dd2766.pdf

DD FORM 2766, AUG 2023 Page 1 of 4CUI (when filled in)

CUI (when filled in)

Controlled by: DHA CUI Category: PRVCY, HLTH

LDC: FEDCON

POC: dha.ncr.bus-ops.mbx.dha-formsmanagement@health.mil

TOTAL FORCE HEALTH READINESS FLOWSHEET

(This form is subject to the Privacy Act of 1974 - Use DD Form 2005)

PRIVACY ACT STATEMENT

AUTHORITIES: Public Law 104-191, Health Insurance Portability and Accountability Act of 1996; 10 U.S.C. Chapter 55, Medical and Dental Care; DoD Manual (DoDM) 6025.18, Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs; and E.O. 9397 (SSN).

PURPOSE: To collect patient information necessary to determine the patient’s readiness to participate in a military deployment.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, these records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: Collected information may be shared with entities including the Departments of Health and Human Services, Veterans Affairs, and other Federal, State, local, or foreign government agencies, or authorized private business entities. Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD.

Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, healthcare operations, and the containment of certain communicable diseases.

For a full listing of the applicable Routine Uses for this system, refer to the applicable SORN.

APPLICABLE SORN: EDHA 07, “Military Health Information System,” (June 15, 2020, 85 FR 36190) https://dpcld.defense.gov/Portals/49/Documents/Privacy/ SORNs/DHA/EDHA-07.pdf

DISCLOSURE: Voluntary. However, failure to provide the information requested may result in delays in assessing your dental health needs for military service and/or for possible deployment.

1. ALLERGIES

a. MEDICATION ALLERGIES b. OTHER ALLERGIES

2. HEALTH CONDITIONS

a. DEPLOYMENT LIMITING HEALTH CONDITIONS b. OTHER HEALTH CONDITIONS/MEDICAL EQUIPMENT REQUIREMENTS

3. MEDICATIONS 4. SUPPLEMENTS 5. HOSPITALIZATIONS 6. SURGERIES

7. COUNSELING

SAFE SEX/FAMILY PLANNING DATE

CONTRACEPTIVE COUSELING (Pre-Deployment) DATE

TRAVEL DATE

SICKLE CELL TRAIT (SCT) DATE

OTHER DATE

LIVING WILL/DATE FILED:

8. OCCUPATIONAL HISTORY/RISK

a. PRP YES NO

b. AUOF YES NO

c. FLYING STATUS YES NO

d. DIVE/SUBMARINER YES NO

e. OTHER: YES NO If other, specify:

INDIVIDUAL’S IDENTIFICATION (Use this space for mechanical imprint) RECORDS MAINTAINED AT:

INDIVIDUAL’S NAME

LAST FIRST M.I.

SEX

MALE

FEMALE

STATUS RANK/GRADE DEPT/SERVICE

ORGANIZATION DoD EIN/SSN DATE OF BIRTH https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/DHA/EDHA-07.pdf https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/DHA/EDHA-07.pdf

DD FORM 2766, AUG 2023 Page 2 of 4CUI (when filled in)

TOTAL FORCE HEALTH READINESS FLOWSHEET

9. FAMILY HISTORY (Service Members Only) (M = Mother, F = Father, S = Sibling, MGM = Maternal Grandmother, MGF = Maternal

Grandfather, PGM = Paternal Grandmother, PGF = Paternal Grandfather)

a. CANCER (Specify)

b. CARDIOVASCULAR DISEASE (Specify)

c. DIABETES (Specify)

d. MENTAL ILLNESS/CHEMICAL DEPENDENCY (Specify)

e. OTHER (Specify)

10. SCREENING EXAMS (N = Normal, AB = Abnormal, NA = Not Indicated per USPSTF or Service Policy)

a. TEST b. LAST/DATE c. N/AB d. RESULT b. DATE c. N/AB d. RESULT b. DATE c. N/AB d. RESULT

(1) WEIGHT

(2) HEIGHT

(3) BLOOD PRESSURE

(4) CHOLESTEROL

(5) ASCVD RISK SCORE

(6) HEARING

(7) ORAL/DENTAL

(8) EYE/VISION

(9) PAP SMEAR

(10)

(11)

11. IMMUNIZATIONS (Enter date for each dose as ddmmyyyy. Where applicable enter titer date and Medical Immune exemption as “MI –ddmmyyyy”. Enter type of immunization above date in split boxes for lines e, g, l, o.)

a. Hep A / Titer

b. Hep B / Titer

c. Twinrix

d. MMR / Titer

e. Varicella / Titer

f. Td or Tdap

g. Polio

h. Influenza (NH or SH)

i. COVID-19

j. Yellow Fever

k. Meningococcal ACWY

l. Japanese Encephalitis

m. Typhoid (Vivotif or Typhim

VI)

n. Rabies

o. Anthrax

p. Smallpox (ACAM or Jynneos)

q. Other:

r. Other:

s. PPD or IGRA (Enter mm or result and date)

(1a) mm/result

(1b) DATE

(2a) mm/result

(2b) DATE

(3a) mm/result

(3b) DATE

(4a) mm/result

(4b) DATE

(5a) mm/result

(5b) DATE

(6a) mm/result

(6b) DATE

DoD EIN/SSN NAME

DD FORM 2766, AUG 2023 Page 3 of 4CUI (when filled in)

TOTAL FORCE HEALTH READINESS FLOWSHEET

12. READINESS

a. DNA/DATE b. BLOOD TYPE/DATE/RESULT c. RH / DATE / RESULT: d. SICKLE CELL SCREEN/ DATE/RESULT:

e. G6PD (Glucose-6-phosphate dehydrogenase) DATE QUALITY QUANTITY

f. PHA (DD3024) DATE (1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6)

g. DENTAL EXAM

(1) DATE / CLASS (2) DATE / CLASS (3) DATE / CLASS (4) DATE / CLASS

h. PERMANENT PROFILE

CHANGE/WAIVER?

(1) DATE/LENGTH OF WAIVER (2) P: (3) U: (4) L: (5) H: (6) E: (7) S:

DEPLOYMENT WAIVERS:

(1) DATE TYPE (2) DATE TYPE

i. GLASSES/GASMASK Rx:

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

j. HEARING AIDS/

BATTERIES

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

HEARING AID TYPE: BATTERY TYPE REQUIRED FOR HEARING AID:

k. HEARING PROTECTION

DEVICE (HPD)

SINGLE HPD TYPE: DUAL HPD TYPE: ENHANCED COMMUNICATION PROTECTION:

l. HIV Test

(1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

13. DEPLOYMENT HEALTH (DH)

a. LOCATION CCMD

b. LOCATION COUNTRY

c. DH REQUIREMENTS

COMPLETED (1) DATE (2) DATE (3) DATE (4) DATE (5) DATE (6) DATE

(1) RECORD REVIEW

(2) PRE-DHA (DD2795)

(3) WALKING BLOOD BANK

SCREENED: Y N

ELIGIBLE: Y N

SCREENED: Y N

ELIGIBLE: Y N

SCREENED: Y N

ELIGIBLE: Y N

SCREENED: Y N

ELIGIBLE: Y N

SCREENED: Y N

ELIGIBLE: Y N

SCREENED: Y N

ELIGIBLE: Y N

(4) ANAM

(5) PRE-DEPLOYMENT

SERUM

(6) MHA IN THEATER

(DD2978)

(7) PDHA (DD2796)

(8) MHA REDEPLOYMENT

(DD2978)

(9) POST-DEPLOYMENT

SERUM

(10) SHPE/SHA (if required)

(11) PDHRA (DD2900)

(12) DMHA4 (DD2978/3024)

(13) DMHA5 (DD2978/3024)

d. FORCE HEALTH

PROTECTION RX

ITEM DOSE QUANTITY ISSUED ISSUE DATE

DoD EIN/SSN NAME

DD FORM 2766, AUG 2023 Page 4 of 4CUI (when filled in)

TOTAL FORCE READINESS FLOWSHEET

(Continuation Sheet)

OTHER (Test, Exam, etc.) FREQ DATE RESULTS/NOTES

REMARKS

INDIVIDUAL’S IDENTIFICATION (Use this space for mechanical imprint) RECORDS MAINTAINED AT:

INDIVIDUAL’S NAME

LAST FIRST M.I.

SEX

MALE

FEMALE

STATUS RANK/GRADE DEPT/SERVICE

ORGANIZATION DoD EIN/SSN DATE OF BIRTH

DRAFT

SAMPLE

DD FORM 2766, AUG 2023

Page of CUI (when filled in) Document classification when filled in is CUI CUI (when filled in) Document classification when filled in is CUI Controlled by: DHA CUI Category: PRVCY, HLTH

LDC: FEDCON

POC: dha.ncr.bus-ops.mbx.dha-formsmanagement@health.mil

DD FORM 2766, AUG 2023

Page of CUI (when filled in) Document classification when filled in is CUI CUI (when filled in) Document classification when filled in is CUI

DD FORM 2766, AUG 2023

Page of CUI (when filled in) Document classification when filled in is CUI CUI (when filled in) Document classification when filled in is CUI

TOTAL FORCE HEALTH READINESS FLOWSHEET

(This form is subject to the Privacy Act of 1974 - Use DD Form 2005)

PRIVACY ACT STATEMENT

AUTHORITIES: Public Law 104-191, Health Insurance Portability and Accountability Act of 1996; 10 U.S.C. Chapter 55, Medical and Dental Care; DoD Manual (DoDM) 6025.18, Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs; and E.O. 9397 (SSN).

PURPOSE: To collect patient information necessary to determine the patient’s readiness to participate in a military deployment.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, these records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: Collected information may be shared with entities including the Departments of Health and Human Services, Veterans Affairs, and other Federal, State, local, or foreign government agencies, or authorized private business entities. Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, healthcare operations, and the containment of certain communicable diseases. For a full listing of the applicable Routine Uses for this system, refer to the applicable SORN.

APPLICABLE SORN: EDHA 07, “Military Health Information System,” (June 15, 2020, 85 FR 36190) https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/DHA/EDHA-07.pdf DISCLOSURE: Voluntary. However, failure to provide the information requested may result in delays in assessing your dental health needs for military service and/or for possible deployment.

1. ALLERGIES

a. MEDICATION ALLERGIES

b. OTHER ALLERGIES

2. HEALTH CONDITIONS

a. DEPLOYMENT LIMITING HEALTH CONDITIONS

b. OTHER HEALTH CONDITIONS/MEDICAL EQUIPMENT REQUIREMENTS

3. MEDICATIONS

4. SUPPLEMENTS

5. HOSPITALIZATIONS

6. SURGERIES

7. COUNSELING

SAFE SEX/FAMILY PLANNING

DATE

CONTRACEPTIVE COUSELING (Pre-Deployment)

DATE

TRAVEL

DATE

SICKLE CELL TRAIT (SCT)

DATE

OTHER

DATE

LIVING WILL/DATE FILED:

8. OCCUPATIONAL HISTORY/RISK

a. PRP

b. AUOF

c. FLYING STATUS

d. DIVE/SUBMARINER

e. OTHER:

If other, specify:

INDIVIDUAL’S NAME

SEX

TOTAL FORCE HEALTH READINESS FLOWSHEET

9. FAMILY HISTORY (Service Members Only) (M = Mother, F = Father, S = Sibling, MGM = Maternal Grandmother, MGF = Maternal Grandfather, PGM = Paternal Grandmother, PGF = Paternal Grandfather)

a. CANCER (Specify)

b. CARDIOVASCULAR DISEASE (Specify)

c. DIABETES (Specify)

d. MENTAL ILLNESS/CHEMICAL DEPENDENCY (Specify)

e. OTHER (Specify)

10. SCREENING EXAMS (N = Normal, AB = Abnormal, NA = Not Indicated per USPSTF or Service Policy)

a. TEST

b. LAST/DATE

c. N/AB

d. RESULT

b. DATE

c. N/AB

d. RESULT

b. DATE

c. N/AB

d. RESULT

(1) WEIGHT

(2) HEIGHT

(3) BLOOD PRESSURE

(4) CHOLESTEROL

(5) ASCVD RISK SCORE

(6) HEARING

(7) ORAL/DENTAL

(8) EYE/VISION

(9) PAP SMEAR

(10) (11)

11. IMMUNIZATIONS (Enter date for each dose as ddmmyyyy. Where applicable enter titer date and Medical Immune exemption as “MI –ddmmyyyy”. Enter type of immunization above date in split boxes for lines e, g, l, o.)

a. Hep A / Titer

b. Hep B / Titer

c. Twinrix

d. MMR / Titer

e. Varicella / Titer

f. Td or Tdap

g. Polio

h. Influenza (NH or SH)

i. COVID-19

j. Yellow Fever

k. Meningococcal ACWY

l. Japanese Encephalitis

m. Typhoid (Vivotif or Typhim VI)

n. Rabies

o. Anthrax

p. Smallpox (ACAM or Jynneos)

q. Other:

r. Other:

s. PPD or IGRA (Enter mm or result and date)

TOTAL FORCE HEALTH READINESS FLOWSHEET

12. READINESS

e. G6PD (Glucose-6-phosphate dehydrogenase)

f. PHA (DD3024)

g. DENTAL EXAM

h. PERMANENT PROFILE CHANGE/WAIVER?

DEPLOYMENT WAIVERS:

i. GLASSES/GASMASK Rx:

j. HEARING AIDS/BATTERIES

k. HEARING PROTECTION DEVICE (HPD)

l. HIV Test

13. DEPLOYMENT HEALTH (DH)

a. LOCATION CCMD

b. LOCATION COUNTRY

c. DH REQUIREMENTS COMPLETED

(1) DATE

(2) DATE

(3) DATE

(4) DATE

(5) DATE

(6) DATE

(1) RECORD REVIEW

(2) PRE-DHA (DD2795)

(3) WALKING BLOOD BANK

SCREENED:

ELIGIBLE:

SCREENED:

ELIGIBLE:

SCREENED:

ELIGIBLE:

SCREENED:

ELIGIBLE:

SCREENED:

ELIGIBLE:

SCREENED:

ELIGIBLE:

(4) ANAM

(5) PRE-DEPLOYMENT SERUM

(6) MHA IN THEATER (DD2978)

(7) PDHA (DD2796)

(8) MHA REDEPLOYMENT (DD2978)

(9) POST-DEPLOYMENT SERUM

(10) SHPE/SHA (if required)

(11) PDHRA (DD2900)

(12) DMHA4 (DD2978/3024)

(13) DMHA5 (DD2978/3024)

d. FORCE HEALTH PROTECTION RX

ITEM

DOSE

QUANTITY ISSUED

ISSUE DATE

TOTAL FORCE READINESS FLOWSHEET

(Continuation Sheet) OTHER (Test, Exam, etc.)

FREQ

DATE

RESULTS/NOTES

INDIVIDUAL’S NAME

SEX

9.0.0.2.20120627.2.874785 DD Form 2766, "TOTAL FORCE HEALTH READINESS FLOWSHEET"