J-7a DD2813 Exam Screen v1.pdf

DEPARTMENT OF DEFENSE 0MB No. 0720.0022

ACTIVE DUTY/RESERVE/GUARD/CIVILIAN FORCES DENTAL EXAMINATION

0MB apprcvaf expires Aug 31, 2016

The public ~rting burden for lllis colledlan al lnfarmatian Is estimated la average 3 minutes cf: nisponse, lndud~lhe - for l'8\llewlng lnstrudlans, searawn~ existing data 1a1JrCes, galllenn~ and maintaining dala naedad, and campleti~ and review~ tile calledlon of lnlarmatlon. Sen camments nigardi::\ s burden estimate or any ether as pad al 111 s call action al lnfarmatian, lnc:lu ,ng suggestions for nlduc:ing the burden. to the partment of lense, \Nashlnglan Headquarters SeNices, Eicacuttve eNices Oirectarate, lnformatlan Management Oillislai, 4800 Mar1< Center Drive, Alaxandr1a, VA 22350-3100 (0720-0022). Respondents lltla~d be aweni that natw lhltanding any ether provision al law, no person shal be subject la any penalty for failing to camply wtth a caDectlon cf lnformauan tt It daes net display e currenuy valid 0MB cantrol number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 136; 10 U.S.C. 1074f, DoD Directives 1404.10, 5101 .1, 5136.01, and 6490.02E; DoD Instruction 6025.19; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): To obtain Information In order to record an assessment of an Individual's dental health.

ROUTINE USE(S): Information collected may be used and disclosed generally as permitted under 45 CFR Parts 160 and 164, Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules, as Implemented by DoD 6025.18-R, the DoD Health Information Privacy Regulation. Information may also be used and disclosed In accordance with 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, which Incorporates the DoD "Blanket Routine Uses· published at http://dpclo.defense.gov/privacy/SORNs/blanket routine uses.html. Information from this system may be shared with other Federal and State agencies and civilian health care providers, as necessary, to provide medical care and treatment and to guide possible referrals.

DISCLOSURE: Voluntary; however, failure to provide the Information may result in delays in assessing your dental health needs for military service and/or for possible deployment outside the United States and its territories and possessions.

1. SERVICE MEMBER'S NAME (Last First, Middle Initial) 2. SOCIAL SECURITY NUMBER 3. BRANCH OF SERVICE

4. UNIT OF ASSIGNMENT 5. UNIT ADDRESS

6. EXAMINATION RESULTS

Dear Doctor, The individual you are examining is an Active Duty/Guard/Reserve/Civilian member of the United States Armed Forces. This member needs your assessment of his/her dental health for worldwide duty. Please mark (X) the block that best describes the condition of the member, using as a suggested minimum a clinical examination with mirror and probe, and bitewing radiographs.

This form Is meant to determine fitness for prolonged duty without ready access to dental care and Is not Intended to address the member's comerehenslve dental needs.

(1) Patient has good oral health and is not expected to require dental treatment or reevaluation for 12 months.

(2) Patient has some oral conditions, but you do not expect these conditions to result in dental emergencies within 12 months if not treated (i.e., requires prophylaxis, asymptomatic caries with minimal extension into dentin, edentulous areas not requiring immediate prosthetic treatment).

(3) Patient has oral conditions that you do expect to result in dental emergencies within 12 months if not treated.

Examples of such conditions are: (X the applicable block or specify in the space provided)

' (a) Infections: Acute oral infections., pulpal or periapical pathology, chronic oral infections, or other pathologic lesions and lesions requ[ring biopsy or awaiting biopsy report.

! (b) Carles/Restorations: Dental caries or fractures with moderate or advanced extension into dentin; defective restorations or temporary restorations that patients cannot maintain for 12 months.

(c) Missing Teeth: Edentulous areas requiring immedfate prosthodontic treatment for adequate mastication, l communication, or acceptable esthetics.

(d) Periodontal Conditions: Acute gingivitis or pericoronitis, active moderate to advanced periodontitis, periodontal abscess, progressive mucogingival condition, moderate to heavy subgingival calculus, or periodontal manifestations of systemic disease or hormonal disturbances.

(e) Oral Surgery: Unerupted, partially erupted, or malposed teeth with historical, clinical, or radiographic signs or symptoms of pathosis that are recommended for removal.

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(f) Other: Temporomandibufar dtsorders or myofasoial pain dysfunction requiring active treatment.

(4) If you selected Block (3) above, please indicate the condition(s) you identified in this patient if they appear above, or briefly describe the condition(s) below:

(5) Were X-rays consulted? I I YES I INo IF YES, DATE X-RAY WAS TAKEN (YYYYMMDD)

7. DENTISl"S NAME (Last, First, Middle Initial) 8. DENTIST'S ADDRESS (Street, City, State, 9-digit ZIP Code)

9. DENTIST'S TELEPHONE NUMBER (Include Area Code)

10. DENTIST'S SIGNATURE/STATE LICENSE NUMBER 11. DATE OF EXAMINATION (YYYYMMDD)

DD FORM 2813, OCT 2013 PREVIOUS EDITION IS OBSOLETE. Adobe Prafe111Cnal X

Attachment J-7a DD2813 Dental Exam Screen

ADDP3

HT9402-20-R-0001 Attachment J-7a