence than
a clinical estimate by a physician of the Service member’s
ability to perform his or her duties.    Particularly
in cases of chronic illness, these documents may be
expected to reflect accurately a member’s capacity to
perform.

E3.P3.3.3.  Adequate Performance Until Referral.   
If the evidence establishes that the Service member
adequately performed his or her duties until the time
the Service member was referred for physical evaluation,
the member may be considered fit for duty even though
medical evidence indicates questionable physical ability
to continue to perform duty.

E3.P3.3.4.  Cause and Effect Relationship.    Regardless
of the presence of illness or injury, inadequate performance
of duty, by itself, shall not be considered as evidence
of unfitness due to physical disability unless it is
established that there is a cause and effect relationship
between the two factors.

E3.P3.4.  Reasonable Performance of Duties 

E3.P3.4.1.  Considerations.    Determining whether a
member can reasonably perform his or her duties includes
consideration of:

E3.P3.4.1.1.  Common Military Tasks.    The member,
due to physical disability, is unable to reasonably
perform the duties of his or her office, grade, rank,
or rating (hereafter called duties) to include during
a remaining period of Reserve obligation.   For example,
whether the member is routinely required to fire his
or her weapon, perform field duty, or to wear load bearing
equipment or protective gear.

E3.P3.4.1.2.  Physical Fitness Test.   Whether the member
is medically prohibited from taking the respective Service's
required physical fitness test.   When an individual
has been found fit by a PEB for a condition which prevents
the member from taking the Service physical fitness
test, the inability to take the physical fitness test
shall not form the basis for an adverse personnel action
against the member.

E3.P3.4.1.3.  Deployability.    When a Service member’s
office, grade, rank or rating requires deployability,
whether a member’s medical condition(s) prevents positioning
the member individually or as part of a unit with or
without prior notification to a location outside the
Continental United States.   Inability to perform the
duties of his or her office, grade, rank, or rating
in every geographic location and under every conceivable
circumstance will not be the sole basis for a finding
of unfitness.   When deployability is used by a Service
as a consideration to determine fitness, the standard
must be applied uniformly to both the Active and Reserve
components of that Service.

E3.P3.4.1.4.  Special Qualifications.    For members
whose medical condition causes loss of qualification
for specialized duties, whether the specialized duties
comprise the member's current duty assignment; or the
member has an alternate branch or specialty; or whether
reclassification or reassignment is feasible.

E3.P3.4.2.  General, Flag, and Medical Officers.   
An officer in pay grade 0-7 or higher or a medical officer
in any grade shall not be determined unfit because of
physical disability if the member can be expected to
perform satisfactorily in an assignment appropriate
to his or her grade, qualifications, and experience.
  Thus, the inability to perform specialized duties
or the fact the member has a condition which is cause
for referral to a PEB is not justification for a finding
of unfitness.

E3.P3.4.3.  Members on Permanent Limited Duty.    A
member previously determined unfit and continued in
a permanent limited duty status or otherwise continued
on active duty, will normally be found unfit at the
expiration of his or her period of continuation.   However,
the member may be determined fit when the member's condition
has healed or improved so that the member would be capable
of performing his or her duties in other than a limited
duty status.

E3.P3.4.4.  Overall Effect.    A member may be determined
unfit as a result of the overall effect of two or more
impairments even though each of them, standing alone,
would not cause the member to be referred into the DES
or be found unfit because of physical disability.

E3.P3.5.  Presumption of Fitness 

E3.P3.5.1.  Application.    Except for Service members
previously determined unfit and continued in a permanent
limited duty status, Service members who are pending
retirement at the time they are referred for physical
disability evaluation enter the DES under a rebuttable
presumption that they are physically fit.   The DES
compensates disabilities when they cause or contribute
to career termination.   Continued performance of duty
until a Service member is approved for length of service
retirement creates a rebuttable presumption that a Service
member’s medical conditions have not caused career termination.

E3.P3.5.2.  Presumptive Period.   Service members shall
be considered to be pending retirement when the dictation
of the member’s MEB occurs after any of the circumstances
designated in paragraphs E3.P3.5.2.1. through E3.P3.5.2.4.,
below.

E3.P3.5.2.1.  When a member’s request for voluntary
retirement has been approved.   Revocation of voluntary
retirement orders for purposes of referral into the
DES does not negate application of the presumption.

E3.P3.5.2.2.  An officer has been approved for Selective
Early Retirement.

E3.P3.5.2.3.  An officer is within 12 months of mandatory
retirement due to age or length of service.

E3.P3.5.2.4.  An enlisted member is within 12 months
of his or her retention control point (RCP) or expiration
of active obligated service (EAOS) but will be eligible
for retirement at his or her RCP/EAOS.

E3.P3.5.3.  Overcoming the Presumption.    The presumption
of fitness rule shall be overcome when:

E3.P3.5.3.1.  Within the presumptive period an acute,
grave illness or injury occurs that would prevent the
member from performing further duty if he or she were
not retiring; or

E3.P3.5.3.2.  Within the presumptive period a serious
deterioration of a previously diagnosed condition, to
include a chronic condition, occurs and the deterioration
would preclude further duty if the member were not retiring;
or

E3.P3.5.3.3.  The condition for which the member is
referred is a chronic condition and a preponderance
of evidence establishes that the member was not performing
duties befitting either his or her experience in the
office, grade, rank, or rating before entering the presumptive
period.   When there has been no serious deterioration
within the presumptive period, the ability to perform
duty in the future shall not be a consideration.

E3.P3.6.  Evidentiary Standards for Determining Unfitness
Because of Physical Disability 

E3.P3.6.1.  Factual Finding.    A factual finding that
a Service member is unfit because of physical disability
depends on the evidence that is available to support
that finding.   The quality of evidence is usually more
important than quantity.   All relevant evidence must
be weighted in relation to all known facts and circumstances
which prompted referral for disability evaluation. 
 Findings will be made on the basis of objective evidence
in the record as distinguished from personal opinion,
speculation, or conjecture.   When the evidence is not
clear concerning a Service member's fitness, an attempt
will be made to resolve doubt on the basis of further
objective investigation, observation, and evidence.
  Benefit of unresolved doubt shall be resolved in favor
of the fitness of the Service member under the rebuttable
presumption that the member desires to be found fit
for duty.

E3.P3.6.2.  Preponderance of Evidence. Findings about
fitness or unfitness for Military Service shall be made
on the basis of preponderance of the evidence.   Thus,
if a preponderance (that is, more than 50 percent) of
the evidence indicates unfitness, a finding to that
effect will be made.   If, on the other hand, a preponderance
of the evidence indicates fitness, the Service member
may not be separated or retired by reason of physical
disability.



E3.P4.  ENCLOSURE 3 PART 4

STANDARDS FOR DETERMINING COMPENSABLE DISABILITIES 

E3.P4.1.  Overview of Compensable Criteria. 

   Members who are determined unfit under the standards
of Part 3 shall be retired or separated with disability
benefits when:

E3.P4.1.1.  The physical disability is not the result
of the member's intentional misconduct or willful neglect
and was not incurred during a period of unauthorized
absence or excess leave; and, either:

E3.P4.1.1.1.  The physical disability was incurred or
aggravated while:

E3.P4.1.1.1.1.  A member of a regular component of the
armed forces entitled to basic pay.

E3.P4.1.1.1.2.  Any other member of the armed forces
entitled to basic pay who has been called or ordered
to active duty (other than for training under 10 U.S.C
10148(a), reference (b)) for a period of more than 30
days.

E3.P4.1.1.1.3.  Any other member of the armed forces,
after September 23, 1996, who is on active duty but
is not entitled to basic pay by reason of 37 U.S.C.
502(b) (reference (d)), due to authorized absence to
participate in an educational program, or for an emergency
purpose, as determined by the Secretary concerned; or

E3.P4.1.1.2.  The physical disability was the proximate
result of, or was incurred in line of duty after September
23, 1996, as a result of:

E3.P4.1.1.2.1.  Performing active duty, annual training,
active duty for training, or other full time duty under
a call or order that specifies a period of 30 days or
less.

E3.P4.1.1.2.2.  Performing IDT, to include IDT for points
only, other than work or study in connection with a
correspondence course of a Uniformed Service.

E3.P4.1.1.2.3.  Traveling directly to or from the place
of active duty or IDT.

E3.P4.1.1.2.4.  After September 23, 1996, an injury,
illness, or disease incurred or aggravated while remaining
overnight, between successive periods of inactive duty
training, at or in the vicinity of the site of the inactive
duty training if the site is outside reasonable commuting
distance from the member’s residence.

E3.P4.2.  Proximate Result 

E3.P4.2.1.  The DES shall make a determination of proximate
result on Reserve component cases when:

E3.P4.2.1.1.  The member is not currently on a call
to active duty of more than 30 days; and

E3.P4.2.1.2.  The unfitting disability was not incurred
or aggravated while the member was on an a call to active
duty of more than 30 days; and

E3.P4.2.1.3.  The unfitting disability may have been
incurred or aggravated while the member was performing
duty of 30 days or less as specified in subsection E3.P4.1.1.1.3.,
above.

 E3.P4.2.2.  A disability shall be deemed the proximate
result of performing duty when it is a direct consequence
of an occurrence during any of the periods of duty specified
in subsection E3.P4.1.1.1.3., above.   All facts, circumstances,
and laws on a particular case must be considered.

E3.P4.3. Applicable Statute for Reserve Component Members.


A Reserve component member shall be adjudicated under
the statutory provisions applicable to his or her duty
status at the time of onset or aggravation of the condition
for which the member is determined unfit.   This means
a Ready Reserve member not on extended active duty at
the time of his or her referral into the DES, but who
is determined unfit for a disability incurred or aggravated
while the member was on a call to active duty of more
than 30 days, comes under the provisions of 10 U.S.C.
1201 - 10 U.S.C. 1203 and not 10 U.S.C. 1204 - 1206
(reference (b)).   In such a situation, “in line of
duty while entitled to basic pay” rather than “proximate
result” is the applicable statutory requirement for
entitlement to disability compensation.

E3.P4.4. Line of Duty Requirements. 

In the DES, line of duty determinations assist the PEB
and appellate review authority in meeting the statutory
requirements under Chapter 61 of reference (b) for separation
or retirement for physical disability.

E3.P4.4.1.  Uses.    Line of duty determinations, when
required, shall be used during physical disability evaluation
to establish the following:

E3.P4.4.1.1.  Whether the disability was incurred or
aggravated while the member was in a duty status.

E3.P4.4.1.2.  Whether the disability of a Reserve component
member was incurred or aggravated while the member was
on extended active duty or performing active duty of
30 days or less, while traveling directly to or from
the place of active duty or IDT or while remaining overnight,
between successive periods of IDT, at or in the vicinity
of the site of the IDT if the site is outside reasonable
commuting distance from the member’s residence.

E3.P4.4.1.3.  Relationship of the Line of Duty (LOD)
determinations shall be made in accordance with the
regulations of the respective Military Department. 
 When an LOD determination is required, the PEB shall
consider the findings made for those issues mutually
applicable to the LOD and PEB determinations.   These
issues include whether a condition is pre-existing and
whether it is aggravated by Service and any issues of
misconduct or negligence.   If the PEB determines the
LOD determination is contradictory to the evidence,
physical disability evaluation may be suspended for
a review of the LOD in accordance with Service regulations.

E3.P4.4.1.4.  Whether the disability is the result of
the member's intentional misconduct or willful neglect,
or was incurred during a period of unauthorized absence.

E3.P4.4.2.  Relationship of Line of Duty Findings to
DES Determinations 

E3.P4.4.2.1.  Line of duty determinations shall be made
under the regulations of the respective Military Department.
  When a line of duty determination is required, the
DES shall consider the finding made for those issues
mutually applicable to line of duty and DES determinations.

E3.P4.4.2.2.  When the DES has reasonable cause to believe
a line of duty finding appears to be contrary to the
evidence, physical disability evaluation shall be suspended
for review of the line of duty determination according
to Service regulations.   The PEB or appellate review
authority shall forward the case to the final line of
duty reviewing authority designated by the Secretary
of the Military Department with a memorandum documenting
the reasons for questioning the line of duty finding.

E3.P4.4.2.3.  The facts recorded in a line of duty investigation
shall be considered in making the proximate result determination
when applicable to Reserve component cases.   However,
the DES, not line of duty investigations, determines
proximate result.

E3.P4.4.3.  Referral Requirement. When a line of duty
determination is required, it shall be accomplished
before the forwarding of a Service member’s case to
the PEB.    However, when the case is being processed
under imminent death procedures and a line of duty is
required, the PEB may commence adjudication of the case
pending receipt of the completed line of duty.   (Refer
to Part 1, subsection E3.P1.6.4.)

E3.P4.4.4.  Presumptive Determinations. The line of
duty determination is presumed to be in the line of
duty without an investigation in the case of:

E3.P4.4.4.1.  Disease, except as described in paragraphs
E3.P4.5.5.1. and E3.P4.5.5.5., below.

E3.P4.4.4.2.  Injuries clearly incurred as a result
of enemy action or attack by terrorists.

E3.P4.4.4.3.  Injuries while a passenger in common commercial
or military carriers.

E3.P4.4.5.  Required Determinations. At a minimum, line
of duty determinations shall be required in the circumstances
listed in paragraphs E3.P4.4.5.1. through E3.P4.4.5.5.,
below.

E3.P4.4.5.1.  Injury, disease, or medical condition
that occurs under strange or doubtful circumstances
or may be due to the member's intentional misconduct
or willful negligence; e.g., motor vehicle accidents.

E3.P4.4.5.2.  Injury involving the abuse of alcohol
or other drugs.

E3.P4.4.5.3.  Self-inflicted injury.

E3.P4.4.5.4.  Injury or disease possibly incurred during
a period of unauthorized absence.

E3.P4.4.5.5.  Injury or disease is apparently incurred
during a course of conduct for which charges have been
preferred under the Uniform Code of Military Justice
(UCMJ)(reference (j)).

E3.P4.4.5.6.  Injury, illness, or disease of a Ready
Reserve member while performing duty of 30 days or less
or while traveling directly to or from the place at
which such duty is performed or while remaining overnight,
between successive periods of IDT, at or in the vicinity
of the site of the IDT if the site is outside reasonable
commuting distance from the member’s residence.

E3.P4.5.  Evidentiary Standards for Determining Compensability
of Unfitting Conditions 

E3.P4.5.1.  Misconduct and Negligence.    Line of duty
determinations concerning intentional misconduct and
willful negligence shall continue to be judged by the
evidentiary standards established by the Secretary of
the Military Department.

E3.P4.5.2.  Presumptions for Members on Ordered Active
Duty of More Than 30 days.    The presumptions listed
in paragraphs E3.P4.5.2.1. through E3.P4.5.2.3., below,
apply to members on orders to active duty of more than
30 days for purposes of determining whether an impairment
was incurred or aggravated while a member was entitled
to basic pay.

E3.P4.5.2.1.  At Time of Entry.    A Service member
is presumed to have been in sound physical and mental
condition upon entering active duty except for medical
defects and physical disabilities noted and recorded
at the time of entrance.

E3.P4.5.2.2.  After Entry 

E3.P4.5.2.2.1.  Presumption.    Any injury or disease
discovered after a Service member enters active duty
-- with the exception of congenital and hereditary conditions
-- is presumed to have been incurred in the line of
duty;

E3.P4.5.2.2.2.  Hereditary and/or Genetic Diseases.
   Any hereditary and/or genetic disease shall be presumed
to have been incurred prior to entry into active duty.
   However, any aggravation of that disease, incurred
in the line of duty, beyond that determined to be due
to natural progression shall be deemed service aggravated.

E3.P4.5.2.3.  Presumption of Aggravation.    The presumption
that a disease is incurred or aggravated in the line
of duty may only be overcome by competent medical evidence
establishing by a preponderance of evidence that the
disease was clearly neither incurred nor aggravated
while serving on active duty or authorized training.
  Such medical evidence must be based upon well-established
medical principles, as distinguished from personal medical
opinion alone.   Preponderance of evidence is defined
as that degree of proof necessary to fully satisfy the
board members that there is greater than a 50% probability
that the disease was neither incurred during nor aggravated
by military service.

E3.P4.5.3.  Prior Service Impairments.    Any medical
condition incurred or aggravated during one period of
service or authorized training in any of the Armed Forces
that recurs or is aggravated during later service or
authorized training, regardless of the time between,
should normally be considered incurred in the line of
duty provided the condition or subsequent aggravation
was not the result of the member's misconduct or willful
negligence.   In those cases in which the service member
reverts to a civilian status after the condition is
incurred, the service member must prove by a preponderance
of evidence that the medical condition was incurred
or aggravated in the line of duty and was not due to
intentional misconduct or willful negligence.

E3.P4.5.4.  Conditions Presumed to be Pre-Existing.
   Occurrence of disease as described in paragraphs
E3.P4.5.4.1. and E3.P4.5.4.2., below, shall be presumed
to have existed prior to entry into Military Service.

E3.P4.5.4.1.  Signs or symptoms of chronic disease identified
so soon after the day of entry on Military Service (usually
within 180 days) that the disease could not have originated
in that short a period will be accepted as proof that
the disease manifested prior to entrance into active
Military Service.

E3.P4.5.4.2.  Signs or symptoms of communicable disease
within less than the medically recognized minimum incubation
period after entry on active Service will be accepted
as evidence that the disease existed prior to Military
Service.

E3.P4.5.5.  Medical waivers.    Members who entered
the Service with a medical waiver for a pre-existing
condition and who are subsequently determined unfit
for the condition shall not be entitled to disability
separation or retired pay unless Military Service permanently
aggravated the condition or hastened the condition's
rate of natural progression.   Members granted medical
waivers shall be advised of this provision at the time
the waiver is granted.

E3.P4.5.6.  Treatment of Pre-Existing Conditions.  
 Generally recognized risks associated with treating
preexisting conditions shall not be considered service
aggravation.

E3.P4.6.  Rating disabilities. 

When a disability is established as compensable, the
disability shall be rated according to the VASRD, as
implemented by DoD Instruction 1332.39 (reference (i))
and federal law.



E3.P5.  ENCLOSURE 3 PART 5

ADMINISTRATIVE DETERMINATIONS

E3.P5.1. Administrative Determinations for Purposes
of Employment under Federal Civil Service. 

Physical disability evaluation shall include a recommendation
or final decision and supporting documentation on whether
the injury or disease that makes the member unfit or
that contributes to unfitness was incurred in combat
with an enemy of the United States; or was the result
of armed conflict; or was caused by an instrumentality
of war during a period of war.   (These determinations
pertain to whether a military retiree later employed
under Federal Civil Service is entitled to the following
benefits: credit of military service towards a Federal
Civil Service retirement under 5 U.S.C. 8332; retention
preference under 5 U.S.C. 3502; exemption from the dual
compensation provisions of 5 U.S.C. 5532; and credit
of military service for Civil Service annual leave accrual
under 5 U.S.C. 6303) (reference (c)).

E3.P5.1.1.  Incurred in Combat with an Enemy of the
United States (5 U.S.C. 8332)(Reference (c)).    The
physical disability is a disease or injury incurred
in line of duty in combat with an enemy of the United
States as defined by the U.S. State Department.

E3.P5.1.2.  Armed conflict (5 U.S.C. 3502, 5532, 6303)(Reference
(c)).    The physical disability is a disease or injury
incurred in the line of duty as a direct result of armed
conflict.   The fact that a member may have incurred
a disability during a period of war or in an area of
armed conflict, or while participating in combat operations
is not sufficient to support this finding.   There must
be a definite causal relationship between the armed
conflict and the resulting unfitting disability.

E3.P5.1.2.1.  Armed conflict includes a war, expedition,
occupation of an area or territory, battle, skirmish,
raid, invasion, rebellion, insurrection, guerrilla action,
riot, or any other action in which Service members are
engaged with a hostile or belligerent nation, faction,
force, or terrorists.

E3.P5.1.2.2.  Armed conflict may also include such situations
as incidents involving a member while interned as a
prisoner of war or while detained against his or her
will in custody of a hostile or belligerent force or
while escaping or attempting to escape from such confinement,
prisoner of war, or detained status.

E3.P5.1.3.  Instrumentality of War During a Period of
War (5 U.S.C 3502, 5532, 6303, 8332 (Reference (c)).
   The injury or disease is caused by an instrumentality
of war (see definitions in enclosure 2) and incurred
in the line of duty during a period of war as defined
in 38 U.S.C. 101 and 302 U.S.C. (reference (k)) and
makes the member unfit. Applicable periods are:

E3.P5.1.3.1.  World War II.    The period beginning
7 December 1941 and ending 31 December 1946 and any
period of continuous service performed after 31 December
1946 and before 26 July 1947 if such period began before
1 January 1947.

E3.P5.1.3.2.  Korea.    The period beginning 27 June
1950 and ending 31 January 1955.

E3.P5.1.3.3.  Vietnam.    The period beginning 5 August
1964 and ending 7 May 1975.   The "Dominican Intervention"
occurred during this period.

E3.P5.1.3.4.  Persian Gulf.    The period beginning
2 August 1990 through date to be prescribed by Presidential
proclamation or law.

E3.P5.2. Determinations for Federal Tax Benefits. 

Physical disability evaluation shall include a determination
and supporting documentation on whether the member's
physical disability compensation is excluded from Federal
gross income under 26 U.S.C. 104 (reference (f)).  
For compensation to be excluded, the member must meet
either of the criteria listed in subsection E3.P5.2.1.
or E3.P5.2.2., below.

E3.P5.2.1.  Status.    On 24 September 1975 the individual
was a member of the Armed Forces, to include the Reserve
components, the National Oceanic and Atmospheric Administration
(NOAA and formerly the Coast and Geodetic Survey), the
U.S. Public Health Service, or was under binding written
agreement to become such a member.

E3.P5.2.1.1.  A Service member who was a member of an
Armed Force of another country on that date is entitled
to the exclusion.

E3.P5.2.1.2.  A Service member who was a contracted
cadet of the Reserve Officers Training Corps on that
date is entitled to the exclusion.

E3.P5.2.1.3.  Entitlement to the exclusion is based
solely on the member's status on that date.   A member
who separates from the Service after that date and incurs
a disability during a subsequent enlistment is entitled
to the exclusion.

E3.P5.2.2.  Combat-related.    This standard covers
those injuries and diseases attributable to the special
dangers associated with armed conflict or the preparation
or training for armed conflict.   A physical disability
shall be considered combat-related if it makes the member
unfit or contributes to unfitness and was incurred under
any of the circumstances listed in paragraphs E3.P5.2.2.1.
through E3.P5.2.2.4., below.

E3.P5.2.2.1.  As a direct result of armed conflict.
  The criteria are the same as in paragraph E3.P5.1.2.,
above.

E3.P5.2.2.2.  While engaged in hazardous service.  
Such service includes, but is not limited to, aerial
flight duty, parachute duty, demolition duty, experimental
stress duty, and diving duty.

E3.P5.2.2.3.  Under conditions simulating war.   In
general, this covers disabilities resulting from military
training, such as war games, practice alerts, tactical
exercises, airborne operations, leadership reaction
courses; grenade and live fire weapons practice; bayonet
training; hand-to-hand combat training; repelling, and
negotiation of combat confidence and obstacle courses.
  It does not include physical training activities,
such as calisthenics and jogging or formation running
and supervised sports.

E3.P5.2.2.4.  Caused by an instrumentality of war. 
 Incurrence during a period of war is not required.
  A favorable determination is made if the disability
was incurred during any period of service as a result
of such diverse causes as wounds caused by a military
weapon, accidents involving a military combat vehicle,
injury, or sickness caused by fumes, gases, or explosion
of military ordnance, vehicles, or material.   However,
there must be a direct causal relationship between the
instrumentality of war and the disability.   For example,
an injury resulting from a Service member falling on
the deck of a ship while participating in a sports activity
would not normally be considered an injury caused by
an instrumentality of war (the ship) since the sports
activity and not the ship caused the fall.   The exception
occurs if the operation of the ship caused the fall.



E3.P6.  ENCLOSURE 3 PART 6

TDRL MANAGEMENT

E3.P6.1. Placement on the TDRL. 

Service members shall be placed on the TDRL when they
would be qualified for permanent disability retirement
but for the fact that the member’s disability is not
determined to be of a permanent nature and stable.

E3.P6.1.1.  A disability shall be considered unstable
when the preponderance of medical evidence establishes
that accepted medical principles indicates the severity
of the condition will change within the next five years
so as to result in an increase or decrease of the disability
rating percentage or a finding of fit.

E3.P6.1.2.  Except for cases processed under imminent
death procedures, members with unstable conditions rated
at a minimum of 80 percent and which are not expected
to improve to less than an 80% rating, shall be permanently
retired.

E3.P6.2.  TDRL Reevaluation 

E3.P6.2.1.  Administrative Finality.    During TDRL
reevaluation, previous determinations concerning application
of any presumption established by this Instruction,
line of duty, misconduct, proximate result, and whether
a medical impairment was service-incurred or preexisting
and aggravated shall be considered administratively
final for those conditions for which the member was
placed on the TDRL unless there is evidence of fraud;
a change of diagnosis that warrants the application
of accepted medical principles for a preexisting condition;
or correction of error in favor of the member.

E3.P6.2.2.  New Diagnoses.    A fitness and compensable
determination shall be made on all diagnoses presenting
during the period of TDRL evaluation.   When a member
is determined fit for the condition for which he or
she was placed on the TDRL, but unfit for a noncompensable
condition incurred while on the TDRL, the member shall
be separated from the TDRL without entitlement to disability
benefits.

E3.P6.2.3.  Member Medical Records.    The Service member
shall provide to the examining physician, for submission
to the PEB, copies of all his or her medical records
(civilian, Department of Veterans Affairs, and all military
medical records) documenting treatment since the last
TDRL reevaluation.

E3.P6.2.4.  Compensability of New Diagnoses.    Conditions
newly diagnosed during TDRL periodic physical examinations
shall be compensable when:

E3.P6.2.4.1.  The condition is unfitting; and

E3.P6.2.4.2.  The condition was caused by the condition
for which the member was placed on the TDRL, or directly
related to its treatment; or

E3.P6.2.4.3.  The evidence of record establishes that
the condition was either incurred while the member was
entitled to basic pay or as the proximate result of
performing duty, whichever is applicable, and was an
unfitting disability at the time the member was placed
on the TDRL.   Otherwise, such conditions shall be deemed
unfitting due to the natural progression of the condition
and noncompensable under Chapter 61 of 10 U.S.C. (reference
(b)), although the member may be eligible for benefits
for these conditions under the DVA.

E3.P6.2.5.  Current Physical Examination.   Service
members on the TDRL shall not be entitled to permanent
retirement or separation with disability severance pay
without a current TDRL or DVA periodic physical examination
acceptable to the Service Secretary.

E3.P6.2.6.  Refusal or Failure to Report.   As provided
under Chapter 61 of reference (b), when a Service member
on the TDRL refuses or fails to report for a required
periodic physical examination or to provide his or her
medical records in accordance with Enclosure 3 Part
6, Paragraph E3.P6.2.3., his or her disability retired
pay may be terminated.   If the member later reports
for the physical examination, retired pay will be resumed
retroactively, to the date the examination was actually
performed.   If the Service member subsequently shows
just cause for his or her failure to report, disability
retired pay may be paid retroactively for a period not
to exceed one year prior to the actual performance of
the physical examination.   If the member does not undergo
a periodic physical examination after disability retired
pay has been terminated, he or she will be administratively
removed from the TDRL on the fifth anniversary of placement
on the list and separated without entitlement to any
of the benefits under reference Chapter 61 of 10 U.S.C.
(reference (b)).

E3.P6.2.7.  Priority.    TDRL examinations, including
hospitalization in connection with the conduct of the
examination, shall be furnished on the same priority
as given to active duty members.

E3.P6.2.8.  Reports from Non MTFs.   MTFs designated
to conduct TDRL periodic physical examinations may use
reports of medical examinations from medical facilities
of another Service, the DVA, other Government Agencies,
and authorized civilian medical facilities and physicians
to complete the examination.   The designated MTF remains
responsible for the adequacy of the examination and
the completeness of the report.   The report must include
the information specified in subsection E3.P1.2.4. of
Part I.

E3.P6.2.9.  Incarcerated Members.    A report of medical
examination shall be requested from the appropriate
authorities in the case of a Service member imprisoned
by civil authorities.   In the event no report, or an
inadequate report, is received, documented efforts will
be made to obtain an acceptable report.   If an examination
is not received, disposition of the case shall be in
accordance with subsection E3.P6.6., above.   The member
shall be advised of the disposition and that remedy
rests with the respective Service's Board for Correction
of Military Records.



E3.P7.  ENCLOSURE 3 PART 7

FINAL DISPOSITION

E3.P7.1.  Final Decision Authority 

E3.P7.1.1.  Secretary of Defense (or Secretary of Transportation).
   Under 10 U.S.C. 1216 (reference (b)), the Secretary
of Defense, or in the case of the Coast Guard, the Secretary
of Transportation shall approve the unfit findings on
an officer in pay grade 0-7 or higher or a medical officer
in any grade who, at the time of referral for physical
disability evaluation, was scheduled for nondisability
retirement under any provision of reference (b) for
age or length of service.

E3.P7.1.2.  Secretary of the Military Department.  
 Except as provided in subsection E3.P7.1.1., above,
the Secretary of the Military Department shall have
delegable authority to make all determinations consistent
with this Instruction regarding unfitness, disability
percentage, entitlement to disability severance and
retired pay.

E3.P7.2.  General Rules Regarding Disposition 

E3.P7.2.1.  Retirement.    Except for members approved
for permanent limited duty (see section E3.P7.3., below),
any military member on active duty or in the Ready Reserves
who is found to be unfit will be retired, if eligible
for retirement, or, if not so eligible, separated. 
 Disciplinary separation or other administrative separations
from the Armed Forces are not prevented by this general
rule.

E3.P7.2.1.1.  Members with a disposition of separation
for physical disability who have 15 but less than 20
years of service computed under Section 1208 of reference
(b) and whose unfitting conditions are not due to the
member's intentional misconduct or willful neglect or
incurred during a period of unauthorized absence shall
be afforded the opportunity to elect separation for
physical disability or to apply for, and if approved,
nondisability retirement under the Temporary Early Retirement
Authority (TERA) under 10 U.S.C. 3911 (reference (b))
during the period of temporary special qualification
authority beginning on October 23, 1993, and ending
on October 1, 1999.   Further, the same opportunity
shall be afforded to members recommended for placement
on or separation from the TDRL.

E3.P7.2.1.2.  Ready Reserve members with 15 but less
than 20 years of qualifying service under Section 12732
of reference (b) who are to be separated for physical
disability other than due to the member's intentional
misconduct, willful failure to comply with standards
and qualifications for retention, willful neglect or
incurred during a period of unauthorized absence shall
be afforded the opportunity to elect either separation
for physical disability or early qualification for retired
pay at age 60 under Section 12731a of reference (b)
during the period of temporary special retirement qualification
authority beginning on October 23, 1992, and ending
on October 1, 1999.   Further, the same opportunity
shall be afforded to Ready Reserve members recommended
for placement on or separation from the TDRL.

E3.P7.2.2.  Fit off the TDRL.    Service members determined
fit as a result of TDRL reevaluation shall be processed
as described below.

E3.P7.2.2.1.  Appointment and/or Enlistment.    Upon
the Service member's request and provided he or she
is otherwise eligible, the member shall be appointed
or enlisted in the applicable grade and component as
outlined in Section 1211 of reference (b).

E3.P7.2.2.2.  Recall to Active Duty.    Subject to paragraph
E3.P7.2.3.3., below:

E3.P7.2.2.2.1.  Regular Component Members.    Subject
to their consent, Regular officers and enlisted members
shall be recalled to duty, provided they are otherwise
eligible and were not required to be separated under
law or regulation at the time they were placed on the
TDRL.   They shall be deemed medically qualified for
those conditions on which a finding of fit was determined.
  Any new condition arising between DES evaluation and
recall must meet the respective Service’s medical standards
for retention.

E3.P7.2.2.2.2.  Reserve Component.    Subject to their
consent, Reserve component officers, warrant officers
and enlisted members shall be reappointed or reenlisted
as a Reserve for service in his or her Reserve component
under 10 U.S.C. 1211 (reference (b)).

 E3.P7.2.2.3.  Separation.    In accordance with Section
1210(f) of reference (b), members required to be separated
or retired for nondisability reasons at the time they
were referred for physical disability evaluation and
placed on the TDRL shall, if determined fit, be separated
or retired, as applicable.

E3.P7.2.2.4.  Termination of TDRL status.    Termination
of TDRL status and retired pay shall be as outlined
in 10 U.S.C. 1211 (reference (b)).

E3.P7.3.  Continuance of Unfit Members on Active Duty
or in the Ready Reserves. 

When, with the recommendation of the Service component,
the Secretary of the Military Department concerned determines
that an unfit Service member's service obligation, skill,
or experience justifies the continuance of that Service
member on active duty or in active status in a permanent
limited duty status, the Service member may be retained
as an exception to the general policy rule in subsection
B.1, above.

E3.P7.4.  Transition benefits. 

Active component members and Reserve component members
who are on active duty are entitled to the transition
benefits established by DoD Directive 1332.35 (reference
(h)) when these members are being separated or retired
for physical disability unless waived by DoD or prohibited
by federal law.

E3.P7.5.  Dispositions for Unfit Members 

E3.P7.5.1.  Permanent Disability Retirement.    Retirement
is directed under Section 1201 or 1204 of reference
(b) when the member is unfit for a permanent and stable
compensable physical disability under the standards
of this Instruction; and

E3.P7.5.1.1.  The member has at least 20 years of service
computed under Section 1208 of reference (b); or

E3.P7.5.1.2.  The total disability rating is at least
30 percent under the VASRD.

E3.P7.5.2.  Placement on the TDRL.    Retirement is
directed under Section 1202 or 1205 of reference (b)
when the requirements for permanent disability retirement
are met except the physical disability is not permanent
and stable.

E3.P7.5.3.  Separation with disability severance pay


E3.P7.5.3.1.  Criteria.    Separation is directed under
Section 1203 or 1206 of reference (b) when the member
is unfit for a compensable physical disability determined
under the standards of this Instruction, and the requirements
listed in subparagraphs E3.P7.5.3.1.1. and E3.P7.5.3.1.2.,
below, are met.   Stability is not a factor for this
disposition.

E3.P7.5.3.1.1.  The member has less than 20 years of
service computed under Section 1208 of reference (b);
and

E3.P7.5.3.1.2.  The disability is rated at less than
30 percent, to include 0 percent.

E3.P7.5.3.2.  Active Service.    Under 10 U.S.C. 1212
(reference (b)), a part of a year of active service
that is six months or more is counted as a whole year,
and a part of a year that is less than six months is
disregarded.   Thus, members with less than six months
of service at the effective date of their disability
separation receive no disability severance pay.

E3.P7.5.3.3.  Transfer to Retired Reserve.    Under
Section 1209 of reference (b), Ready Reserve members
who have completed at least 20 qualifying years of Reserve
service and who would otherwise be qualified for retirement
may forfeit disability severance pay and request transfer
to an Inactive Status List for the purpose of receiving
nondisability retired pay at age 60.   When disability
severance pay is accepted, the member forfeits all rights
to receive retired pay under Chapter 1223 of reference
(b) at age 60.   There are no provisions under reference
(b) to repay disability severance pay for the purpose
of receiving retired pay.

E3.P7.5.3.4.  Ready Reserve Early Qualification for
Retired Pay.    Under 10 U.S.C. 12731 of reference (b),
Reserve component members with at least 15, and less
than 20, years of qualifying service and who would otherwise
be qualified for retirement may waive disability disposition
and request early qualification for retired pay until
1 October, 1999, unless the provisions of this statute
are extended or rescinded.

E3.P7.5.4.  Separation under Chapter 61 of 10 U.S.C.
(Reference (b)) Without Entitlement to Benefits.   
Discharge is directed under Section 1207 of reference
(b) when the member is unfit for a disability incurred
as a result of intentional misconduct, willful neglect,
or during a period of unauthorized absence.

E3.P7.5.5.  Discharge Under Other Than Chapter 61 of
10 U.S.C.(Reference (b)). An unfit member is directed
for discharge under other provisions of reference (b)
when the member is not entitled to physical disability
compensation due to the circumstances listed in paragraphs
E3.P7.5.5.1.through E3.P7.5.5.4., below.

E3.P7.5.5.1.  The disability existed prior to service
and was not permanently aggravated by service; or

E3.P7.5.5.2.  The disability was incurred while the
member was in an excess leave status; or

E3.P7.5.5.3.  The disability was incurred by a Reserve
component member performing duty of 30 days or less,
but the disability was determined not the proximate
result of performing such duty; or

E3.P7.5.5.4.  The medical impairment of a Ready Reserve
member is nonduty-related; disqualifies the member for
retention in the Reserve components; and either the
member does not request referral into DES for a fitness
determination or such referral results in a finding
of unfit.   Disposition of such members shall be under
appropriate Service regulations.

   

 If a member not entitled to physical disability compensation
under Chapter 61 of reference (b) due to the circumstances
listed above has six years or more, but less than 20
years of active service, immediately prior to that discharge,
the member shall be entitled to separation pay as an
involuntary discharge or release from active duty as
prescribed by Section 1174 of reference (b), unless
the Secretary concerned determines that the conditions
under which the member is discharged do not warrant
payment of such pay.

E3.P7.5.6.  Revert With Disability Benefits.    This
disposition is used to return to retired status a retiree
recalled to active duty who was:

E3.P7.5.6.1.  Previously retired for physical disability;
or,

E3.P7.5.6.2.  Determined unfit during the period of
recall. For members previously retired for age or years
of service, the compensable percentage of disability
must be 30 percent or more to receive disability benefits.



E4.  ENCLOSURE 4

GUIDELINES REGARDING MEDICAL CONDITIONS AND PHYSICAL
DEFECTS THAT ARE CAUSE FOR REFERRAL INTO THE DISABILITY
EVALUATION SYSTEM

E4.1.  GENERAL 

E4.1.1.  This enclosure provides a listing, mainly by
body system, of medical conditions and physical defects
which are cause for referral into the Disability Evaluation
System (DES).

E4.1.1.1.  This listing is not all inclusive.

E4.1.1.2.  A service member who has one or more of the
listed conditions or physical defects is not automatically
unfit and therefore may not qualify for separation or
retirement for disability.

E4.1.2.  Individual Secretaries of the Military Departments
may, consistent with this Instruction, modify these
guidelines to fit their particular needs.   These modifications
may include conditions or defects, individually or in
combination that:

E4.1.2.1.  Significantly interfere with the reasonable
fulfillment of the purpose of the individual's employment
in the Military Service;

E4.1.2.2.  May seriously compromise the health or well-being
of the individual if he or she were to remain in the
Military Service.   This may involve dependence on certain
medications, appliances, severe dietary restrictions,
or frequent special treatments, or a requirement for
frequent clinical monitoring.

E4.1.2.3.  May prejudice the best interests of the Government
if the individual were to remain in the Military Service.

E4.1.3.  Any condition that appears to significantly
interfere with performance of duties appropriate to
a service member's, office, grade, rank or rating will
be considered for MEB evaluation.   The MEB shall:

E4.1.3.1.  Confirm the medical diagnosis(es).

E4.1.3.2.  Document the Service member's current medical
condition to include treatment status and potential
for medical recovery.

E4.1.3.3.  Review each case based on relevant facts.

E4.1.3.4.  Bolded and bracketed evaluation procedures
and/or data of special importance to the assessment
process shall be contained in the MEB.

E4.1.3.5.  A suggested annotated format for the MEB
report is at Attachment I of this Instruction.

E4.1.3.6.  If optimal medical treatment has been received
in accordance with service specific guidelines, refer
to the PEB.

E4.2.  MUSCULOSKELETAL SYSTEM 

E4.2.1.  Upper Extremity 

E4.2.1.1.  The ability to pinch, grasp, or grip is prevented
by disease, residuals of disease, acute injury, or chronic
residuals of acute injury to the hand or fingers.

E4.2.1.2.  Amputation of a part or whole of the upper
extremity.

E4.2.1.3.  Recurrent dislocation (not subluxation) when
not surgically correctable.

E4.2.1.4.  Ranges of Joint Motion (ROM):   Motion that
is less than the measurements listed below.   (Measurements
should be validated by three (3) measurements that agree
at the 5% level.   The measuring instrument should be
noted.   Both active and passive ROM should be listed.
  When a normal paired extremity is present a comparison
of the ROM of the normal to the impaired extremity should
be included (See Plate I)).

E4.2.1.4.1.  Shoulder:   Flexion or abduction to at
least 90 degrees.

E4.2.1.4.2.  Elbow and/or Forearm:   Flexion to 100
degrees or extension to 60 degrees. Pronation and/or
Supination arc to at least 80 degrees.

E4.2.1.4.3.  Wrist:   A total of at least 15 degrees
flexion plus extension.

E4.2.1.4.4.  Hand:   The motion at each of the three
finger joints, when added together, must reach 135 degrees
of active flexion or 75 degrees of active extension,
in two or more fingers of the same hand.   The thumb
must be able to be opposed to at least two fingertips.

E4.2.2.  Lower Extremity 

E4.2.2.1.  Disease, residual of disease, acute injury,
or residual of injury that interferes with ambulation
or the wearing of military shoes and/or boots for a
period in excess of 180 days.

E4.2.2.2.  Any documented condition that precludes the
ability to run or walk without a perceptible limp.

E4.2.2.3.  Shortening of an extremity that exceeds two
inches (5 cms).

E4.2.2.4.  Feet:   Any condition that prevents walking,
running, or normal weight bearing.

E4.2.2.5.  Knee:   Internal derangement of the knee
when there is residual instability following remedial
measures such as surgery or physical therapy.

E4.2.2.6.  Joint Ranges of Motion (ROM):   Motion that
is less than the measurements listed below.   (Measurements
should be validated by three (3) measurements that agree
at the 5% level.   The measuring instrument should be
noted.   Both active and passive ROM should be listed.
  When a normal paired extremity is present a comparison
of the ROM of the normal to the impaired extremity should
be included (See Plate II).)

E4.2.2.6.1.  Hip:   Flexion to 90 degrees, or extension
to 0 degrees.

E4.2.2.6.2.  Knee:   Flexion to 90 degrees, or extension
to 15 degrees.

E4.2.2.6.3.  Ankle:   Dorsiflexion to 10 degrees, or
planter flexion to 10 degrees.

E4.2.3.  Inflammatory Condition.    Any inflammatory
condition involving the bones, joints, or muscles of
the extremities, that after accepted therapy, prevents
the military member from performing the preponderance
of duties assigned.

E4.2.4.  Prosthetic Replacement.    Total or partial
prosthetic replacement of a major joint, i.e., hip,
knee, shoulder.

E4.2.5.  Muscles.   Atrophy of, loss of substance of,
direct injury to (or residuals thereof) one or more
muscles or muscle groups that prevents satisfactory
use of the upper or lower extremity.   (Does not include
muscular changes secondary to neurological disorders.
  Refer to section on the Nervous System.)

E4.2.6.  Tendon and/or Ligament Transplantation:   
If restoration of function is not sufficient to adequately
perform the preponderance of duties required.

E4.2.7.  Spine 

E4.2.7.1.  Congenital Disorders.    (e.g., Spina Bifida,
Coxa Vara, Spondylolysis/Spondylolisthesis, Kyphosis,
Scoliosis) When more than mild symptoms cause a deterioration
in performance of required duties.

E4.2.7.2.  Acquired Disorders 

E4.2.7.2.1.  Fractures requiring spinal cord decompression
with residual neurological deficit or loss of mobility
due to fusion.

E4.2.7.2.2.  Spondylolysis and/or Spondylolisthesis
requiring fusion with loss of mobility.

E4.2.7.2.3.  Herniation of nucleus pulposus when more
than mildly symptomatic, with demonstrated neurological
involvement; or subsequent surgical treatment does not
provide symptomatic relief sufficient for performance
of duties.

E4.2.8.  Skull.    Significant loss of substance without
prosthetic replacement, or with prosthetic replacement
in the presence of significant residuals.

E4.2.9.  Fibromyalgia.    This condition must meet the
definition as put forth by the American College of Rheumatology
in 1990.

E4.3.  Organs of Special Senses 

E4.3.1.  Eyes 

E4.3.1.1.  Eye Disease.    Active eye disease or any
progressive organic disease or degeneration, regardless
of the stage of activity, that is resistant to treatment
and affects the distant visual acuity or visual fields
such that distant visual acuity is significantly affected
or the field of vision of the better eye is less than
40 degrees.   (See "Visual Acuity" below.)

E4.3.1.2.  Visual Acuity.    Visual acuity that cannot
be corrected with ORDINARY SPECTACLE LENSES, to at least
20/40 in one eye and 20/100 in the other eye, or 20/20
in one eye and 20/400 in the other eye, or an eye has
been enucleated.

E4.3.1.3.  Aniseikonia.    With subjective eye discomfort,
neurologic symptoms, sensations of motion sickness,
functional difficulties and difficulties in distinguishing
forms, and not corrected by standard optical lenses.

E4.3.1.4.  Binocular Diplopia.    When not surgically
or optically correctable, that is severe, and constant.

E4.3.1.5.  Bilateral Hemianopsia.    Any type that is
permanent, and based on an organic defect.

E4.3.1.6.  Night Blindness.    Of such a degree that
precludes unassisted night travel.

E4.3.1.7.  Vision Fields 

E4.3.1.7.1.  Visual fields with bilateral concentric
constriction to less than 40 degrees.

E4.3.1.7.2.  Visual field in better eye is less than
40 degrees.

E4.3.2.  Ears and/or Hearing 

E4.3.2.1.  Ears 

E4.3.2.1.1.  Otitis Externa, chronic, severe, requiring
frequent and prolonged treatment.

E4.3.2.1.2.  Mastoiditis requiring frequent and prolonged
treatment; or, subsequent to mastoidectomy there is
constant drainage from the mastoid cavity.

E4.3.2.1.3.  Meniere's syndrome or labyrinthine disorders
of sufficient severity to interfere with satisfactory
performance of duties.

E4.3.2.1.4.  Otitis Media, chronic, resistant to conventional
therapy interfering with satisfactory performance of
duties.

E4.3.2.2.  Hearing 

E4.3.2.2.1.  Unaided hearing loss that adversely effects
safe and effective performance of duty.

E4.3.2.2.2.  In the assessment of hearing, when the
unaided average loss in the BETTER ear is 35 Db (ANSI)
or more in the normal speech range (pure tone audiometric
values at the 1000, 2000, 3000, 4000 hertz) the individual
will be evaluated at an audiology and speech center.
Referral to an MEB will be based on the test that most
accurately reflects the degree of hearing loss.

E4.3.2.2.3.  Trained and experienced personnel will
not be categorically disqualified if they are capable
of effective performance of duty with a hearing aid.
Speech discrimination test results should be included.

E4.4.  SYSTEMIC DISEASES 

E4.4.1.  Definition.    Any acute or chronic condition
that affects the body as a whole (systemic) and interferes
with the successful performance of duty, or requires
medication for control, or needs frequent monitoring
by a physician, or that requires geographic assignment
limitations or requires a temporary limitation of duty
exceeding 180 days, or a permanent limitation of duty
that effects the whole body (systemic).

E4.4.1.1.  Infectious 

E4.4.1.1.1.  Systemic Mycoses, e.g. Blastomycosis.

E4.4.1.1.2.  Tuberculosis.   Pulmonary or generalized.

E4.4.1.1.3.  Leprosy.

E4.4.1.1.4.  AIDS.

E4.4.1.1.5.  Sexually Transmitted Diseases

E4.4.1.1.6.  HIV Seropositivity

E4.4.1.2.  Arthritis 

E4.4.1.2.1.  Rheumatoid Arthritis.

E4.4.1.2.2.  Spondyloarthropathy.

E4.4.1.2.2.1.  Ankylosing spondylitis.

E4.4.1.2.2.2.  Reiter's Syndrome.

E4.4.1.2.2.3.  Psoriatic Arthritis.

E4.4.1.2.2.4.  Arthritis associated with inflammatory
bowel disease.

E4.4.1.2.2.5.  Whipple's disease.

E4.4.1.3.  Other Systemic Diseases 

E4.4.1.3.1.  Amyloidosis.

E4.4.1.3.2.  Sarcoidosis.   Progressive, not responsive
to therapy.

E4.4.1.3.3.  Panniculitis.   Relapsing, febrile, nodular.

E4.4.1.3.4.  Myasthenia Gravis.

E4.4.1.3.5.  Porphyria cutanea tarda.

E4.4.1.3.6.  Systemic Lupus Erythematosus.

E4.4.1.3.7.  Sjogren's Syndrome.

E4.4.1.3.8.  Chronic Fatigue Syndrome.

E4.4.1.3.9.  Myopathy.   Inflammatory, metabolic, hereditary.

E4.4.1.3.10.  Progressive systemic sclerosis.

E4.4.1.3.11.  Systemic vasculitis.

E4.4.1.3.12.  Hypersensitivity angiitis. Resistant to
treatment and more than mildly symptomatic.

E4.4.1.3.13.  Behcet's syndrome.

E4.4.1.3.14.  Adult-onset Still's disease.

E4.4.1.3.15.  Mixed connective tissue disease (overlapping
syndromes).

E4.5.  RESPIRATORY SYSTEM 

E4.5.1.  Upper Airway 

E4.5.1.1.  Sinusitis.    Sinusitis or rhinitis (atrophic),
with Suppuration. Unresponsive to conventional therapy.

E4.5.1.2.  Larynx 

E4.5.1.2.1.  Obstructive edema of the glottis requiring
tracheostomy.

E4.5.1.2.2.  Vocal cord paralysis seriously interfering
with speech or airway.

E4.5.1.2.3.  Stenosis of such a degree as to cause respiratory
embarrassment on moderate exertion.

E4.5.1.3.  Trachea.    Stenosis or narrowing of such
a degree as to cause respiratory embarrassment on moderate
exertion.

E4.5.2.  Lower Airway.    (Rating is usually based upon
Pulmonary Function Tests (PFTs) measuring residual function.
  Tests should be validated (two of studies agreeing
at the 5% level).   In addition, studies before and
after medication should be done).

E4.5.2.1.  Infection 

E4.5.2.1.1.  Pulmonary Tuberculosis.

E4.5.2.1.1.1.  If treatable but more than 15 months
will be required before service member can be returned
to active duty.

E4.5.2.1.1.2.  Cases unresponsive to therapy.

E4.5.2.1.2.  Histoplasmosis, blastomycosis, toxoplasmosis,
or other mycosis not responding to accepted therapy.

E4.5.2.2.  Asthma.    (A clinical syndrome characterized
by cough, wheeze, dyspnea and physiological evidence
of reversible air flow obstruction or airway hyperreactivity
that generally persists over six (6) months.   Reversible
air flow obstruction is defined as more than 15% increase
in FEV1 following administration of an inhaled Bronchodilator.
  Airway hyperreactivity is defined as the exaggerated
decrease in air flow induced by a standard methacholine
challenge test.   Chronic asthma requires the regular
use of medication to allow the individual to perform
the preponderance of military duties.)

E4.5.2.3.  Bronchiectasis or bronchiolectasis.    Cylindrical
or saccular with residuals requiring repeated medical
care.

E4.5.2.4.  Bronchitis.    Chronic, severe, recurrent
unresponsive to repeated medical care.

E4.5.2.5.  Atelectasis.    Unresponsive to conventional
therapy requiring repeated medical care.

E4.5.2.6.  Pulmonary Sarcoidosis.    Progressive, unresponsive
to conventional therapy.

E4.5.2.7.  Pneumoconiosis.    Severe, with dyspnea on
moderate exertion.

E4.5.2.8.  Cystic disease of the lung 

E4.5.2.9.  Pulmonary Emphysema 

E4.5.2.10.  Pulmonary Fibrosis 

E4.5.2.11.  Residuals.    Residuals of pneumothorax,
hemothorax, empyema, or residuals of operative procedures
on the lungs or chest wall.

E4.5.2.12.  Bronchial Stenosis 

E4.5.2.13.  Diaphragmatic Dysfunction.    Diaphragmatic
dysfunction resulting in dyspnea on minimal exertion,
not responsive to therapy.

E4.5.2.14.  Lung Transplant. 

E4.6.  CARDIOVASCULAR SYSTEM 

E4.6.1.  Heart.    (In assessing the function of the
heart, various functional therapeutic classifications
(FTC) may be used as standards (New York Heart Association,
Canadian Cardiovascular Society, etc.)   Each of the
Cardiac conditions should be given an FTC.)

E4.6.1.1.  Arteriosclerotic Heart Disease.

E4.6.1.1.1.  Coronary Artery Disease.

E4.6.1.1.1.1.  Angina Pectoris.

E4.6.1.1.1.2.  Myocardial Ischemia

E4.6.1.1.1.3.  Myocardial Infarction.

E4.6.1.1.1.4.  Congestive Heart Failure.

E4.6.1.2.  Inflammatory.

E4.6.1.2.1.  Endocarditis.

E4.6.1.2.2.  Pericarditis, chronic or repetitive.

E4.6.1.2.3.  Rheumatic Heart Disease.

E4.6.1.2.4.  Syphilitic Heart Disease.

E4.6.1.3.  Cardiac Arrhythmias and/or Pacemakers.  
(See also pare E4.5.2.2., above)

E4.6.1.3.1.  Supraventricular Arrhythmias.    When life
threatening or symptomatic enough to interfere with
duty performance.

E4.6.1.3.2.  Heart Block (second or third degree AV
block) and chronic symptomatic bradyarrhythmias with
poor response to conventional therapy.

E4.6.1.3.3.  Ventricular Arrhythmias.    When potentially
life threatening or symptomatic enough to interfere
with the performance of duty.

E4.6.1.3.4.  Residuals of Sudden Cardiac Death Syndrome
Following Successful Resuscitation.

E4.6.1.3.5.  Near or recurrent syncope of cardiac origin.

E4.6.1.3.6.  Permanent indwelling pacemakers or defibrillators
or other permanent antitachycardia devices.

E4.6.1.4.  Hypertrophic Cardiomyopathy.

E4.6.1.5.  Dilated Cardiomyopathy.

E4.6.1.6.  Myocardial Disease.

E4.6.1.7.  Valvular Heart Disease.

E4.6.1.8.  Hypertensive Cardiac Disease.

E4.6.1.9.  Post Operative or other invasive procedures
involving the heart, pericardium, or vascular system.

E4.6.1.9.1.  Permanent Prosthetic Valve Implantation.

E4.6.1.9.2.  Coronary Artery Revascularization.

E4.6.1.9.3.  Coronary or Valvular Angioplasty or Plaque
removal.

E4.6.1.9.4.  Cardiac Arrhythmia Ablation procedures,
unless free of unfitting symptoms and signs.

E4.6.1.9.5.  Reconstructive Cardiovascular surgery.

E4.6.1.9.6.  Cardiac Transplant.

E4.6.1.10.  Any cardiovascular disorder requiring chronic
drug therapy in order to prevent the occurrence of potentially
fatal or severely symptomatic events that would interfere
with duty performance.

E4.6.2.  Vascular System 

E4.6.2.1.  Arteriosclerosis Obliterans.    Evidence
of arterial disease such as intermittent, ischemic rest
pain, or gangrenous/ulcerative skin changes of a permanent
nature.   Involvement of one or more organs or systems,
or anatomic region with symptoms of arterial insufficiency.

E4.6.2.2.  Major Cardiovascular Anomalies. 

E4.6.2.2.1.  Coarctation of the Aorta.

E4.6.2.2.2.  Aneurysm of any major vessel.

E4.6.2.3.  Periarteritis Nodosa.

E4.6.2.4.  Chronic Venous Insufficiency.

E4.6.2.5.  Raynaud's Syndrome.

E4.6.2.6.  Thromboangiitis Obliterans.   With claudication
(see E4.6.2.1., above).

E4.6.2.7.  Recurrent Thrombophlebitis.

E4.6.2.8.  Varicose Veins.   Severe and symptomatic
despite conventional therapy.

E4.6.2.9.  Any vascular reconstruction.

E4.6.3.  Miscellaneous Conditions. 

E4.6.3.1.  Cold Injury.

E4.6.3.1.1.  Frostbite, if significant or with residuals.

E4.6.3.1.2.  Trench foot.

E4.6.3.1.3.  Hypothermia.

E4.6.3.2.  Erythromyalgia.

E4.6.3.3.  Hypertensive Cardiovascular and/or Vascular
disease.

E4.6.3.3.1.  Diastolic pressure consistently greater
than 100mm Hg following adequate therapy; and/or,

E4.6.3.3.2.  Associated changes in the brain, heart,
kidney, or optic fundi.

E4.6.3.4.  Neurocirculatory Syncope

E4.6.4.  Anticoagulant Therapy.    When chronically
required.

E4.7.  GASTROINTESTINAL SYSTEM 

E4.7.1.  General.    Any organic condition of the Gastrointestinal
System that prevents adequate maintenance of the service
member's nutritional status, or requires significant
dietary restrictions.

E4.7.2.  Inflammatory and/or Infectious Conditions.


E4.7.2.1.  Esophagitis.

E4.7.2.1.1.  Infectious (e.g., Candidiasis).

E4.7.2.1.2.  Reflux.   When not responsive to therapy.

E4.7.2.1.3.  Hiatal hernia.   When not responsive to
therapy.

E4.7.2.2.  Gastritis.   When not responsive to therapy.

E4.7.2.3.  Hepatitis.

E4.7.2.3.1.  Persistent symptoms or persistent evidence
of impaired liver function.

E4.7.2.3.2.  Inability to serve as a blood donor.

E4.7.2.3.3.  Persistence of biochemical markers indicating
chronicity.

E4.7.2.4.  Pancreatitis, chronic, with residuals (such
as malabsorption/glucose abnormality due to enzyme deficiency),
or recurrent.

E4.7.2.5.  Regional Enteritis.

E4.7.2.6.  Ulcerative Colitis.

E4.7.2.7.  Proctitis, significantly symptomatic.

E4.7.2.8.  Intra-abdominal abscess.   When unresponsive
to therapy.

E4.7.2.9.  Hepatic abscess.   When unresponsive to therapy.

E4.7.3.  Obstructive Conditions 

E4.7.3.1.  Congenital.

E4.7.3.1.1.  Diverticula.

E4.7.3.1.2.  Webs.

E4.7.3.1.3.  Strictures.

E4.7.3.2.  Acquired.

E4.7.3.2.1.  Diverticula.

E4.7.3.2.2.  Webs.

E4.7.3.2.3.  Strictures.

E4.7.3.2.4.  Peritoneal Adhesive Bands.

E4.7.4.  Dysfunctional Conditions 

E4.7.4.1.  Achalasia of the Esophagus.

E4.7.4.2.  Biliary Dyskinesia.

E4.7.4.3.  Cirrhosis.   Moderate with evidence of portal
hypertension, abdominal veins and/or impaired liver
function and/or significant impairment of health.

E4.7.4.4.  Ulcers (Duodenal, Gastric, Intestinal) when
there are complications or residuals.

E4.7.4.5.  Postgastrectomy and/or Dumping Syndromes.

E4.7.4.6.  Permanent Gastrostomy, Enterostomy, Ileostomy,
Colostomy, Pancreatoenterostomy.

E4.7.4.7.  Total Gastrectomy, Pancreatectomy

E4.7.4.8.  Fecal Incontinence.

E4.7.5.  Abdominal Wall Defects.    Hernia, recurrent,
when repair is contraindicated and the defect interferes
with duty performance.   This includes removal, e.g.,
post mastectomy reconstructive surgery.

E4.8.  GENITOURINARY SYSTEM 

E4.8.1.  Urinary System.    (There are three general
dysfunctions of the urinary system: Renal Dysfunction,
Voiding Dysfunction, Urinary Tract Infection. Some conditions
involve a combination.)

E4.8.1.1.  Renal Dysfunction.    (Medical workup will
include Creatinine Clearance to quantitate the degree
of dysfunction.(See Table 5 of DoD Instruction 1332.39
(reference (i))

E4.8.1.1.1.  Retained Renal Calculus.   When resulting
in recurrent symptoms, abnormal renal function, or recurrent
infection and is not correctable by therapy.

E4.8.1.1.2.  Cystic Kidney, when renal function is impaired
or the focus of recurrent infection.

E4.8.1.1.3.  Glomerulonephritis.

E4.8.1.1.4.  Hydronephrosis.   When not correctable.

E4.8.1.1.5.  Hypoplasia of the kidney.   When symptomatic
(high blood pressure, frequent infections, e.g.).

E4.8.1.1.6.  Chronic Nephritis.

E4.8.1.1.7.  Nephrosis.

E4.8.1.1.8.  Stricture of the Ureter, if clinically
significant and not correctable.

E4.8.1.1.9.  Residuals of Ureteral Operations, including:

E4.8.1.1.9.1.  Ureterocolostomy and/or Ureterosigmoidostomy.

E4.8.1.1.9.2.  Ureterocystostomy.

E4.8.1.1.9.3.  Ureteroileostomy.

E4.8.1.1.9.4.  Ureteroplasty.

E4.8.1.1.10.  Pyeloplasty, with significant residuals.

E4.8.1.1.11.  Nephrectomy.   When there are complications
with the remaining kidney.

E4.8.1.1.12.  Nephrostomy, Pyelostomy, Ureterostomy.
  When there is persistent drainage.

E4.8.1.1.13.  Renal Transplant.

E4.8.1.1.13.1.  Recipient.

E4.8.1.1.13.2.  Donor.   If there is malfunction of
the remaining kidney.

E4.8.1.1.14.  Pyelonephritis, if chronic.

E4.8.1.2.  Voiding Dysfunction 

E4.8.1.2.1.  Cystitis, when complications or residuals
preclude satisfactory performance of duty.

E4.8.1.2.2.  Urinary Incontinence, if unresponsive to
treatment.

E4.8.1.2.3.  Neurogenic Bladder.

E4.8.1.2.4.  Epispadias.   When there is an inability
to perform required duty due to soilage or recurrent
infection.

E4.8.1.2.5.  Stricture of the Urethra, not amenable
to treatment.

E4.8.1.2.6.  Cystectomy

E4.8.1.2.7.  Cystoplasty.   When residual urines are
greater than 50cc and/or there is refractory infection.

E4.8.1.2.8.  Urethrostomy.

E4.8.1.3.  Urinary Tract Infection 

E4.8.1.3.1.  Chronic Urethritis.

E4.8.1.3.2.  Chronic Pyonephrosis/Pyelonephritis.

E4.8.1.3.3.  Perirenal Abscess.

E4.8.1.3.4.  Cystoplasty.   When there is refractory
infection.

E4.8.2.  Female Genitourinary Conditions 

E4.8.2.1.  Dysmenorrhea.    When severity is such that
duty performance is affected.

E4.8.2.2.  Endometriosis.    When the severity is such
that duty performance is affected.

E4.8.2.3.  Menopausal Syndrome.    When constitutional
symptoms prevent duty performance.

E4.8.2.4.  Chronic Pelvic Pain.    When the severity
is such that duty performance is affected.

E4.8.2.5.  Hysterectomy.    When residual complications
preclude satisfactory performance of duty.

E4.8.2.6.  Oophorectomy.    When residual symptoms preclude
satisfactory duty performance.

E4.9.  HEMIC AND LYMPHATIC SYSTEMS 

E4.9.1.  Anemia.    When symptomatic and not responsive
to therapy.

E4.9.2.  Hemolytic Crises.    When complicated, chronic,
and symptomatic.

E4.9.3.  Leukopenia.    When not responsive to therapy
or when therapy is prolonged, or when complicated by
recurrent infections.

E4.9.4.  Polycythemia.    When unresponsive to therapy.

E4.9.5.  Purpura or Bleeding disorders. 

E4.9.6.  Chronic Anticoagulation Therapy. 

E4.9.7.  Hypercoagulable states with thromboembolic
disease. 

E4.9.8.  Indwelling Filter to prevent embolic phenomena.


E4.9.9.  Leukemia, or history thereof. 

E4.9.10.  Lymphomas, or history thereof. 

E4.9.10.1.  Hodgkin's.

E4.9.10.2.  Non-Hodgkin's.

E4.10.  SKIN AND CELLULAR TISSUES 

E4.10.1.  When conditions are severe, unresponsive to
therapy, and interfere with the satisfactory performance
of duty, wearing of the uniform, or using military equipment.

E4.10.2.  Systemic Conditions including: 

E4.10.2.1.  Amyloidosis.

E4.10.2.2.  Dermatomyositis.

E4.10.2.3.  Dermatographism.

E4.10.2.4.  Eczema.

E4.10.2.5.  Chronic Lymphedema.

E4.10.2.6.  Erythema Multiforme.

E4.10.2.7.  Hyperhidrosis.

E4.10.2.8.  Leukemia Cutis or Mycosis Fungoides.

E4.10.2.9.  Neurofibromatosis.

E4.10.2.10.  Psoriasis.

E4.10.2.11.  Parapsoriasis.

E4.10.2.12.  Scleroderma.

E4.10.2.13.  Pemphigus.

E4.10.2.14.  Exfoliative Dermatitis.

E4.10.2.15.  Epidermolysis Bullosa.

E4.10.2.16.  Urticaria.

E4.10.2.17.  Lichen Planus.

E4.10.2.18.  Cutaneous Lupus Erythematosus.

E4.10.3.  Localized Conditions 

E4.10.3.1.  Radiodermatitis.   Particularly if there
is malignant degeneration not amenable to therapy.

E4.10.3.2.  Intractable Plantar Keratosis.

E4.10.3.3.  Scars and Keloids.   Locally extensive and
adherent so as to interfere with the function of a body
part or prevent the wearing of the uniform.

E4.10.3.4.  Xanthoma.

E4.10.3.5.  Cysts and Tumors.   When not amenable to
accepted therapy.

E4.10.3.6.  Atopic Dermatitis.

E4.10.3.7.  Ulcers of the skin.   When not responsive
to therapy.

E4.10.4.  Infectious Conditions 

E4.10.4.1.  Acne, Cystic, Severe.   When unresponsive
to therapy.

E4.10.4.2.  Dermatitis Herpetiformis.

E4.10.4.3.  Panniculitis.

E4.10.4.4.  Cutaneous Tuberculosis.

E4.10.4.5.  Elephantiasis.

E4.10.5.  Other Chronic Skin Disorders. 

E4.11.  ENDOCRINE SYSTEM AND METABOLIC CONDITIONS 

E4.11.1.  General.    Any abnormality that does not
respond to therapy satisfactorily or where replacement
therapy presents significant management problems.

E4.11.2.  Diabetes 

E4.11.2.1.  All cases requiring oral hypoglycemics.

E4.11.2.2.  All cases requiring insulin and/or restrictive
diet for control.

E4.11.2.3.  When individuals requiring insulin for maintenance
are under poor control ("brittle diabetics").

E4.11.3.  Acromegaly. 

E4.11.4.  Adrenal Hyper or Hypofunction. 

E4.11.5.  Diabetes Insipidus. 

E4.11.6.  Hyper or Hypothyroidism.    When not controlled
by accepted therapy.

E4.11.7.  Hyper or Hyoparathyroidism.    Especially
when residuals or complications of surgical treatment
(renal, skeletal or mental alterations) prevent performance
of duty.

E4.11.8.  Hyperinsulinism.    When caused by malignancy
or not readily controlled.

E4.11.9.  Gout.    In advanced cases with frequent (>3/yr)
acute exacerbations or severe bone, joint, or renal
damage.

E4.11.10.  Osteomalacia.    With residuals that prevent
the performance of duties.

E4.11.11.  Hypogammaglobulinemia. 

E4.11.12.  Hypercoaulable States. 

E4.11.13.  Heat Injury 

E4.11.13.1.  Recurrent Heat Exhaustion.    Manifested
by collapse, including syncope, occurring during or
immediately following exercise or in an environment
of increased heat.   Must occur at least three or more
times in twenty-four months.   No remedial factor can
be identified.

E4.11.13.2.  Heat Stroke.    Hyperpyrexia (core temperature
>106 degrees Fahrenheit), collapse, encephalopathy and
organ damage and/or systemic inflammatory activation
during the episode.   In the absence of encephalopathy,
exertional rhabdomyolysis and myoglobinuria are sufficient.
  A trial of duty may be recommended if complicating
factors have been identified and there are no residuals.

E4.12.  NERVOUS SYSTEM 

E4.12.1.  General.   (To better measure conditions involving
the nervous system, it is mandatory that certain yardsticks
be employed.   In DEMENTIA AND HEAD TRAUMA CASES , neuropsychiatric
measurements should be performed as early as possible.
  In MIGRAINE CASES, the number of incapacitating episodes
(those that require the individual to stop the activity
in which engaged and seek medical treatment) per week,
month or year should be noted and verified by a physician.
  In SEIZURE DISORDER CASES, the evaluation will be
done by a neurologist.   An EEG, MRI/CT will be included
in the initial examination.   When subsequent seizure
episodes occur while on medical therapy, blood levels
of prescribed medication(s) will be determined.   All
cases of neuropathies will have EMG and nerve conduction
studies performed.   Cases of multiple sclerosis will
have an MRI.   Estimation of the degree of social and
industrial impairment incurred by the Service member
due to migraine and seizure disorder should be included.)

E4.12.2.  Neurogenic Muscular Atrophy 

E4.12.2.1.  Amyotrophic Lateral Sclerosis.

E4.12.2.2.  All Primary Muscle Disorders.

E4.12.2.2.1.  Facioscapulohumeral Dystrophy.

E4.12.2.2.2.  Limb Girdle Dystrophy.

E4.12.2.2.3.  Myotonia Dystr