Statement of Principles concerning osteonecrosis (Reasonable Hypothesis) (No. 13 of 2020)

The Statement of Principles presents several core concepts that govern how osteonecrosis will be assessed for the purposes of veterans’ and defence force compensation claims.

1. Disease definition and coding. Osteonecrosis is defined clinically in s6(2) , bone death due to loss of blood supply , and explicitly includes dysbaric osteonecrosis. The instrument notes ICD‑10‑AM codes that typically map to osteonecrosis (K10.2, M87, M90.3-M90.5) but clarifies that the operative meaning is the clinical definition (s6(2)-(4)). The instrument therefore ties clinical description to coding without making the code determinative.

2. Reasonable hypothesis threshold. The RMA states that “at least one” of the listed factors must exist as a minimum before “it can be said that a reasonable hypothesis has been raised connecting osteonecrosis … with the circumstances of a person’s relevant service” (s8). The instrument thus supplies a catalogue of factors and quantitative/temporal thresholds that constitute the RMA’s medical view of what minimally supports a service connection.

3. Temporal relationships and “clinical onset”. Many factors are tied to specific windows relative to the clinical onset of osteonecrosis. For example, trauma or surgery to the affected bone must occur within two years before clinical onset (s8(1)); certain drug exposures require the last dose to be within specified windows (s8(16), s8(17), s8(25)(g)-(h)); decompression sickness or hyperbaric exposure are limited to five years before clinical onset (s8(21)-(22)), and childbirth is limited to one year before clinical onset (s8(24)). The instrument repeatedly uses the phrase “clinical onset of osteonecrosis” but does not define it in Schedule 1; the timing of clinical onset therefore becomes a pivotal, fact‑sensitive issue in claims.

4. Enumerated biological, pharmacological and exposure factors. Section 8 lists 26 discrete factors. They include mechanical insults (trauma, fracture, joint dislocation), behavioural exposures (smoking measured in pack‑years, alcohol quantified in grams per week), medical conditions (solid organ malignancy, autoimmune disorders from a specified list, haematological diseases from a specified list, chronic renal failure), hypercoagulable states (an enumerated list in Schedule 1), infectious and local pathological states (local infections, osteomyelitis), and treatment or exposure histories (specified glucocorticoid therapy thresholds, specific medications such as bevacizumab/denosumab/testosterone, organ/stem cell transplants, radiotherapy involving the affected site, internal radium deposition, decompression sickness/hyperbaric exposure, pregnancy/childbirth). A group of additional jaw‑specific factors are set out in s8(25) and Schedule 1 defines additional drug categories (osteoclast inhibitors, antiangiogenic agents).

5. Interplay with other Statements. If a listed factor refers to an injury or disease already covered by another Statement of Principles, that other Statement applies according to its terms (s10). The RMA thus builds an interlocking set of Statements; a single clinical feature may trigger cross‑reference to another Statement for detailed treatment.

6. Relationship to relevant service. Presence of a factor alone is insufficient: it must be “related to the relevant service rendered by the person” (s9(1)). This requires linking the factor to the person’s operational, peacekeeping, hazardous, British nuclear test defence service, or warlike/non‑warlike service, as those categories are defined in Schedule 1’s definition of “relevant service”.

7. Special rule for inability to obtain management. Factor 26 (inability to obtain appropriate clinical management) is constrained by s9(2): it applies only to material contribution or aggravation where the osteonecrosis existed or was contracted before or during, but did not arise out of, the person’s relevant service. This isolates the use of service‑period lack of access as an aggravating cause rather than a primary causal claim for conditions arising out of service.

Overall, the instrument operationalises a medical test into a discrete list of factors and thresholds that claimants and decision‑makers must map against a person’s medical record and service history. The Schedule supplies precise clinical cutoffs and drug/dose equivalences that convert narrative histories into deterministic thresholds (for example the glucocorticoid cumulative dose and minimum average rate table in Schedule 1).

This Statement of Principles affects three overlapping groups directly and several actors indirectly.

Directly affected individuals:

• Veterans and former members (and their dependants for certain entitlements) who lodge claims under sections of the VEA and MRCA specified in s4, namely claims to which s120A of the VEA or s338 of the MRCA apply. The instrument itself applies to claims captured by those statutory provisions (s4). The Schedule defines “relevant service” and therefore sets the categories of service that can engage the Statement (Schedule 1 - definition of relevant service).
• Current and former members of Peacekeeping Forces and members of the Forces where their service falls within the definitions in Schedule 1. The RMA’s view in s7 explicitly references veterans, members of Peacekeeping Forces, and members of the Forces under the VEA or MRCA.

Medical and administrative decision‑makers:

• Decision‑makers processing claims under the VEA and MRCA. The Statement provides the RMA’s view on which medical/scientific factors meet the minimal “reasonable hypothesis” threshold (s7, s8). Those decision‑makers will use the Statement as a standard to assess whether the medical evidence, aligned with service history, is sufficient to meet the statutory claim thresholds specified in the VEA/MRCA provisions to which the instrument applies (s4).
• Medical practitioners who provide reports and records for claims will be asked to supply the specific data the Statement requires: dates of clinical onset, substance use histories quantified per Schedule 1 definitions (pack‑years, alcohol in grams/week), medication regimens with cumulative doses, radiotherapy fields, transplant dates, diving/hyperbaric exposure logs, and evidence of inability to obtain care.

Indirectly affected parties:

• Defence and veteran advocacy organisations that support claim preparation; they must advise claimants on gathering the specific evidence the Statement demands.
• Courts and tribunals that review decisions under the VEA or MRCA: although the Statement itself is an administrative medical view, it feeds into contested assessments of causation that may be litigated under the statutory appeals framework (the instrument however does not itself set appeal processes).

Who bears evidential burdens and costs:

• Claimants effectively bear the burden of adducing the medical records and evidence satisfying an enumerated factor and its timing relative to clinical onset, and demonstrating the factor’s relation to relevant service (s8, s9). Evidence collection may entail obtaining comprehensive hospital, surgical, dental, pharmacy, radiotherapy, transplant and dive/hyperbaric records, quantified substance‑use histories, and specialist reports that compute glucocorticoid cumulative dose per Schedule 1. These are practical and documentary burdens on claimants.

Who decides:

• The RMA sets the Statement (s3). The RMA’s view in s7 is the medical basis; however, decision‑making on entitlements under the VEA or MRCA rests with the statutory decision‑makers established by those Acts. The Statement therefore informs but does not itself adjudicate individual claims.

Geographical and temporal scope:

• The Statement applies to claims made under the specified VEA/MRCA provisions from its commencement date (23 March 2020) forward; the instrument does not purport to be retrospective or amend earlier Statements, although the effect of its commencement date will depend on the operative statutory rules governing claims (s2, s4).

This instrument itself is not a statute that imposes criminal sanctions; rather it sets medical criteria that affect statutory rights under the VEA and MRCA. The key duties and rights that arise from the instrument are therefore evidentiary and administrative.

Rights created or shaped by the instrument:

• Claimants have the right to have their claim assessed against the RMA’s Statement of Principles. The Statement specifies what medical or exposure factors the RMA considers minimally sufficient to raise a reasonable hypothesis that osteonecrosis (or death from osteonecrosis) is related to relevant service (s8). If a claimant can establish an enumerated factor that is related to his or her relevant service (s9(1)), that will meet the RMA’s threshold for a reasonable hypothesis under this Statement.

Duties or evidentiary expectations placed on claimants:

• Claimants are expected to present evidence that at least one of the factors in s8 exists and was related to relevant service (s8, s9). The Statement contains a number of technical measurement duties embedded in its definitions: compute pack‑years per Schedule 1 (pack‑years equals 20 tailor‑made cigarettes per day for a year, and one tailor‑made cigarette approximates one gram of tobacco); quantify alcohol consumption in grams per week using the Australian standard of ten grams per standard drink (note to s8(4)); document cumulative glucocorticoid dosing and average dose per Schedule 1 thresholds; supply dates for clinical onset and for exposures or treatments within the listed windows (trauma within two years, decompression exposure within five years, etc.). These are practical duties in the sense they define the documentary standards that evidence must meet for the RMA’s threshold to be satisfied.

Duties of decision‑makers and administrative actors:

• Decision‑makers applying the VEA and MRCA are to take the RMA’s Statement into account when deciding whether a reasonable hypothesis exists. Section 10 establishes a duty to defer to other Statements of Principles if a listed factor refers to another injury or disease for which another Statement is in force, with that other Statement’s factors applying in accordance with its terms. This creates a framework obligation to reconcile inter‑Statement references.

Limitations and conditional rights:

• The right to rely on factor 26, inability to obtain appropriate clinical management, is limited: it applies only to material contribution to or aggravation of osteonecrosis where the osteonecrosis was suffered or contracted before or during, but did not arise out of, the person’s relevant service (s9(2)). In effect, relief via factor 26 is conditional on the pre‑existence or concurrent onset of the disease and on a causal narrative that pinpoints lack of access during service as material contribution or aggravation.

Administrative discretion and evidentiary standards:

• The instrument specifies a “reasonable hypothesis” threshold for causal connection (s8) which is an evidentiary concept; it does not, within this text, specify the procedural standard or burden of proof for final entitlements under the VEA/MRCA. The RMA’s Statement therefore supplies medical thresholds which the statutory decision‑maker must apply within the broader statutory decision process, potentially exercising discretion as to whether the medical evidence and the service history taken together satisfy the statutory entitlement criteria.

Rights to cross‑reference other Statements:

• Section 10 gives claimants and decision‑makers the right and duty to apply other Statements where a factor refers to an injury/disease covered elsewhere. This can alter which criteria are determinative for a particular aspect of a claim.

Overall, the Statement imposes documentary and factual duties on claimants to quantify exposures and medications against specific numerical thresholds and temporal windows; it grants claimants the right to have those factors treated as a sufficient medical basis for a reasonable hypothesis when they are also related to relevant service.

The Statement of Principles instrument does not itself create criminal offences, civil penalties, or an enforcement regime. It is a medical‑scientific statement made under subsection 196B(2) of the VEA (s3) and functions as an evidentiary guide used in the statutory claims process under the VEA and MRCA. The instrument contains no express provisions imposing fines, imprisonment, or regulatory sanctions for non‑compliance.

Enforcement in practice occurs through administrative decision‑making under the VEA and MRCA:

• The RMA’s Statement provides evaluative criteria for decision‑makers assessing entitlement under the VEA/MRCA. If a claimant fails to establish an enumerated factor or fails to show that a factor is related to their relevant service as required by s9(1), that claimant may be denied the entitlement being sought under the VEA or MRCA. Denial of statutory benefits is the primary administrative consequence arising from failure to meet the Statement’s thresholds.
• Where a factor references an injury or disease governed by another Statement, s10 requires application of that other Statement’s factors “as in force from time to time”, which can alter the outcome. An administrative decision that relies on or misapplies the RMA’s Statement can be subject to internal merits review or judicial review under the appeal mechanisms provided in the VEA/MRCA framework, but the instrument itself does not set or describe those avenues.

Evidence and proof consequences:

• The Statement sets out precise thresholds that convert clinical facts into determinative indicators for a reasonable hypothesis. For example, failure to document glucocorticoid exposure at or above the Schedule 1 cumulative dose and average daily rate will usually mean s8(16) is not satisfied. Such evidentiary shortcomings will therefore be enforced in the sense of being grounds for a negative claim outcome.

No financial penalties in the instrument:

• There is no provision in this Statement that prescribes monetary penalties for false statements, forged records, or other misconduct. Any such penalties would derive from other laws (for example fraud statutes) or the broader VEA/MRCA processes; the Statement does not itself specify them.

Implementation and compliance monitoring:

• The RMA does not attach explicit compliance audits or reporting requirements to this Statement. The practical enforcement mechanism is administrative review of claims by the tribunal or agency charged with assessing VEA/MRCA entitlements, applying the RMA’s Statement as medical evidence. The Statement therefore establishes a normative standard which administrative decision‑makers enforce by accepting or rejecting claims, rather than by imposing statutory penalties.

In short, the instrument is an evidentiary and definitional tool for administrative adjudication. Its “enforcement” is operationalised by decision outcomes under the VEA/MRCA claims system; the instrument itself contains no penalty provisions.

The Statement is expressly made under subsection 196B(2) of the VEA (s3), and it applies to claims falling within s120A of the VEA or s338 of the Military Rehabilitation and Compensation Act 2004 (MRCA) (s4). The instrument therefore sits as a medical‑technical input into the statutory schemes contained in those Acts. The Statement does not itself amend those Acts or create standalone statutory rights outside the VEA/MRCA framework.

Key cross‑references and interactions in the text:

• Application to statutory claim provisions. Section 4 limits the instrument’s application to claims to which s120A of the VEA or s338 of the MRCA applies. The text does not restate the procedural or burdens‑of‑proof rules contained in those sections; those remain governed by the respective Acts. Practitioners should therefore treat the Statement as a specialised evidentiary input for those statutory claim frameworks rather than a self‑executing entitlement.

• Relationship to other Statements of Principles. Section 10 provides a direct mechanism for cross‑Statement interaction: where a factor in this Statement refers to an injury or disease that is the subject of another Statement determined under s196B(2) of the VEA, the factors in that other Statement apply “in accordance with the terms of that Statement as in force from time to time” (s10). This creates an interlocking system in which overlapping medical conditions are governed by whichever Statement is operative for that specific disease. In practice, this requires claim handlers to identify references within s8 that point to other Statements and to apply the contemporary terms of those Statements.

• Use of ICD‑10‑AM coding. Section 6(3)-(4) references ICD‑10‑AM codes (Tenth Edition, effective 1 July 2017) and ties the clinical concept of osteonecrosis to specific diagnostic codes while reiterating that the clinical definition in s6(2) governs application. This interaction means that coding systems used in hospitals and health records will often correlate with the condition in administrative decisions, but the RMA’s clinical definition remains primary.

• Overlap with medical‑practice standards and professional reporting. The Statement’s technical thresholds (for example, glucocorticoid cumulative doses in Schedule 1, or the measurement of pack‑years) require medical practitioners to translate their clinical records into the numerical thresholds specified. This imports clinical and prescribing records from ordinary medical practice into the statutory claims context. The Statement therefore interfaces with professional obligations under health‑regulation frameworks insofar as practitioners must provide accurate dosing histories and diagnostic timelines.

• No express conflict‑resolution clause. The Statement does not specify how conflicts between its content and other statutory provisions should be resolved beyond s10’s cross‑reference mechanism. The VEA and MRCA contain their own procedural and interpretive rules; for example, statutory definitions of “relevant service” in Schedule 1 are cross‑referenced rather than redefined here. The absence of an express supremacy provision means that practitioners must apply the Statement within the interpretive rules of the governing statutes.

• Interaction with records and privacy laws. The Statement anticipates extensive use of medical records, pharmacy records, and possibly service logs (diving/hyperbaric exposure) to substantiate factors and timings. The instrument does not address privacy law or freedom‑of‑information protocols; these remain governed by separate legislation (not reproduced here). Claimants must therefore navigate privacy and records disclosure regimes to assemble evidence under this Statement.

• Temporal application and amendments. Section 2 sets a commencement date (23 March 2020). Section 10’s reference to other Statements “as in force from time to time” anticipates that other Statements may be amended; practitioners must therefore check the operative versions of any cross‑referenced Statements at the time of decision.

In practice, the Statement operates as a specialised medical annex to the VEA/MRCA claims framework. It interacts with other laws and instruments mainly by requiring evidence gathering and by cross‑referencing other Statements of Principles; the wider statutory and regulatory environment (privacy laws, medical practice obligations, etc.) governs how that evidence is obtained and used.

The instrument itself is presented as “Statement of Principles concerning OSTEONECROSIS (Reasonable Hypothesis) (No. 13 of 2020)” with a date of 28 February 2020 and an explicit commencement date of 23 March 2020 (front page and s2). It is made under subsection 196B(2) of the VEA (s3). The text provided contains no internal amendments or subsequent modification notes; it is presented as the operative instrument at the time of production.

What the instrument records about its identity and timing:

• Instrument title and number: No. 13 of 2020 (front page).
• Date on instrument: 28 February 2020 (front page).
• Commencement: 23 March 2020 (s2).

Absence of within‑document amendment log:

• The instrument does not contain an amendment schedule, transitional provisions, repeals, or a record of prior versions. The text reproduces the Statement and Schedule as adopted at the date on its face.

Implications for practitioners:

• Because s10 cross‑references other Statements “as in force from time to time”, practitioners must check for amendments to those other Statements that could affect the application of factors listed here. This Statement itself, as provided, has no recorded amendments; practitioners should confirm whether the RMA has published subsequent revisions post‑commencement (those would not be visible in this instrument).

How to record change in practice:

• If an amendment is later made to this Statement, the RMA would typically publish the amended Statement and specify its commencement details. That process is not detailed in the instrument itself. The user of this analysis should therefore treat this text as the original No. 13 of 2020 version and verify against the RMA’s public register for any later modifications.

No retrospective amendment clause:

• The instrument does not include a clause addressing retrospective operation. The stated commencement date (s2) is the only temporal marker in the instrument; retrospective application would be governed by the VEA and MRCA and any transition rules that those Acts impose.

In short, the document as supplied contains a single dated version with a stated commencement date and no internal record of amendment. Practitioners must check external sources (the RMA register or the Commonwealth Gazette) for any subsequent amendments after 23 March 2020.

The Statement itself does not cite any case law, does not record judicial decisions about its content, and contains no litigation record. The instrument is a technical medical Statement made under subsection 196B(2) of the VEA (s3) and does not include references to court determinations, tribunal decisions, or precedents.

What this means for users:

• There is no litigation history contained in the instrument to signal how courts or tribunals have interpreted these specific factors, temporal windows or definitions. Any judicial consideration of this Statement or its application to particular claims would exist outside the instrument and would need to be researched in case law databases, tribunal decisions and published judgments if relevant to a particular claim. The instrument itself provides the RMA’s medical view but does not record adjudicative responses to that view.

Points of potential contestability that often generate litigation (based on the instrument’s content):

• The measurement and dating of “clinical onset”. The Statement repeatedly anchors factors to the clinical onset of osteonecrosis, a fact‑intensive determination that can be contested in adjudication. The instrument does not define “clinical onset” (Schedule 1 does not contain that term), so disputes over when clinical onset occurred may be a focal point for contest in appeals.
• Application of numerical thresholds. The Schedule’s specific numerical thresholds (for example cumulative glucocorticoid doses or pack‑years calculations) are deterministic. Disputes may arise about how conversions are calculated or whether recorded prescriptions equate to actual intake.
• Relationship to relevant service. The instrument requires that any factor be related to relevant service (s9(1)). Litigation may arise over the sufficiency of evidence linking the factor to the service episode, or over whether a claimed inability to obtain management during service satisfies s9(2) for factor 26.

Absent from the instrument:

• There are no named cases, no appellate history and no citations to judicial interpretations. Practitioners should therefore treat the instrument as a primary administrative source that may be subject to later judicial analysis; they must search external legal databases for any decisions that have since interpreted or applied this Statement in specific factual contexts.

This Statement contains multiple technical traps and evidentiary pitfalls that frequently affect claim outcomes. The following are concrete “gotchas” drawn from the instrument’s text and definitions.

1. “Clinical onset” is central but undefined. Nearly every temporal window is expressed relative to the “clinical onset of osteonecrosis” (see s8 and the various time‑limits). Schedule 1 does not define “clinical onset”. Consequently, the date that constitutes clinical onset is often contested and pivotal. Practitioners should not assume a diagnosis date on a chart equals clinical onset without corroborating evidence.

2. Presence of a factor is necessary but not sufficient: relationship to relevant service is required. Section 8 requires at least one factor exist; section 9(1) requires that the factor be “related to the relevant service rendered by the person”. Having a qualifying factor unrelated to any relevant service episode does not meet the Statement’s test. The evidential task is twofold: prove the factor and link it to service.

3. Factor 26 is tightly constrained. The “inability to obtain appropriate clinical management” factor applies only where the osteonecrosis was suffered or contracted before or during, but did not arise out of, the person’s relevant service (s9(2)). It cannot be used to convert lack of treatment during service into a primary causative service event where the condition arose as a result of service activities.

4. Glucocorticoid thresholds are precise and require dose calculations. Schedule 1 sets cumulative and average dose thresholds (for example prednisolone cumulative 3 650 mg and minimum average rate 10 mg/day). Practitioners must compute cumulative exposure and average dose accurately across regimens and convert other glucocorticoids to equivalent doses using the table in Schedule 1. Failure to compute equivalencies or to document actual patient adherence can be dispositive.

5. Pack‑years calculation and tobacco equivalence. Schedule 1 equates one pack‑year to 20 tailor‑made cigarettes per day for a year, approximates one tailor‑made cigarette to one gram of tobacco, and quantifies pack‑years in weight terms (7.3 kg per pack‑year). These conversions can produce unexpected numerical results when assessing cigar or pipe use. Documentation must support the precise calculation.

6. Alcohol quantification uses grams per week and the Australian standard. Section 8(4) sets a minimum average consumption of 160 grams of alcohol per week for at least six months within the one year before clinical onset. The instrument’s note states the Australian standard of 10 grams per standard drink applies. Practitioners must convert reported consumption into grams and produce verifying records or corroborated histories.

7. Time windows for specific drug exposures and therapies are narrow. For example bevacizumab, denosumab or testosterone must have been taken within 30 days before clinical onset (s8(17)); osteoclast inhibitors or antiangiogenic agents require six months’ treatment with last dose within two years for jaw osteonecrosis (s8(25)(g)-(h)). Missing those windows or lacking prescription/administration records can lead to failure of the factor to meet the threshold.

8. Hyperbaric and decompression definitions are technical. Schedule 1 defines hyperbaric exposure by several discrete criteria (for example breath‑hold diving to at least 5 metres for at least one minute on at least ten occasions within a continuous six month period, or underwater diving with compressed air to depths of at least 15 metres for continuous periods of at least 30 minutes). Casual references to “diving” without logs that match these criteria will not meet the factor test.

9. Jaw osteonecrosis has separate and additional criteria. Section 8(25) lists jaw‑specific factors including dental infections within three months, acute trigeminal zoster within six months, diabetes mellitus at clinical onset, anaemia, substance use disorder involving cocaine, and exposure to osteoclast inhibitors/antiangiogenics with specific duration and recency thresholds. Practitioners must identify the anatomical site of osteonecrosis and apply the jaw subset where relevant.

10. Cross‑reference to other Statements can change the applicable test. If a listed factor refers to an injury or disease covered by another Statement, section 10 requires that other Statement’s terms to apply as in force. Failing to identify or apply the current version of that other Statement may produce incorrect assessments.

11. ICD‑10‑AM codes are referenced but not dispositive. Section 6(3) notes relevant ICD‑10‑AM codes but clarifies the operative clinical definition is in s6(2). Reliance on a code alone without clinical evidence that matches the definition may be insufficient.

12. Documentation burdens and fragmented records. Many factors require records from disparate sources , dental records, radiotherapy planning and field documentation, pharmacy dispensing logs, dive logs, transfusion/transplantation registries, dialysis or GFR history, and psychiatric/substance use records. The administrative burden and practical difficulty of obtaining these records across public and private providers can be a decisive hurdle.

13. Chronic renal failure and dyslipidaemia thresholds are clinical. Schedule 1 provides precise GFR and lipid thresholds. For chronic renal failure, evidence of dialysis or transplant or sustained GFR <15 mL/min/1.73 m2 for three months is required. For dyslipidaemia, specific lipid numbers are listed. Absent laboratory documentation, a claimant may fail the factor.

14. The instrument does not state evidentiary hierarchy. The Statement sets medical thresholds but does not specify whether certain forms of evidence (e.g. contemporaneous records versus retrospective affidavits) are preferred. Decision‑makers will need to assess weight and probative value, which may produce inconsistent outcomes.

Practitioners should plan evidence collection around these technical thresholds and temporal windows and be alert that small errors in date calculations, dose conversion or consumption quantification can decide outcomes.

This section sets out a practical compliance checklist, mapped to the Statement’s requirements, for claimants, advocates and medical/reporting practitioners. The objective is to produce the evidence necessary to establish at least one factor in s8 and to show that the factor was related to relevant service (s9(1)). The list presumes the claimant seeks to maximise the RMA’s reasonable hypothesis threshold.

1. Establish and document “clinical onset”.

• Collate medical records that identify first symptoms, first clinical diagnosis, imaging dates (MRI, CT, X‑ray), surgical notes and specialist documentation that can anchor the date of clinical onset.
• If there is ambiguity, obtain a specialist report that explains why a particular date should be treated as clinical onset and sets out the clinical reasoning and evidence chain.

2. Identify the affected anatomical site.

• Confirm whether the osteonecrosis concerns the jaw (s8(25)) or other bones. Jaw osteonecrosis triggers a different subset of factors and thresholds. Produce dental charts, oral surgery notes, periodontology records and imaging as appropriate.

3. Map each potential factor in s8 to documentary evidence.

• Trauma/surgery (s8(1)-(2)): produce operative reports, emergency department records, imaging, fracture clinic notes demonstrating the event occurred within two years of clinical onset.
• Smoking (s8(3)): prepare a lifetime smoking history with pack‑years computed per Schedule 1 (one pack‑year = 20 cigarettes/day for one year; one cigarette ≈ 1 gram of tobacco). Obtain corroborating GP notes, clinic letters and, if available, smoking cessation program records.
• Alcohol (s8(4)): quantify consumption in grams per week (Australian standard 10 grams per drink), and obtain contemporaneous primary care notes, admission records, or specialist assessments documenting consumption for at least six months within the prior year.
• Solid organ malignancy, autoimmune disorders, haematological disease (s8(5)-(7)): supply oncology, immunology and haematology records, pathology reports and treatment histories that demonstrate the condition existed at clinical onset.
• Hypercoagulable states (s8(8) and Schedule 1): provide laboratory reports, haematology consultant notes, and thrombophilia testing results.
• Chronic renal failure (s8(9) and Schedule 1): produce serial eGFR or creatinine results, dialysis logs, nephrology correspondence, or transplant records demonstrating GFR <15 mL/min/1.73 m2 for at least three months or ongoing dialysis.
• Dyslipidaemia (s8(10) and Schedule 1): produce lipid panels showing the thresholds in Schedule 1.
• Cushing syndrome, pancreatitis, HIV, local infections, osteomyelitis (s8(11)-(15)): provide relevant specialised medical, pathology and microbiology evidence.
• Glucocorticoid therapy (s8(16) and Schedule 1): compile full prescribing records, dispensed medication history, dosages, routes, dates and compute cumulative dose and average daily rate using Schedule 1 equivalency table. If prescriptions are incomplete, gather hospital discharge summaries and specialist letters to substantiate dosing.
• Specific drugs and agents (s8(17), s8(25)(g)-(h)): document dates and duration of bevacizumab, denosumab, testosterone, osteoclast inhibitors (eg bisphosphonates), or antiangiogenics. Pharmacy dispensing records and hospital infusion logs are essential due to narrow recency windows (30 days or two years as specified).
• Transplants and radiotherapy (s8(18)-(19)): obtain transplant operative records and radiotherapy planning documents showing that the affected site was in the radiation field.
• Radium deposition, decompression sickness, hyperbaric exposure (s8(20)-(22) and Schedule 1): provide service records, dive logs, hyperbaric chamber entries, decompression sickness treatment records, and any military exposure logs.
• Pregnancy and childbirth (s8(23)-(24)): produce obstetric records confirming pregnancy at clinical onset or childbirth within one year prior.
• Jaw‑specific factors (s8(25)): prepare dental records showing periodontitis/dental pulp and apical disease within three months, pathology confirming syphilitic palatine gumma, zoster records within six months for trigeminal involvement, diabetes control logs, haemoglobin levels for anaemia, and substance use disorder documentation for cocaine.
• Inability to obtain appropriate clinical management (s8(26) and s9(2)): for cases where the claimant relies on this factor, document the pre‑existence of osteonecrosis, contemporaneous requests for care, formal denial or lack of availability of treatment during relevant service episodes, and evidence that lack of management materially contributed to aggravation. Remember s9(2) limits this to situations where the condition was suffered or contracted before or during, but did not arise out of, the relevant service.

4. Demonstrate linkage to relevant service.

• For each factor, produce service records, deployment orders, ship logs, unit medical records, or other military documentation that links the exposure, treatment history, or lack of care to the person’s relevant service. Schedule 1’s definition of “relevant service” lists operational, peacekeeping, hazardous, British nuclear test defence, warlike or non‑warlike service; ensure the specific category claimed is supported by service documentation.

5. Cross‑reference other Statements where indicated.

• Check whether any factor refers to an injury or disease governed by another Statement of Principles. If so, obtain and apply the most current version of that Statement per s10. For example, if a factor invokes a coded disease governed elsewhere, apply that Statement’s factors to the aspect of the claim as required.

6. Prepare specialist medico‑legal reports.

• Obtain specialist reports that compute the required thresholds (eg cumulative glucocorticoid dosing, pack‑year calculations, GFR trajectories), explain clinical onset with reference to imaging and symptoms, and give a professional opinion on whether the factor is likely related to the person’s relevant service in accordance with s9(1).

7. Preserve a clear chain of contemporaneous records.

• Because the Statement heavily privileges dates and measurable thresholds, contemporaneous records (hospital notes, lab reports, pharmacy dispensations, dental charts, dive logs) carry greater evidentiary weight than retrospective recollection. Obtain copies of all contemporaneous documentation where possible.

8. For borderline or missing evidence, obtain treating practitioner corroboration.

• When complete records are unavailable, secure treating clinician affidavits or declarations that explain gaps, reconstruct dosing histories, and attest to clinical timelines. These will be weighed against the absence of contemporaneous documentation.

9. Account for conversion and equivalence calculations.

• When converting between glucocorticoids, ensure equivalence calculations follow Schedule 1’s table and explain the conversion methodology in reports. For pack‑years and alcohol grams, show the arithmetic used and reference the Schedule 1 notes.

10. Maintain awareness of commencement date and other Statements.

• The instrument commenced on 23 March 2020 (s2). Confirm whether a claim’s relevant events and the version of related Statements fall within or beyond this instrument’s operative period. Apply s10 to integrate other Statements “as in force from time to time”.

11. Anticipate appeals and maintain the evidence file.

• Given that adjudicators may disagree on clinical onset or the sufficiency of evidence, keep a comprehensive file that anticipates likely lines of challenge, including alternate dating evidence and attested histories.

12. Consider privacy and record access processes early.

• Because evidence may come from military, public and private providers, initiate record requests early, comply with identity verification and consent requirements, and if necessary, use the statutory mechanisms under the VEA/MRCA to obtain records.

Following this checklist aligns evidence collection and reporting with the Statement’s technical demands and reduces the risk that a claim will fail due to procedural or evidentiary omissions.