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VA Form 10-10176 Environmental Hazard Registry (E H R) Worksheet (Working Template)

VA Form 10-10176 Environmental Hazard Registry (E H R) Worksheet (Working Template) 2025

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The document is a working template for the Environmental Hazard Registry (EHR) Worksheet, which collects information on health issues affecting Veterans deployed in various conflicts. It outlines the required demographic and exposure data, including military service details, health assessments, and potential environmental hazards such as Agent Orange and ionizing radiation. The form emphasizes voluntary participation while noting that failure to provide information may affect registry enrollment. It also includes privacy statements regarding the handling of personal data.

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Click ‘Get Form’ to open the VA Form 10-10176 in our platform.
Begin by filling out the Demographics section. Enter your last name, first name, middle name, date of birth, and address details including city, state, and zip code.
In the Military Related Exposures section, indicate any exposures you are seeking evaluation for by selecting the appropriate options and providing start and end dates along with service location.
Complete the Social History section by answering questions about physical activity, tobacco use, alcohol consumption, and illicit substance use. Be sure to provide detailed remarks where necessary.
Proceed to the Self-Assessment of Health section. Rate your health status and list any current diagnoses or symptoms related to your registry exam.
Finally, review all entered information for accuracy before saving or submitting your completed form through our editor.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the hardest VA claim to get?

What is the Hardest VA Claim to Get? Mental Health Conditions (e.g., PTSD, Depression) Sleep Apnea. Tinnitus and Hearing Loss. Military Sexual Trauma (MST) Chronic Pain Without a Clear Diagnosis.

What is the VA environmental registry?

VAs health registry evaluation is a free, voluntary medical assessment for Veterans who may have been exposed to certain environmental hazards during military service.

What does VA actually stand for?

U.S. Department of Veterans Affairs (VA) The Department of Veterans Affairs (VA) runs programs benefiting veterans and members of their families.

What are the symptoms of VA toxic exposure?

Toxicants in burn pit smoke may affect the skin, eyes, respiratory and cardiovascular systems, gastrointestinal tract and internal organs. Acute effects include eye irritation and burning, coughing and throat irritation, breathing difficulties, and skin itching and rashes.

What does the VA consider toxic exposure?

Toxic exposure refers to a veterans contact with harmful substances during military service that can lead to chronic health problems. The VA acknowledges that many veterans have been exposed to toxic substances, including Agent Orange, burn pits, and industrial chemicals.

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