This is the accessible text file for GAO report number GAO-04-1069 
entitled 'VA and Defense Health Care: More Information Needed to 
Determine If VA Can Meet an Increase in Demand for Post-Traumatic 
Stress Disorder Services' which was released on September 21, 2004.

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as part 
of a longer term project to improve GAO products' accessibility. Every 
attempt has been made to maintain the structural and data integrity of 
the original printed product. Accessibility features, such as text 
descriptions of tables, consecutively numbered footnotes placed at the 
end of the file, and the text of agency comment letters, are provided 
but may not exactly duplicate the presentation or format of the printed 
version. The portable document format (PDF) file is an exact electronic 
replica of the printed version. We welcome your feedback. Please E-mail 
your comments regarding the contents or accessibility features of this 
document to Webmaster@gao.gov.

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately.

Report to the Ranking Democratic Member, Committee on Veterans' 
Affairs, House of Representatives: 

September 2004: 

VA AND DEFENSE HEALTH CARE: 

More Information Needed to Determine If VA Can Meet an Increase in 
Demand for Post-Traumatic Stress Disorder Services: 

GAO-04-1069: 

GAO Highlights: 

Highlights of GAO-04-1069, a report to the Ranking Democratic Member, 
Committee on Veterans' Affairs, House of Representatives

Why GAO Did This Study: 

Post-traumatic stress disorder (PTSD) is caused by an extremely 
stressful event and can develop after the threat of death or serious 
injury as in military combat. Experts predict that about 15 percent of 
servicemembers serving in Iraq and Afghanistan will develop PTSD. 
Efforts by VA to inform new veterans, including Reserve and National 
Guard members, about the expanded availability of VA health care 
services could result in an increased demand for VA PTSD services. GAO 
identified the approaches DOD uses to identify servicemembers at risk 
for PTSD and examined if VA has the information it needs to determine 
whether it can meet an increase in demand for PTSD services. GAO 
visited military bases and VA facilities, reviewed relevant documents, 
and interviewed DOD and VA officials to determine how DOD identifies 
servicemembers at risk for PTSD, and what information VA has to 
estimate demand for VA PTSD services.

What GAO Found: 

DOD uses two approaches to identify servicemembers at risk for PTSD: 
the combat stress control program and the post-deployment health 
assessment questionnaire. The combat stress control program trains 
servicemembers to recognize the early onset of combat stress, which 
can lead to PTSD. Symptoms of combat stress and PTSD include insomnia, 
nightmares, and difficulties coping with relationships. To assist 
servicemembers in the combat theater, teams of DOD mental health 
professionals travel to units to reinforce the servicemembers’ 
knowledge of combat stress symptoms and to help identify those who may 
be at risk for combat stress and PTSD. DOD also uses the post-
deployment health assessment questionnaire to identify physical 
ailments and mental health issues commonly associated with deployments, 
including PTSD. The questionnaire includes the following four screening 
questions that VA and DOD mental health experts developed to identify 
servicemembers at risk for PTSD: 

Have you ever had any experience that was so frightening, horrible, 
or upsetting that, in the past month, you

* have had any nightmares about it or thought about it when you did 
not want to?
* tried hard not to think about it or went out of your way to avoid 
situations that remind you of it?
* were constantly on guard, watchful, or easily startled?
* felt numb or detached from others, activities, or your surroundings?

VA lacks the information it needs to determine whether it can meet an 
increase in demand for VA PTSD services. VA does not have a count of 
the total number of veterans currently receiving PTSD services at its 
medical facilities and Vet Centers—community-based VA facilities that 
offer trauma and readjustment counseling. Without this information, VA 
cannot estimate the number of new veterans its medical facilities and 
Vet Centers could treat for PTSD. VA has two reports on the number of 
veterans it currently treats, with each report counting different 
subsets of veterans receiving PTSD services. Veterans who are 
receiving VA PTSD services may be counted in both reports, one of the 
reports, or not included in either report. VA does receive demographic 
information from DOD, which includes home addresses of servicemembers 
that could help VA predict which medical facilities or Vet Centers 
servicemembers may access for health care. By assuming that 15 percent 
or more of servicemembers who have left active duty status will 
develop PTSD, VA could use the home zip codes of servicemembers to 
broadly estimate the number of servicemembers who may need VA PTSD 
services and identify the VA facilities located closest to their 
homes. However, predicting which veterans will seek VA care and at 
which facilities is inherently uncertain, particularly given that the 
symptoms of PTSD may not appear for years.

What GAO Recommends: 

GAO recommends that VA determine the total number of veterans 
receiving VA PTSD services and provide facility-specific information 
to VA medical facilities and Vet Centers. VA concurred with GAO’s 
recommendation and plans to aggregate data on the total number of 
veterans it treats for PTSD at VA facilities. DOD concurred with GAO’s 
findings and conclusions.

www.gao.gov/cgi-bin/getrpt?GAO-04-1069.

To view the full product, including the scope and methodology, click 
on the link above. For more information, contact Cynthia A. Bascetta 
at (202) 512-7101.

[End of section]

Contents: 

Letter: 

Results In Brief: 

Background: 

DOD Uses Two Approaches to Identify Servicemembers At Risk for PTSD: 

VA Lacks Information Needed to Determine Whether It Can Meet an 
Increase in Demand for PTSD Services: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments: 

Appendixes: 

Appendix I: Scope and Methodology: 

Appendix II: Department of Defense Post-Deployment Health Assessment 
Questionnaire DD-2796: 

Appendix III: Comments from the Department of Veterans Affairs: 

Appendix IV: Comments from the Department of Defense: 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Acknowledgments: 

Related GAO Products: 

Figures: 

Figure 1: DOD's Process for "Yes" Responses to PTSD Questions on DD 
2796: 

Figure 2: Veterans Included in VA's Annual Reports: 

Abbreviations: 

DOD: Department of Defense: 

NEPEC: Northeast Program Evaluation Center: 

OIG: Office of Inspector General: 

PTSD: post-traumatic stress disorder: 

VA: Department of Veterans Affairs: 

Letter September 20, 2004: 

The Honorable Lane Evans: 
Ranking Democratic Member: 
Committee on Veterans' Affairs:
House of Representatives: 

Dear Mr. Evans: 

Mental health experts predict that because of the intensity of warfare 
in Iraq and Afghanistan 15 percent or more of the servicemembers 
returning from these conflicts will develop post-traumatic stress 
disorder (PTSD).[Footnote 1],[Footnote 2] his rate approximates the 
PTSD rate for Vietnam War veterans.[Footnote 3] PTSD, which is caused 
by an extremely stressful event, can develop after military combat and 
exposure to the threat of death or serious injury. Symptoms of PTSD, 
which may appear within months or be delayed for years after the 
stressful event, include insomnia, intense anxiety, nightmares about 
the event, and difficulties coping with work, family, and social 
relationships. Although there is no cure for PTSD, experts believe that 
early identification and treatment of PTSD symptoms may lessen the 
severity of the condition and improve the overall quality of life for 
servicemembers and veterans. If left untreated, PTSD can lead to 
substance abuse, severe depression, and suicide.

The Department of Veterans Affairs (VA) has intensified its efforts to 
inform new veterans from the Iraq and Afghanistan conflicts about the 
health care services--including treatment for PTSD--it offers to 
eligible veterans. These efforts, along with expanded availability of 
VA health care services for Reserve and National Guard members, could 
result in an increased percentage of veterans from Iraq and Afghanistan 
seeking PTSD services through VA. Concerns have been raised about 
whether VA can provide PTSD services for a new influx of veterans, 
while at the same time continuing these services for veterans that VA 
currently treats for PTSD.

You asked that we review the Department of Defense's (DOD) efforts to 
identify servicemembers who have served in Iraq and Afghanistan and are 
at risk for PTSD, and VA's efforts to ensure that PTSD services are 
available for all veterans. Specifically, we identified the approaches 
DOD uses to identify servicemembers who are at risk for PTSD. We also 
examined if VA has the information it needs to determine whether it can 
meet an increase in demand for VA PTSD services.

To determine the approaches DOD uses to identify servicemembers who are 
at risk for PTSD, we reviewed documents, interviewed DOD officials, and 
visited a military installation for each of DOD's uniform services, 
some of which had large numbers of servicemembers returning from Iraq 
and Afghanistan. We have reviewed how well DOD's uniform services 
implemented these approaches in previous work and did not address that 
issue in this review.[Footnote 4] To determine whether VA has the 
information it needs to estimate the future demand for VA PTSD 
services, we interviewed VA headquarters and facility officials to 
discuss the number of veterans receiving treatment for PTSD and future 
demand for these services in areas of the country where large numbers 
of servicemembers were returning from Iraq and Afghanistan. To obtain 
additional information on identifying and treating veterans with PTSD, 
we interviewed VA's PTSD experts at the National Center for 
PTSD.[Footnote 5] We reviewed VA's annual capacity reports, which 
include information on the number of seriously mentally ill veterans 
receiving PTSD services. We also reviewed the findings of the VA Office 
of Inspector General (OIG) who is responsible for reporting to Congress 
on the accuracy of VA's capacity reports. We did not include data from 
VA's annual capacity reports because the OIG found that the data were 
not sufficiently reliable. We also interviewed VA headquarters and 
facility officials and DOD officials to determine what information they 
share about returning servicemembers. For a complete description of our 
scope and methodology, see appendix I. Our work was conducted from May 
through September 2004 in accordance with generally accepted government 
auditing standards.

Results In Brief: 

DOD uses two approaches to identify servicemembers at risk for PTSD: 
the combat stress control program and the post-deployment health 
assessment questionnaire. The combat stress control program trains 
servicemembers to recognize the early symptoms of combat stress, which 
can be a precursor to PTSD. To assist servicemembers in the combat 
theater, teams of DOD mental health professionals travel to units to 
reinforce the servicemembers' knowledge of combat stress symptoms and 
to help identify those who may be at risk for combat stress or PTSD. 
DOD uses the post-deployment health assessment questionnaire to 
identify physical ailments and mental health issues commonly associated 
with deployments, including PTSD. The questionnaire includes four 
screening questions that VA and DOD mental health experts developed to 
identify servicemembers who may be at risk of developing PTSD. DOD 
generally requires servicemembers deployed outside of the United States 
to complete this questionnaire within 30 days before leaving a 
deployment location or within 5 days after returning to the United 
States. Completed questionnaires must be reviewed by a DOD clinical 
provider, who interviews servicemembers to determine if further medical 
evaluation is necessary.

VA lacks the information it needs to determine whether it can meet an 
increase in demand for VA PTSD services. VA does not have a count of 
the total number of veterans currently receiving PTSD services at its 
medical facilities and Vet Centers--community-based VA facilities that 
offer trauma and readjustment counseling. Without this information, VA 
cannot estimate the number of additional veterans its medical 
facilities and Vet Centers could treat for PTSD. A VA official told us 
that a count of the total number of veterans with a diagnosis of PTSD 
who receive VA services at medical facilities could be obtained from 
VA's existing database. However, this database does not include Vet 
Centers' information because this information is kept separate from the 
medical facilities' data. VA has two reports on the number of veterans 
it currently treats, with each report counting different subsets of 
veterans receiving PTSD services. Veterans who are receiving VA PTSD 
services may be counted in both reports, one of the reports, or not 
included in either report. For example, veterans receiving PTSD 
services exclusively in Vet Centers may not be counted in either 
report. On the other hand, VA does have information it can use to 
broadly estimate the number of servicemembers who may access VA health 
care, including PTSD services. In September 2003, DOD provided VA with 
demographic information on servicemembers from the Iraq and Afghanistan 
conflicts who have left active duty status and are eligible for VA 
health care. The demographic information includes the names and home 
addresses of servicemembers. In July 2004, VA provided this information 
to its facilities for planning future services for additional veterans. 
By assuming that 15 percent or more of returning servicemembers will 
develop PTSD, based on the predictions of mental health experts, VA and 
its facilities could use DOD's demographic information to broadly 
estimate demand for PTSD services. However, predicting which veterans 
will seek VA care and at which facilities is inherently uncertain, 
particularly given that the symptoms of PTSD may not appear for years. 
Based on DOD's demographic information, some VA medical facility 
officials expressed concern about their ability to meet an increase in 
demand for VA PTSD services from servicemembers returning from Iraq and 
Afghanistan.

To help VA better estimate the number of additional veterans it could 
treat for PTSD and to plan for the future demand for VA PTSD services, 
we recommend that VA determine the total number of veterans receiving 
VA PTSD services and provide facility-specific information to VA 
medical facilities and Vet Centers. VA and DOD commented on a draft of 
this report. In its comments VA concurred with our recommendation and 
acknowledged that more coordinated efforts are needed to improve its 
existing PTSD data. VA stated that it plans to aggregate at the 
national level the number of veterans receiving PTSD services at VA 
medical facilities and Vet Centers. DOD concurred with the findings and 
conclusions in this report and provided technical comments on the 
report, which we incorporated as appropriate.

Background: 

PTSD can develop following exposure to life-threatening events, natural 
disasters, terrorist incidents, serious accidents, or violent personal 
assaults like rape. PTSD is the most prevalent mental disorder arising 
from combat. People who experience stressful events often relive the 
experience through nightmares and flashbacks, have difficulty sleeping, 
and feel detached or estranged. These symptoms may occur within the 
first 4 days after exposure to the stressful event or be delayed for 
months or years. Symptoms that appear within the first 4 days after 
exposure to a stressful event are generally diagnosed as acute stress 
reaction or combat stress. If the symptoms of acute stress reaction or 
combat stress continue for more than 1 month, PTSD is diagnosed.

PTSD services are provided in VA medical facilities and VA community 
settings. VA medical facilities offer PTSD services as well as other 
services, which range from complex specialty care, such as cardiac or 
spinal cord injury, to primary care. VA's community settings include 
more than 800 community-based outpatient clinics and 206 Vet Centers. 
Community-based outpatient clinics are an extension of VA's medical 
facilities and mainly provide primary care services.[Footnote 6] Vet 
Centers offer PTSD and family counseling, employment services, and a 
range of social services to assist veterans in readjusting from wartime 
military service to civilian life. Vet Centers also function as 
community points of access for many returning veterans, providing them 
with information and referrals to VA medical facilities. Vet Centers 
were established as entities separate from VA medical facilities to 
serve Vietnam veterans, who were reluctant to access health care 
provided in a federal building. As a result, Vet Centers are not 
located on the campuses of VA medical facilities.

VA has specialized PTSD programs that are staffed by clinicians who 
have concentrated their clinical work in the area of PTSD treatment. VA 
specialized PTSD programs are located in 97 VA medical facilities and 
provide services on an inpatient and outpatient basis. VA PTSD services 
include individual counseling, support groups, and drug therapy and can 
be provided in non-specialized clinics, such as general mental health 
clinics.

Veterans who served in any conflict after November 11, 1998 are 
eligible for VA health care services for any illness, including PTSD 
services, for 2 years from the date of separation from military 
service, even if the condition is not determined to be attributable to 
military service.[Footnote 7] This 2-year eligibility includes those 
Reserve and National Guard members who have left active duty and 
returned to their units. After 2 years, these veterans will be subject 
to the same eligibility rules as other veterans, who generally have to 
prove that a medical problem is connected to their military service or 
have relatively low incomes. In July 2004, VA reported that so far 
32,684 or 15 percent of veterans who have returned from service in Iraq 
or Afghanistan, including Reserve and National Guard members, have 
accessed VA for various health care needs.

DOD and VA have formed a Seamless Transition Task Force with the goal 
of meeting the needs of servicemembers returning from Iraq and 
Afghanistan who will eventually become veterans and may seek health 
care from VA. To achieve this goal, DOD and VA plan to improve the 
sharing of information, including individual health information, 
between the two departments in order to enhance VA's outreach efforts 
to identify and serve returning servicemembers, including Reserve and 
National Guard members, in need of VA health care services. Since April 
2003, VA requires that every returning servicemember from the Iraq and 
Afghanistan conflicts who needs health care services receive priority 
consideration for VA health care appointments.[Footnote 8]

DOD Uses Two Approaches to Identify Servicemembers At Risk for PTSD: 

DOD uses two approaches to identify servicemembers who may be at risk 
of developing PTSD: the combat stress control program and the post-
deployment health assessment questionnaire. DOD's combat stress control 
program identifies servicemembers at risk for PTSD by training all 
servicemembers to identify the early onset of combat stress, which if 
left untreated, could lead to PTSD. DOD uses the post-deployment health 
assessment questionnaire to screen servicemembers for physical ailments 
and mental health issues commonly associated with deployments, 
including PTSD. The questionnaire contains four screening questions 
that were developed jointly by DOD and VA mental health experts to 
identify servicemembers at risk for PTSD.

DOD Trains Servicemembers to Identify Symptoms That Could Lead to PTSD: 

DOD's combat stress control program identifies servicemembers at risk 
for PTSD by training all servicemembers to identify the early onset of 
combat stress symptoms, which if left untreated, could lead to PTSD. 
The program is based on the principle of promptly identifying 
servicemembers with symptoms of combat stress in a combat theater, with 
the goal of treating and returning them to duty.[Footnote 9] This 
principle is consistent with the views of PTSD experts, who believe 
that early identification and treatment of combat stress symptoms may 
reduce the risk of PTSD. To assist servicemembers in the combat 
theater, teams of DOD mental health professionals travel to units to 
reinforce the servicemembers' knowledge of combat stress symptoms and 
to help identify those who may be at risk for combat stress or PTSD. 
The teams may include psychiatrists, psychologists, social workers, 
nurses, mental health technicians, and chaplains. DOD requires that the 
effectiveness of the combat stress control program be monitored on an 
annual basis.

DOD Uses the Post-Deployment Questionnaire to Identify Servicemembers 
At Risk for PTSD: 

DOD generally uses the post-deployment health assessment questionnaire, 
DD 2796, to identify servicemembers at risk for PTSD following 
deployment outside of the United States.[Footnote 10] (See app. II for 
a copy of the DD 2796.) DOD requires certain servicemembers deployed to 
locations outside of the United States to complete a DD 2796 within 30 
days before leaving a deployment location or within 5 days after 
returning to the United States.[Footnote 11]This applies to all 
servicemembers returning from a combat theater, including Reserve and 
National Guard members.

The DD 2796 is a questionnaire used to determine the presence of any 
physical ailments and mental health issues commonly associated with 
deployments, any special medications taken during deployment, and 
possible environmental or occupational exposures. The DD 2796 includes 
the following four screening questions that VA and DOD mental health 
experts developed to identify servicemembers at risk for PTSD: 

Have you ever had any experience that was so frightening, horrible, or 
upsetting that, in the past month, you; 
* have had any nightmares about it or thought about it when you did 
not want to? 
* tried hard not to think about it or went out of your way to avoid 
situations that remind you of it? 
* were constantly on guard, watchful, or easily startled? 
* felt numb or detached from others, activities, or your surroundings?

[End of table]

Once completed, the DD 2796 must be initially reviewed by a DOD health 
care provider, which could range from a physician to a medic or 
corpsman.[Footnote 12] Figure 1 illustrates DOD's process for 
completion and review of the DD 2796. The form is then reviewed, 
completed, and signed by a health care provider, who can be a 
physician, physician assistant, nurse practitioner, or an independent 
duty medical technician or corpsman. This health care provider reviews 
the completed DD 2796 to identify any "yes" responses to the screening 
questions--including questions related to PTSD--that may indicate a 
need for further medical evaluation. The review is to take place in a 
face-to-face interview with the servicemember and be conducted either 
on an individual basis, as we observed at the Army's Fort Lewis in 
Washington, or in a group setting, as we found at the Marine Corps' 
Camp Lejeune in North Carolina. If a servicemember answers "yes" to a 
PTSD question, the health care provider is instructed to gather 
additional information from the servicemember and use clinical judgment 
to determine if the servicemember should be referred for further 
medical evaluation to a physician, physician's assistant, nurse, or an 
independent duty medical technician.[Footnote 13],[Footnote 14]To 
document completion of the DD 2796, DOD requires that the 
questionnaire be placed in the servicemember's permanent medical 
record and a copy sent to the Army Medical Surveillance Activity, 
which maintains a database of all servicemembers' completed health 
assessment questionnaires.[Footnote 15]

Figure 1: DOD's Process for "Yes" Responses to PTSD Questions on DD 
2796: 

[See PDF for image] 

[End of figure] 

The National Defense Authorization Act for Fiscal Year 1998 required 
DOD to establish a quality assurance program to ensure, among other 
things, that post-deployment mental health assessments are 
completed[Footnote 16] for servicemembers who are deployed outside of 
the United States. Completion of the DD 2796 is tracked as part of this 
quality assurance program.[Footnote 17] DOD delegated responsibility 
for developing procedures for the required quality assurance program to 
each of its uniform services. The uniform services have given unit 
commanders the responsibility to ensure completion of the DD 2796 by 
all servicemembers under their command. To ensure the DD 2796 is 
completed, one DOD official we interviewed told us that servicemembers 
would not be granted leave to go home until the DD 2796 was completed. 
Another official told us that Reserve and National Guard members would 
not be given their active duty discharge paperwork until the DD 2796 
was completed.

VA Lacks Information Needed to Determine Whether It Can Meet an 
Increase in Demand for PTSD Services: 

VA does not have all the information it needs to determine whether it 
can meet an increase in demand for VA PTSD services. VA does not have a 
count of the total number of veterans currently receiving PTSD services 
at its medical facilities and Vet Centers. Without this information, VA 
cannot estimate the number of veterans its medical facilities and Vet 
Centers could treat for PTSD. VA could use demographic information it 
receives from DOD to broadly estimate the number of servicemembers who 
may access VA health care, including PTSD services. By assuming that 15 
percent or more of returning servicemembers will develop PTSD, VA could 
use the demographic information to broadly estimate demand for PTSD 
services. However, predicting which veterans will seek VA care and at 
which facilities is inherently uncertain, particularly given that the 
symptoms of PTSD may not appear for years.

VA Does Not Have Information on the Total Number of Veterans Currently 
Receiving PTSD Services: 

VA does not have a count of the total number of veterans currently 
receiving PTSD services at its medical facilities and Vet Centers. 
Without this information, VA cannot estimate the number of additional 
veterans its facilities could treat for PTSD. On August 27, 2004, a 
Northeast Program Evaluation Center (NEPEC) official told us that a 
count of the total number of veterans with a diagnosis of PTSD who 
receive VA services at medical facilities could be obtained from VA's 
existing database. However, this database does not include Vet Centers' 
information because this information is kept separate from the medical 
facilities' data.

VA publishes two reports that contain information on some of the 
veterans receiving PTSD services at its medical facilities. Neither 
report includes all veterans receiving PTSD services at VA medical 
facilities and Vet Centers. VA's annual capacity report, which is 
required by law,[Footnote 18] provides data on VA's most vulnerable 
populations, such as veterans with spinal cord injuries, blind 
veterans, and seriously mentally ill veterans with PTSD.[Footnote 19] 
The NEPEC annual report mainly provides data on veterans with a primary 
diagnosis of PTSD.[Footnote 20] VA has not developed a methodology that 
would allow it to count the number of veterans receiving PTSD services 
at its medical facilities and Vet Centers.

The PTSD data used in VA's annual capacity report and the data used in 
NEPEC's annual report are drawn from different--though not mutually 
exclusive--subgroups of veterans receiving PTSD services at VA's 
medical facilities. VA developed criteria that allow it to determine 
which veterans should be included in each subgroup. VA's criteria, 
which differ in each report, are based on the type and frequency of 
mental health services provided to veterans with PTSD at its medical 
facilities. (See Figure 2 for the veterans included in each of VA's 
annual reports.)

Figure 2: Veterans Included in VA's Annual Reports: 

[See PDF for image] 

Note: Analysis of VA's Fiscal Year 2002 "Maintaining Capacity to 
Provide for the Specialized Treatment and Rehabilitative Needs of 
Disabled Veterans" and NEPEC's "Long Journey Home XII Treatment of 
Posttraumatic Stress Disorder in the Department of Veterans Affairs: 
Fiscal Year 2003 Service Delivery and Performance." Examples of VA 
specialized mental health services include PTSD and substance abuse.

[A] This refers to Table E1 in Appendix E of The Long Journey Home XII 
Treatment of Posttraumatic Stress Disorder in the Department of 
Veterans Affairs: Fiscal Year 2003 Service Delivery and Performance 
Northeast Program Evaluation Center, VA Connecticut Healthcare System 
(Connecticut: April 2004).

[End of figure] 

Veterans who are receiving VA PTSD services may be counted in both 
reports, only counted in the NEPEC report, or not included in either 
report. For example, a veteran who is seriously mentally ill and has a 
primary diagnosis of PTSD is counted in both reports. On the other 
hand, a veteran who has a primary diagnosis of PTSD but is not defined 
as seriously mentally ill is counted in the NEPEC report but not in the 
capacity report. Finally, a veteran who is receiving PTSD services only 
at a Vet Center is not counted in either report.

Furthermore, both the VA OIG and VA's Committee on Care of Veterans 
with Serious Mental Illness have found inaccuracies in the data used in 
VA's annual capacity report.[Footnote 21]For example, OIG found 
inconsistencies in the PTSD program data reported by some VA medical 
facilities. OIG found that some medical facilities reported having 
active PTSD programs, although the facilities reported having no staff 
assigned to these programs. Additionally, the Committee on Care of 
Veterans with Serious Mental Illness, commenting on VA's fiscal year 
2002 capacity report, stated the data VA continues to use for reporting 
information on specialized programs are inaccurate and recommended 
changes in future reporting.[Footnote 22],, VA agreed with OIG that the 
data were inaccurate and is continuing to make changes to improve the 
accuracy of the data in its annual capacity report. VA's fiscal year 
2003 capacity report to Congress is currently undergoing review by OIG, 
which informed us that VA has not incorporated all of the changes 
necessary for OIG to certify that the report is accurate. OIG further 
stated that it will continue to oversee this process.

VA Has Information to Broadly Estimate Future Demand for PTSD Services: 

VA has information it can use to broadly estimate what the increase in 
demand for VA PTSD services may be from returning servicemembers. In 
September 2003, DOD began providing VA with demographic information on 
servicemembers returning from the Iraq and Afghanistan conflicts who 
have left active duty status and are eligible for VA health 
care.[Footnote 23] The information includes name, home address 
including zip code, branch of service, and gender.[Footnote 24] Using 
servicemembers' home zip codes could help VA predict the facilities or 
Vet Centers that could experience an increase in demand for care. By 
assuming that 15 percent or more of returning servicemembers will 
eventually develop PTSD, based on the predictions of mental health 
experts, VA could use the demographic information to broadly estimate 
the number of returning servicemembers who may need VA PTSD services 
and the VA facilities located closest to servicemembers' homes. 
However, predicting which veterans will seek VA care and at which 
facilities is inherently uncertain, particularly given that the 
symptoms of PTSD may not appear for years.

VA headquarters received demographic information from DOD in September 
2003; however, during our review we found that VA had not shared this 
information with its facilities. On July 21, 2004, VA provided this 
information to its medical facilities for planning future services for 
veterans returning from the Iraq and Afghanistan conflicts. However, VA 
did not provide the demographic information to Vet Centers. Officials 
at seven VA medical facilities told us that while the demographic 
information VA receives from DOD has limitations, it is the best 
national data currently available and would help them plan for new 
veterans seeking VA PTSD services.

Officials at six of the seven VA medical facilities we visited 
explained that while they are now able to keep up with the current 
number of veterans seeking PTSD services, they may not be able to meet 
an increase in demand for these services.[Footnote 25] In addition, 
some of the officials expressed concern about their ability to meet an 
increase in demand for VA PTSD services from servicemembers returning 
from Iraq and Afghanistan based on DOD's demographic information. 
Officials are concerned because facilities have been directed by VA to 
give veterans of the Iraq and Afghanistan conflicts priority 
appointments for health care services, including PTSD service. As a 
result, VA medical facility officials estimate that follow-up 
appointments for veterans currently receiving care for PTSD may be 
delayed. VA officials estimate the delay may be up to 90 days. Veterans 
of the Iraq and Afghanistan conflicts will not be given priority 
appointments over veterans who have a service-connected disability and 
are currently receiving services.[Footnote 26]

Conclusions: 

While the VA OIG continues to oversee VA's efforts to improve the 
accuracy of data in the capacity reports, VA does not have a report 
that counts all veterans receiving VA PTSD services. Although VA can 
use DOD's demographic information to broadly estimate demand for VA 
PTSD services, VA does not know the number of veterans it now treats 
for PTSD at its medical facilities and Vet Centers. As a result, VA 
will be unable to estimate its capacity for treating additional 
veterans who choose to seek VA's PTSD services, and therefore, unable 
to plan for an increase in demand for these services.

Recommendation for Executive Action: 

To help VA estimate the number of additional veterans it could treat 
for PTSD and to plan for the future demand for VA PTSD services from 
additional veterans seeking these services, we recommend that the 
Secretary of Veterans Affairs direct the Under Secretary for Health to 
determine the total number of veterans receiving VA PTSD services and 
provide facility-specific information to VA medical facilities and Vet 
Centers.

Agency Comments: 

In commenting on a draft of this report, VA concurred with our 
recommendation and acknowledged that more coordinated efforts are 
needed to improve its existing PTSD data. VA stated that it plans to 
aggregate, at the national level, the number of veterans receiving PTSD 
services at VA medical facilities and Vet Centers. We believe VA should 
provide these data to both its medical facilities and Vet Centers so 
they have the information needed to plan for future demand for PTSD 
services. In addition, VA provided two points of clarification. First, 
VA stated that it is in the process of developing a mental health 
strategic plan that will project demand by major diagnoses and identify 
where projected demand may exceed resource availability. VA stated that 
future revisions to the mental health strategic plan would include Vet 
Center data. Second, VA stated that it would seek additional 
information from DOD on servicemembers who have served in Iraq and 
Afghanistan to improve its provision of health care services to these 
new veterans. VA's written comments are reprinted in appendix III. DOD 
concurred with the findings and conclusions in this report and provided 
technical comments, which we incorporated as appropriate. DOD's written 
comments are reprinted in appendix IV.

As agreed with your office, unless you publicly announce its contents 
earlier, we plan no further distribution of this report until 30 days 
after its date. We will then send copies of this report to the 
Secretary of Veterans Affairs and other interested parties. We also 
will make copies available to others upon request. In addition, the 
report will be available at no charge at the GAO Web site at 
[Hyperlink, http://www.gao.gov].

If you or your staff have any questions about this report, please call 
me at (202) 512-7101. Another contact and key contributors are listed 
in appendix V.

Sincerely yours,

Signed by: 

Cynthia A. Bascetta: 
Director, Health Care--Veterans' Health and Benefits Issues: 

[End of section]

Appendixes: 

Appendix I: Scope and Methodology: 

To determine the approaches DOD uses to identify servicemembers who are 
at risk for PTSD, we reviewed directives on screening servicemembers 
deployed to locations outside of the United States, interviewed DOD 
officials, and visited a military installation for each of DOD's 
uniformed services. At each of the military installations, we discussed 
with officials the steps taken by each of the uniformed services to 
implement DOD's approaches, particularly the steps involved in 
completing the post-deployment health assessment questionnaire, DD 
2796, as it relates to PTSD. How well the uniformed services 
implemented DOD's approaches were reported in other GAO reports. The 
uniformed services included in our review were Army, Marines, Air 
Force, and Navy. We did not include the Coast Guard in this review 
because few Coast Guard servicemembers are involved in the Iraq and 
Afghanistan conflicts. The military installations visited were: Fort 
Lewis Army Base and Madigan Army Medical Center in Washington, Seymour 
Johnson Air Force Base in North Carolina, Camp Lejeune Marine Base and 
the Naval Hospital Camp Lejeune in North Carolina, and the Naval 
Medical Center San Diego in California. We also asked DOD officials 
whether they provide information to VA that could help VA plan how to 
meet the demand for VA PTSD services from servicemembers returning from 
the Iraq and Afghanistan conflicts.

To determine whether VA has the information it needs to determine 
whether it can meet an increase in demand for PTSD services, we 
interviewed PTSD experts from the National Center for PTSD established 
within VA and members of the Under Secretary for Health's Special 
Committee on PTSD.[Footnote 27] We also visited three divisions of the 
National Center for PTSD: the Executive Division in White River 
Junction, Vermont; the Education Division in Palo Alto, California; and 
NEPEC in West Haven, Connecticut to review the Center's reports on 
specialized PTSD programs.

We also reviewed VA's fiscal year 2001 and 2002 annual reports on VA's 
capacity to provide services to special populations, including veterans 
with PTSD, and NEPEC's annual reports on specialized PTSD programs to 
determine the criteria VA uses to count the number of veterans 
receiving VA PTSD services. We reviewed the findings of VA's Committee 
on Care of Veterans with Serious Mental Illness and the VA OIG, who 
have reported on the accuracy of VA's annual capacity report to 
Congress on the number of veterans receiving specialized services, 
including PTSD services. We interviewed officials from each of these 
groups to clarify their findings. We did not include data from the 
annual capacity reports because the OIG reported that the data were not 
sufficiently reliable. We also interviewed the director of NEPEC to 
discuss the information included in NEPEC's annual reports.

To determine whether VA facilities have the information needed to 
determine whether they can meet an increase in demand for PTSD 
services, we interviewed officials at 7 VA medical facilities, and 15 
Vet Centers located near the medical facilities to discuss the number 
of veterans currently receiving VA PTSD services and the impact that an 
increase in demand would have on these services. We also discussed 
DOD's demographic information with four of the seven medical facilities 
we visited. We contacted VA medical facilities located in Palo Alto and 
San Diego in California; Durham and Fayetteville in North Carolina; 
White River Junction, Vermont; West Haven, Connecticut; and Seattle, 
Washington. We also contacted Vet Centers located in Vista, San Diego, 
and San Jose in California; Raleigh, Charlotte, Greenville, Greensboro, 
and Fayetteville in North Carolina; South Burlington and White River 
Junction in Vermont; Hartford, Norwich, and New Haven in Connecticut; 
and Seattle and Tacoma in Washington.

Our work was conducted from May through September 2004 in accordance 
with generally accepted government auditing standards.

[End of section]

Appendix II: Department of Defense Post-Deployment Health Assessment 
Questionnaire DD-2796: 

[See PDF for image] 

[End of figure] 

[End of section]

Appendix III: Comments from the Department of Veterans Affairs: 

THE SECRETARY OF VETERANS AFFAIRS: 
WASHINGTON:

September 14, 2004:

Ms. Cynthia A. Bascetta: 
Director:
Health Care Team:
U. S. Government Accountability Office: 
441 G Street, NW:
Washington, DC 20548:

Dear Ms. Bascetta:

The Department of Veterans Affairs (VA) has reviewed the Government 
Accountability Office's (GAO) draft report, VA AND DEFENSE HEALTH CARE: 
More Information Needed to Determine If VA Can Meet an Increase in 
Demand for Post-Traumatic Stress Disorder Services, (GAO-04-1069). 
While we concur with GAO's recommendation, several points of 
clarification are indicated and are discussed in the enclosure.

The Department will continue efforts to refine workload estimates and 
improve coordination of PTSD-related program elements. VA appreciates 
the opportunity to comment on your draft report.

Sincerely yours,

Signed by: 

Anthony J. Principi:

Enclosure:

Enclosure:

THE DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT 
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT:

VA AND DEFENSE HEALTH CARE: More Information Needed To Determine if VA 
Can Meet an Increase in Demand for Post-Traumatic Stress Disorder 
Services (GAO-04-1069):

To help VA estimate the number of additional veterans it could treat 
for PTSD and to plan for the future demand for VA PTSD services from 
additional veterans seeking these services, we recommend that the 
Secretary of Veterans Affairs direct the Under Secretary for Health to 
determine the total number of veterans receiving VA PTSD services and 
provide facility-specific information to VA medical facilities and Vet 
Centers.

Concur - GAO reports that VA lacks the information needed to determine 
whether it can meet an increase in demand for Post-Traumatic Stress 
Disorder (PTSD) services by post-deployment veterans. Facility-
specific and Vet Center-specific data currently exist. Medical care 
utilization, including mental health care and PTSD care, is already 
analyzed at a national level. The Veterans Health Administration (VHA) 
plans to aggregate this information with Vet Center utilization data to 
provide a national report of network, medical center and Vet Center 
utilization. VHA will provide this information to GAO. Although the 
ability of this workload data to project future demand is limited, it 
will provide some assistance in estimating workload demand and resource 
readiness. Additionally, VA has developed a mental health strategic 
plan that will project demand by major diagnoses and provide capability 
for gap analysis. VHA will consider PTSD-specific workload information 
from Vet Center workload in future revisions of this demand model. 
Existing data from medical center utilization will be used on an 
interim basis until the new model completes reliability testing and 
refinement. The mental health strategic plan is under final review. 
Estimated completion date is October 31, 2004.

While VA concurs with GAO's overall conclusions and recommendation, VA 
offers the following points of clarification as an adjunct:

* The narrowly defined scope of analysis in GAO's review does not 
account for the multiple health concerns that are also associated with 
veterans who are returning from combat. PTSD treatment cannot be 
effectively addressed in isolation, and VHA's approach to treating 
post-deployment veterans focuses on all associated health concerns, not 
just PTSD. VHA acknowledges that more coordinated efforts are needed 
to consolidate and trend existing PTSD workload information. The 
complexity of problems associated with veterans' military experiences 
and post-deployment adjustment requires VA to maintain a comprehensive 
mental health and health care system.

Fundamental to VA's efforts is DoD's timely provision of demographic, 
health and exposure information to VA. DoD has supplied demographic 
data for returning veterans. VHA analyzes and trends these data 
quarterly. These data are provided to the network offices for follow-up 
outreach efforts. As GAO suggests, VHA will identify related 
demographic data requirements that might assist in determining expanded 
workload demands prior to implementing the mental health strategic 
plan. Provision of basic post-deployment health data would assist VA in 
providing health care to individual veterans and in supporting improved 
rating decisions on disability compensation claims by returning 
veterans. These data would also assist VA in better understanding and 
planning for the health problems for all returning Operations Enduring 
Freedom and Iraqi Freedom veterans. Although DoD officials have 
provided VA with useful demographics on separated veterans, DoD has not 
provided the collective electronic records from the post-deployment 
health screening, including PTSD and other mental health information. 
VA continues to seek access to these records and to strengthen the 
Department's cooperative ties with DoD mental health officials and is 
hopeful that information sharing will be expedited. Recent 
deliberations of the VA/DoD Health Executive Council to highlight 
mental health issues as a primary focus are encouraging. 

[End of section]

Appendix IV: Comments from the Department of Defense: 

OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE:
HEALTH AFFAIRS:
TRICARE MANAGEMENT ACTIVITY:

SKYLINE FIVE, SUITE 810, 
5111 LEESBURG PIKE: 
FALLS CHURCH, VIRGINIA 22041-3206:


Ms. Cynthia A. Bascetta: 
Director, Health Care-Veterans' Health and Benefits Issues:
U.S. Government Accountability Office: 
441 G Street, N.W.
Washington, DC 20548:

SEP 10 2004:

Dear Ms. Bascetta:

This is the Department of Defense (DoD) response to the Government 
Accountability Office (GAO) draft report, "VA AND DEFENSE HEALTH CARE: 
More Information Needed to Determine If VA Can Meet an Increase in 
Demand for Post Traumatic Stress Disorder Services," dated September 2, 
2004 (GAO Code 290387/GAO-04-1069).

The Department appreciates the opportunity to comment on the draft 
report and concurs with the GAO findings and conclusions.

Please direct any questions to my points of contact on this matter, Mr. 
Kenneth Cox (functional) at (703) 681-0039, ext. 3602 and Mr. Gunther 
J. Zimmerman (Audit Liaison) at (703) 681-3492, ext. 4065.

Sincerely,

Signed for: 

Richard A. Mayo, RADM, MC, 
USN Deputy Director:

Enclosures:

1. Overall Comments 
2. Technical Comments:  

[End of section]

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Marcia A. Mann, 202-512-9526: 

Acknowledgments: 

In addition to the contact named above Mary Ann Curran, Linda Diggs, 
Martha Fisher, Krister Friday, and Marion Slachta made key 
contributions to this report.

[End of section]

Related GAO Products: 

Defense Health Care: DOD Needs to Improve Force Health Protection and 
Surveillance Processes. 
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-158T]
Washington, D.C.: October 16, 2003.

Defense Health Care: Quality Assurance Process Needed to Improve Force 
Health Protection and Surveillance. 
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-1041]
Washington, D.C.: September 19, 2003.

Disabled Veterans' Care: Better Data and More Accountability Needed to 
Adequately Assess Care. 
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-57] 
Washington, D.C.: April 21, 2000.

(290387): 


FOOTNOTES

[1] Servicemembers include active duty members of the Army, Marines, 
Air Force, and Navy and members of the Reserves and National Guard. 

[2] Hoge, Charles W., MD et. al. "Combat Duty in Iraq and Afghanistan, 
Mental Health Problems, and Barriers to Care", The New England Journal 
of Medicine, 351 (2004): 13-22. 

[3] Kulka, R., et.al. Trauma and the Vietnam War Generation: Report of 
Findings from the National Vietnam Veterans Readjustment Study. (New 
York: 1990). 

[4] Previous GAO reports have addressed DOD's compliance with screening 
requirements for returning servicemembers deployed outside of the U.S.: 
GAO, Defense Health Care: Quality Assurance Process Needed to Improve 
Force Health Protection and Surveillance, GAO-03-1041 (Washington, 
D.C.: Sept. 19, 2003) and Defense Health Care: DOD Needs to Improve 
Force Health Protection and Surveillance Processes, GAO-04-158T 
(Washington, D.C.: Oct. 16, 2003).

[5] The Veterans' Health Care Act of 1984 required the establishment of 
the National Center on PTSD (now known as National Center for PTSD) as 
a research and education organization within VA. See Pub. L. No. 98-
528, § 110(c), 98 Stat. 2686, 2692 (codified at 38 U.S.C. § 1712A 
note). The Center advances the clinical care and social welfare of 
veterans through research, education, and training clinicians in the 
causes, diagnosis, and treatment of PTSD, but does not provide clinical 
care for veterans.

[6] Veterans treated at community-based outpatient clinics are included 
in the medical facility's count of veterans treated for PTSD.

[7] See 38 U.S.C. § 1710(e)(1)(D); VHA Directive 2004-017, Establishing 
Combat Veteran Eligibility. Conflicts are situations in which the 
servicemembers are subjected to danger comparable to the danger 
encountered in combat with enemy armed forces during a period of war, 
as determined by the Secretary of VA. Veterans who served on active 
duty in combat operations during a period of war after the Persian Gulf 
War will also be eligible for care under section 1710(e)(1)(D). 
Eligibility under 38 U.S.C. § 1710(e)(1)(D) does not extend, however, 
to veterans whose disabilities are found to have resulted from a cause 
other than the service described in the statute. 

[8] Servicemembers who served in the Iraq and Afghanistan conflicts do 
not have priority over veterans with service-connected disabilities.

[9] If a servicemember's symptoms persist, the servicemember is 
transferred to a medical facility where specialty care is available.

[10] The questionnaire is used to satisfy the requirement for post-
deployment mental health assessments established by the National 
Defense Authorization Act for Fiscal Year 1998. See Pub. L. No. 105-85, 
§ 765(a)(1), 111 Stat. 1629, 1826 (adding new section 1074f(b) to title 
10, United States Code).

[11] Servicemembers who are deployed for 30 or more continuous days to 
locations without permanent treatment facilities are required to 
complete DD 2796. Servicemembers who are deployed to locations with 
permanent treatment facilities are not required to complete the 
questionnaire because these locations are not high risk for 
environmental or occupational exposures.

[12] Medics and corpsmen are enlisted personnel who have been trained 
to give first aid and basic medical treatment, especially in combat 
situations. 

[13] Independent duty medical technicians are enlisted personnel who 
receive advanced training and are certified to provide treatment and 
prescribe medications within defined parameters. 

[14] Reserve and National Guard members who are referred for further 
medical evaluation may remain on active duty status until the medical 
problem is treated and resolved or the condition becomes stable.

[15] The Army has lead responsibility for DOD's medical surveillance 
and operates a centralized data repository. 

[16] See Section 765(a)(1), 111 Stat. at 1826 (codified at 10 U.S.C. § 
1074f(d)).

[17] In September 2003, we found that DOD had not established an 
effective quality assurance program and recommended that this be done. 
See GAO-03-1041.

[18] See 38 U.S. C. § 1706(b)(5).

[19] Seriously mentally ill veterans are those diagnosed with a mental, 
behavioral or emotional disorder of sufficient duration to 
substantially interfere with one or more life activities, including 
basic daily living skills such as eating, bathing, or dressing.

[20] Department of Veterans Affairs, The Long Journey Home XII 
Treatment of Posttraumatic Stress Disorder in the Department of 
Veterans Affairs: Fiscal Year 2003 Service Delivery and Performance, 
Northeast Program Evaluation Center, VA Connecticut Healthcare System 
(Connecticut: April 2004). The Northeast Program Evaluation Center, a 
division of the National Center for PTSD, monitors and evaluates the 
implementation and performance of VA's specialized PTSD programs. 

[21] The VA OIG is required to examine each of VA's annual reports on 
its specialized services, including PTSD, and submit to Congress a 
certification as to its accuracy. See 38 U.S.C. § 1706(b)(5)(C). 

[22] The Committee on Care of Severely Chronically Mentally Ill 
Veterans assesses VA's capability to meet the rehabilitation and 
treatment needs of such veterans. See 38 U.S.C. § 7321. The Committee, 
established within VA, is generally referred to as the Committee on 
Care of Veterans with Serious Mental Illness.

[23] Not all such servicemembers are eligible for VA health care. For 
example, a servicemember who has been dishonorably discharged would not 
be eligible for VA services.

[24] VA has used this information to send letters to servicemembers who 
have left active duty status, informing them of their eligibility for 
VA's health care services. 

[25] One medical facility believed it could accommodate, with the 
facility's current staffing levels, a one to two percent increase in 
additional veterans seeking PTSD services. However, it would have to 
restructure its PTSD services provided to current veterans.

[26] A service-connected disability is an injury or disease that was 
incurred or aggravated while on active military duty. 

[27] VA was required to establish a Special Committee on PTSD by the 
Veterans' Health Care Act of 1984. See Section 110(b), 98 Stat. at 2691 
(codified at 38 U.S.C. § 1712A note). Among other things, the committee 
assesses VA's care of veterans who require specialized treatment for 
PTSD.

GAO's Mission: 

The Government Accountability Office, the investigative arm of 
Congress, exists to support Congress in meeting its constitutional 
responsibilities and to help improve the performance and accountability 
of the federal government for the American people. GAO examines the use 
of public funds; evaluates federal programs and policies; and provides 
analyses, recommendations, and other assistance to help Congress make 
informed oversight, policy, and funding decisions. GAO's commitment to 
good government is reflected in its core values of accountability, 
integrity, and reliability.

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through the Internet. GAO's Web site ( www.gao.gov ) contains 
abstracts and full-text files of current reports and testimony and an 
expanding archive of older products. The Web site features a search 
engine to help you locate documents using key words and phrases. You 
can print these documents in their entirety, including charts and other 
graphics.

Each day, GAO issues a list of newly released reports, testimony, and 
correspondence. GAO posts this list, known as "Today's Reports," on its 
Web site daily. The list contains links to the full-text document 
files. To have GAO e-mail this list to you every afternoon, go to 
www.gao.gov and select "Subscribe to e-mail alerts" under the "Order 
GAO Products" heading.

Order by Mail or Phone: 

The first copy of each printed report is free. Additional copies are $2 
each. A check or money order should be made out to the Superintendent 
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 
more copies mailed to a single address are discounted 25 percent. 
Orders should be sent to: 

U.S. Government Accountability Office

441 G Street NW, Room LM

Washington, D.C. 20548: 

To order by Phone: 



Voice: (202) 512-6000: 

TDD: (202) 512-2537: 

Fax: (202) 512-6061: 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470: 

Public Affairs: 

Jeff Nelligan, managing director,

NelliganJ@gao.gov

(202) 512-4800

U.S. Government Accountability Office,

441 G Street NW, Room 7149

Washington, D.C. 20548: