evaluate the TBI at the highest level in which a criterion is met. 3.310 structural structural and Because “normal imaging,” “abnormal imaging” greater than 24 may be found at more than one severity level, “AOC hours” evaluate severity based on other criteria in the table. If no other criteria are present, then determine the level of severity as follows. If AOC is greater than 24 hours and no other criteria are present, determine the severity as moderate. If structural imaging is noted as normal and no other criteria are present, determine the severity as mild. If structural imaging is noted as abnormal and no other criteria are present, determine the severity as moderate. If the level of severity cannot be determined based on the available evidence, then apply the provisions of and order a VA examination/medical opinion as necessary. Evidence that may be relevant in ascertaining the initial severity of TBI d. Evidence That May be symptoms includes Relevant to the Initial Severity lay statements provided by the Veteran Factors lay statements from witnesses to the injury history provided by the Veteran in medical reports, to include VA exams, and service treatment records (STRs) at any time after the TBI. The that establishes the initial severity of the TBI does not Note: evidence necessarily have to be contemporaneous to the injury as long as it relates to the condition of TBI at or shortly after the time of the injury. A Korean War Veteran submits a claim for SC for Parkinsonism Example: secondary to his SC TBI. The discharge examination from 1954 Veteran’s mentions a history of TBI in service. However, it does not contain information sufficient to determine the level of severity of the initial TBI injury. The Veteran provides a statement that he experienced a loss of consciousness during the Battle of Chosin Reservoir. A review of prior VA examination reports reveals a history provided by the Veteran that he was told by fellow soldiers that he fell unconscious for almost an hour after two grenades exploded near him. Although service records do not reveal the specific level of TBI Analysis: during service, the is credible, consistent with Veteran’s statement circumstances of his service, and therefore sufficient to determine that he experienced a moderate level of TBI during service.
3.310 evaluate the TBI at the highest level in which a criterion is met. Because “normal structural imaging,” “abnormal structural imaging” and “AOC greater than 24 hours” may be found at more than one severity level, evaluate severity based on other criteria in the table. If no other criteria are present, then determine the level of severity as follows. If AOC is greater than 24 hours and no other criteria are present, determine the severity as moderate. If structural imaging is noted as normal and no other criteria are present, determine the severity as mild. If structural imaging is noted as abnormal and no other criteria are present, determine the severity as moderate. If the level of severity cannot be determined based on the available evidence, then apply the provisions of and order a VA examination/medical opinion as necessary. d. Evidence That May be Relevant to the Initial Severity Factors Evidence that may be relevant in ascertaining the initial severity of TBI symptoms includes lay statements provided by the Veteran lay statements from witnesses to the injury history provided by the Veteran in medical reports, to include VA exams, and service treatment records (STRs) at any time after the TBI. Note: The evidence that establishes the initial severity of the TBI does not necessarily have to be contemporaneous to the injury as long as it relates to the condition of TBI at or shortly after the time of the injury. Example: A Korean War Veteran submits a claim for SC for Parkinsonism secondary to his SC TBI. The Veteran’s discharge examination from 1954 mentions a history of TBI in service. However, it does not contain information sufficient to determine the level of severity of the initial TBI injury. The Veteran provides a statement that he experienced a loss of consciousness during the Battle of Chosin Reservoir. A review of prior VA examination reports reveals a history provided by the Veteran that he was told by fellow soldiers that he fell unconscious for almost an hour after two grenades exploded near him. Analysis: Although service records do not reveal the specific level of TBI during service, the Veteran’s statement is credible, consistent with circumstances of his service, and therefore sufficient to determine that he experienced a moderate level of TBI during service.