IN THE CASE OF: BOARD DATE: 3 October 2017 DOCKET NUMBER: AR20160004637 BOARD VOTE: _________ _______ ________ GRANT FULL RELIEF ________ ________ ________ GRANT PARTIAL RELIEF ________ ________ ________ GRANT FORMAL HEARING ___x____ ___x____ ___x____ DENY APPLICATION 2 Enclosures 1. Board Determination/Recommendation 2. Evidence and Consideration IN THE CASE OF: BOARD DATE: 3 October 2017 DOCKET NUMBER: AR20160004637 BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined the overall merits of this case are insufficient as a basis for correction of the records of the individual concerned. ___________x______________ CHAIRPERSON I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case. IN THE CASE OF: BOARD DATE: 3 October 2017 DOCKET NUMBER: AR20160004637 THE BOARD CONSIDERED THE FOLLOWING EVIDENCE: 1. Application for correction of military records (with supporting documents provided, if any). 2. Military Personnel Records and advisory opinions (if any). THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE: 1. The applicant requests, in effect, correction of his DD Form 214 (Certificate of Release or Discharge from Active Duty) to show he was honorably discharged based on physical disability. 2. The applicant states that he was in good health when he entered military service. The medical condition that led to his separation from the U.S. Army was the result of his military service. a. He states that his service was "uncharacterized" because it was cut short due to his injuries. However, his service should be characterized as "honorable" or as "general, under honorable conditions." He acknowledges that he failed his Army Physical Fitness Test (APFT) and that this was a basis for his separation. However, he passed two APFTs before being placed on physical profile due to his medical condition. b. He also states the authority and narrative reason for separation shown on his DD Form 214 indicate that he was not physically fit to perform his duties. However, he was medically cleared before he entered military service. He adds that he sustained an injury after he started basic combat training (BCT), which prevented him from continuing his training. 3. The applicant provides a DD Form 293 (Application for the Review of Discharge from the Armed Forces of the United States) and copies of his: * entrance medical examination documents * a medical record * APFT results * DA Form 4707 (Entrance Physical Standards Board (EPSBD) Proceedings), page 1 only * DD Form 214 * Department of Veterans Affairs (VA) benefit letters COUNSEL'S REQUEST, STATEMENT, AND EVIDENCE: 1. Counsel requests, in effect, correction of the applicant's DD Form 214 to show he was honorably discharged based on physical disability. 2. Counsel defers to the applicant. 3. Counsel forwards the applicant's application with enclosures. CONSIDERATION OF EVIDENCE: 1. A DD Form 2807-1 (Report of Medical History), prepared by the applicant on 23 October 2008, shows no reported medical or physical problems, except for one surgery with the note, "I was told to go to the hospital by my family doctor for my appendix, which was removed (20 May 2001)." 2. A DD Form 2808 (Report of Medical Examination), prepared by the examining physician on 23 October 2008, in pertinent part, shows in: * item 74 (Examinee/Applicant), is qualified for service * item 75 (PULHES): 111111 * item 77 (Summary of Defects and Diagnoses), no entries (i.e., is blank) 3. The applicant enlisted in the U.S. Army Reserve (USAR) on 7 November 2008 for a period of 8 years. He further enlisted in the Regular Army on 31 December 2008 and entered active duty for a period of 5 years and 29 weeks. 4. A Moncrief Army Community Hospital, Magnetic Resonance Imaging (MRI) report, dated 29 January 2009, shows: * Reason for Order: "[Applicant] 28 year old male with pain in neck and low back for 2 weeks after falling from top bunk onto back. Pain has been consistently 8 [on a scale of] 10 with very little relief from conservative [sic] patient. Patient also reports 'shooting' radicular symptoms on right side to foot with certain positions. MRI to assess for disc pathology." * "Impression: Focal central to left parcentral disc protrusion at L5/S1 causing mild stenosis of the left lateral recess/transiting left S1 nerve root. 5. Two DA Forms 705 (APFT Scorecards) show the applicant: * passed the APFT on 13 and 19 January 2009 with scores of 226 and 242, respectively * was on profile for the APFT administered on 31 January, and also on 10, 16, and 24 February 2009 6. A DA Form 4707, dated 11 February 2009, shows an EPSBD considered the applicant's medical records, laboratory findings, and medical examinations. a. It shows in: * History of EPTS [Existed Prior To Service] Condition: "The patient is a 28 year old male here for EPTS evaluation of severe back pain. Soldier had a prior back injury about two years ago which was exacerbated during BCT to the point that Soldier cannot complete required training." * Diagnosis: Mid Back Pain * Profile and Assignment Limitations: PULHES: 112111 – Profile Mid Back Pain (724.1) from 10 February 2009 to 10 March 2009 b. The examining physicians recommended the applicant be separated from the U.S. Army for failure to meet medial procurement standards in accordance with (IAW) Army Regulation (AR) 40-501 (Standards of Medical Fitness), chapter 2 (Physical Standards for Enlistment, Appointment, and Induction), paragraph 2-29g. c. The EPSBD also shows on: * 12 February 2009, the medical authority noted "Retention Is Not Practical" and he approved the EPSBD proceedings * 24 February 2009, the applicant was informed of the findings, concurred with the EPSBD proceedings, and requested discharge without delay * 24 February 2009, the unit commander recommended the applicant be discharged from the Army d. On 26 February 2009, the applicant acknowledged that he was advised of the basis for the contemplated action to separate him under the provisions of (UP) AR 635-200 (Active Duty Enlisted Administrative Separations), chapter 5 (Separation for Convenience of the Government), paragraph 5-11, based on separation of personnel who did not meet procurement medical fitness standards. (1) He was afforded the opportunity to consult with counsel and indicated he did not desire to consult with military or civilian counsel. (2) He elected not to submit statements in his own behalf. (3) He indicated he understood that, if the recommendation for separation was approved, he may receive an honorable or an entry-level separation with an uncharacterized discharge. (4) The applicant placed his signature on the document. 7. On 28 February 2009, the separation authority approved the applicant's separation with issuance of an uncharacterized discharge. 8. The applicant's DD Form 214 shows he entered active duty on 31 December 2008 and he was discharged on 5 March 2009. He had completed 2 months and 5 days of net active service during this period. It also shows in: * item 24 (Character of Service), "Uncharacterized" * item 25 (Separation Authority): AR 635-200, paragraph 5-11 * item 26 (Separation Code): "JFW" (Failed Medical/Physical/Procurement Standards) * item 28 (Narrative Reason for Separation): "Failed Medical/Physical/ Procurement Standards" * item 21a (Signature of Member Being Separated), the applicant digitally signed the document 9. On 20 August 2014, the applicant submitted an application to the Army Discharge Review Board (ADRB) requesting a change to the characterization of his discharge. On 18 November 2015, the ADRB determined that he was properly and equitably discharged. His request for a change in the character and/or reason of his discharge was denied. 10. In support of his application the applicant provided additional documents not previously considered. a. A DD Form 293 (Application for the Review of Discharge from the Armed Forces of the United States). Based on his request (i.e., medical discharge), his request does not fall under the purview of the ADRB. b. He provided copies of letters and rating decisions from the VA Cleveland Regional Office, Cleveland, OH. The documents show, in pertinent part, that he was granted service connected compensation for: * degenerative disc disease of the lumbosacral spine (rated 20%) effective 6 March 2009 * sciatica, right lower extremity (rated 20%) effective 15 December 2010 11. In the processing of this case, an advisory opinion was obtained from the Army Review Boards Agency (ARBA) medical staff, dated 30 March 2017. a. The ARBA Senior Medical Advisor reviewed the applicant's military personnel records and electronic medical records. (1)  He noted the applicant's first clinic visit for low back pain was on 22 January 2009 (with onset of pain 4 days prior). He denied recent past medical history of significant injury. He was diagnosed with facet syndrome with lower back and neck pain. (2) On 23 January 2009, he received a physical therapy evaluation for low back and neck pain after falling off his bunk 5 days earlier. (3) On 4 February 2009, in a clinic visit for lumbar spine assessment of lower back pain, the applicant indicated it was "secondary to falling off of bunk." The applicant indicated he would obtain copies of his civilian medical records. On 5 February 2009, Dr. P__ S____ sent a release of information for the applicant's civilian medical records. (4) A clinical reevaluation on 10 February 2009, along with a review of the applicant's civilian medical records, revealed the applicant had a back injury about 2 years prior, which was exacerbated during BCT to the point that the applicant could not complete the required training. (5) The EPSBD Proceedings, dated 11 February 2009, documented the history of the EPTS condition. (6)  The senior medical advisor summarized the VA rating decisions. b. He noted that the applicant reported falling off of a bunk 4 days prior to his 22 January 2009 clinic visit, which would have been 18 January 2009. He also noted that the applicant passed his APFT on 19 January 2009 with a score of 242 total points (out of a possible 300 points). c. The ARBA Senior Medical Advisor found the applicant did not meet medical accession standards for history of EPTS (non-disclosed) lower back injury IAW AR 40-501, chapter 2, and following the provisions set forth in AR 635-40 (Physical Evaluation for Retention, Retirement, or Separation) that were applicable to the applicant's era of service. d. He also found the applicant met medical retention standards for right hand injury IAW AR 40-501, chapter 3 (Medical Fitness Standards for Retention and Separation, Including Retirement), and IAW AR 635-40 that were applicable to the applicant's era of service. e. The ARBA Senior Medical Advisor concluded that the applicant's medical conditions were duly considered during his medical separation processing. He found no evidence of a medical disability or condition which would support a change to the character or reason for the applicant's administrative discharge. 12. On 3 April 2017, the applicant was provided a copy of the ARBA advisory opinion to allow him the opportunity to submit comments or a rebuttal. 13. On 13 April 2017, the applicant provided his response. He stated that his pre-service civilian chiropractor reported no injury or abnormality in his findings. He summarized the notes of his clinic visits of 22 and 23 January 2009 and the results of his 30 January 2009 MRI. He noted that the EPSBD reported "these conditions correlate with mechanism of injury and point tenderness." He added the VA found that he had a bone density that was 30% higher than the average person his age and this rules out potential bone loss as a cause for the L2 wedging. He states, "In conclusion, these conditions could not have occurred prior to enlistment and support that these injuries did occur after [he] fell from his bunk." REFERENCES: AR 635-200 sets forth the basic authority for the separation of enlisted personnel. a. Chapter 5, paragraph 5-11, provides that Soldiers who were not medically qualified under procurement medical fitness standards when accepted for enlistment or who became medically disqualified under these standards prior to entry on active duty or active duty for training (ADT) for initial entry training, may be separated. Such conditions must be discovered during the first 6 months of active duty and will result in an EPSBD, which must be convened within the Soldier's first 6 months of active duty. b. Chapter 3 (Character of Service/Description of Service) provides in: (1) paragraph 3-7a, an honorable characterization may be awarded to a Soldier upon completion of his/her period of enlistment or period for which called or ordered to active duty or ADT, or where required under specific reason for separation, unless an entry-level status separation (uncharacterized) is warranted; and (2) paragraph 3-7b, a general discharge is a separation from the Army under honorable conditions. When authorized, it is issued to a Soldier whose military record is satisfactory, but not sufficiently meritorious to warrant an honorable discharge. c. Section II (Terms) of the glossary states that entry-level status for Reserve Soldiers begins upon enlistment in the USAR or Army National Guard of the United States and, for Soldiers ordered to ADT for one continuous period, it terminates 180 days after beginning training. DISCUSSION: 1. The applicant contends his records should be corrected to show he was honorably discharged or discharged under honorable conditions based on an unfitting physical condition because he sustained an injury during BCT that resulted in his uncharacterized discharge. 2. Records show the applicant entered active duty on 31 December 2008. a. On 22 January 2009, he reported to the medical clinic with pain in his neck and low back after falling from a bunk onto his back 4 days earlier. He received medical treatment, including physical therapy, and (with his authorization) the applicant's civilian medical records were released to Army medical personnel. b. His civilian medical records revealed that he had a back injury about 2 years prior. Army medical officials determined that his prior back injury was aggravated by his fall from the bunk and exacerbated during training to the point that the applicant could not complete BCT. 3. An EPSBD was convened within 6 weeks of the applicant entering active duty and found his condition medically disqualifying under procurement medical fitness standards. The board noted the applicant's EPTS back injury in the EPSBD proceedings. The applicant concurred with the EPSBD proceedings and requested discharge. Prior to the applicant completing 180 days of active service, the separation authority directed the applicant be separated from the Army. The regulatory guidance states that an entry-level status Soldier's separation will be uncharacterized. 4. The applicant's administrative separation under the provisions of AR 635-200, paragraph 5-11, based on being not medically qualified under procurement medical fitness standards prior to entry on active duty was in compliance with all requirements of law and applicable regulations with no indication of procedural errors which would have jeopardized his rights. In addition, the type of discharge directed, narrative reason, and character of service shown on the applicant's DD Form 214 are appropriate and correct. //NOTHING FOLLOWS// ABCMR Record of Proceedings AR20150000953 Enclosure 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS ABCMR Record of Proceedings (cont) AR20160004637 2 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 1 ABCMR Record of Proceedings (cont) AR20160004637 8 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 2