RHRP-II Attachment 27 - Army PDHRA Referral Form

STATEMENT OF MEDICAL EXAMINATION AND DUTY STATUS

For use of this form, see AR 600-8-4, the proponent agency is DCS, G-1.

INJURY IS CONSIDERED TO HAVE BEEN INCURRED IN LINE OF

6. INDIVIDUAL WAS

d.

c.

b.

a.

12. THE FOLLOWING DISABILITY MAY RESULT

IS NOT LIKELY TO RESULT IN A CLAIM AGAINST THE GOVERNMENT FOR FUTURE MEDICAL CARE.

13. BLOOD ALCOHOL

TEST MADE

14. NO. OF MG ALCOHOL/100 ML BLOOD

25. MODE OF TRANSPORTATION

WAS NOT UNDER THE INFLUENCE OF

33. DATE

27. DISTANCE INVOLVED 28. NORMAL TIME FOR TRAVEL

17. TYPED OR PRINTED NAME OF ATTENDING

PHYSICIAN OR PATIENT ADMINISTRATOR

16. DATE

WAS NOT MENTALLY SOUND

WAS NOT INCURRED IN LINE OF DUTY.

10. NATURE AND EXTENT OF

7. NAME OF HOSPITAL OR TREATMENT FACILITY

4. ORGANIZATION AND STATION

a. DATE

5. ACCIDENT INFORMATION

2. SSN 3. GRADE

SECTION I - TO BE COMPLETED BY ATTENDING PHYSICIAN OR HOSPITAL PATIENT ADMINISTRATOR

8. HOUR AND DATE ADMITTED 9. HOUR AND DATE EXAMINED

DISEASEINJURY RESULTING IN DEATH (Explain)

OUT PATIENT

DEAD ON ARRIVALADMITTED

CIVILIAN MILITARY

11. MEDICAL OPINION:

(Attach Psychiatric evaluation if appropriate).

DA FORM 2173, OCT 1972

22. INDIVIDUAL WAS ON

type of duty missed, hours of duty, and how it did or did not interfere with performance)

19. DUTY STATION

b. TO

20. HOUR AND DATE OF ABSENCE

18. SIGNATURE

SECTION II - TO BE COMPLETED BY UNIT COMMANDER OR UNIT ADVISER

YES

PRESENT FOR DUTY

ABSENT WITH AUTHORITY:

ABSENT WITHOUT AUTHORITY

TEMPORARY PERMANENT PARTIAL PERMANENT TOTAL NO

ON PASS ON LEAVE

YES NO

a. BEGAN b. ENDED

23. HOUR AND DATE TRAINING

ACTIVE DUTY ACTIVE DUTY FOR TRAINING

INACTIVE DUTY TRAINING

24. RESERVIST DIED OF INJURIES RECEIVED PROCEEDING

34. 35. SIGNATURE

26. HOUR BEGINNING TRAVEL

31. FORMAL LINE OF DUTY INVESTIGATION REQUIRED 32.

29. DUTY STATUS AT TIME OF DEATH IF DIFFERENT FROM TIME OF INJURY OR CONTRACTION OF DISEASE

YES NO

PRESENT FOR DUTY ABSENT WITH AUTHORITY ABSENT WITHOUT AUTHORITY

DIRECTLY TO TRAINING DIRECTLY FROM TRAINING

REPLACES DA FORM 2173, 1 JUN 66, WHICH IS OBSOLETE.

WAS INDIVIDUAL

WAS INDIVIDUAL

WASINJURY

INJURY IS

YES NO

TYPED NAME AND GRADE OF UNIT COMMANDER OR

UNIT ADVISER

APD PE v2.01ES

ALCOHOL

DUTY (Not applicable on deaths)

15. DETAILS OF ACCIDENT OR HISTORY OF DISEASE (how, where, when)

THRU: (Include ZIP Code) TO: (Include ZIP Code) FROM: (Include ZIP Code)

b. PLACE (City and State)

1. NAME OF INDIVIDUAL EXAMINED (Last, First, and Middle Initial)

BASIS FOR OPINION:

21. ABSENCE WITHOUT AUTHORITY MATERIALLY INTERFERRED WITH THE PERFORMANCE OF MILITARY DUTY (Explain in Item 30

a. FROM

30. DETAILS OF ACCIDENT - REMARKS (If additional space is needed, continue on reverse) (Attach inclosures as necessary)

DRUGS (Specify) :