PWS Att 3 - Medical Examination.pdf

PDF 808 KB Posted Jan 21, 2025

Attached to: Medical Services NIOSH Morgantown, WV
Solicitation number: 75D30125Q00070
Issued by: Department of Health and Human Services Centers for Disease Control and Prevention Office of Acquisition Services

About this file

Written by GovTribe AI · Jan 22, 2025

This is DD Form 2808, Report of Medical Examination, which is used to obtain medical data for determining medical fitness for enlistment, induction, appointment and retention for applicants and members of the Armed Forces. The form consists of three pages that capture comprehensive medical examination details including clinical evaluations, laboratory findings, measurements, and physical profiles.

The form includes sections for basic demographic information, complete physical examination findings across 43 clinical categories, laboratory test results, vision and hearing assessments, dental evaluation, and physical profile (PULHES) ratings. Key components include spaces to document vital signs, urinalysis, HIV testing, drug screening, audiometer results, and vision testing. The form requires signatures from examining physicians, dentists, and reviewing authorities. This appears to be an attachment referenced in a solicitation for medical services at NIOSH Morgantown, likely used to standardize medical examination documentation requirements.

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REPORT OF MEDICAL EXAMINATION

1. DATE OF EXAMINATION

(YYYYMMDD)

3. LAST NAME - FIRST NAME - MIDDLE NAME

(SUFFIX)

2. SOCIAL SECURITY NUMBER

6. GRADE

4. HOME ADDRESS (Street, Apartment Number, City, State and ZIP Code) 5. HOME TELEPHONE

NUMBER

(Include Area Code)

7. DATE OF BIRTH

(YYYYMMDD)

8. AGE 9. SEX

Female

Male

10.a. RACIAL CATEGORY (X one or more)

White

Black or African American

American Indian or Alaska Native

12. AGENCY (Non-Service Members Only) 13. ORGANIZATION UNIT AND UIC/CODE11. TOTAL YEARS GOVERNMENT

SERVICE

a. MILITARY b. CIVILIAN

16. NAME OF EXAMINING LOCATION, AND ADDRESS

(Include ZIP Code)

14.a. RATING OR SPECIALTY (Aviators Only) b. TOTAL FLYING TIME

44. NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 73 and use additional sheets if necessary.)

DoD exception to SF 88 approved by ICMR, August 3, 2000.

PREVIOUS EDITION IS OBSOLETE.

Asian

c. LAST SIX MONTHS

15.a. SERVICE

Army

Navy

Marine Corps

Air Force

Active Duty

Reserve

National Guard

c. PURPOSE OF EXAMINATION

Enlistment

Commission

Retention

Separation

Medical Board

Retirement

U.S. Service Academy

ROTC Scholarship Program

Other

Nor-mal

Ab-norm NE

17. Head, face, neck, and scalp

18. Nose

19. Sinuses

20. Mouth and throat

22. Drums (Perforation)

23. Eyes - General (Visual acuity and refraction under items 61 - 63)

24. Ophthalmoscopic

25. Pupils (Equality and reaction)

26. Ocular motility (Associated parallel movements, nystagmus)

21. Ears - General (Int. and ext. canals/Auditory acuity under item 71)

27. Heart (Thrust, size, rhythm, sounds)

28. Lungs and chest (Include breasts)

29. Vascular system (Varicosities, etc.)

30. Anus and rectum (Hemorrhoids, Fistulae) (Prostate if indicated)

31. Abdomen and viscera (Include hernia)

32. External genitalia (Genitourinary)

33. Upper extremities

34. Lower extremities (Except feet)

35. Feet (See Item 35 Continued)

36. Spine, other musculoskeletal

37. Identifying body marks, scars, tattoos

38. Skin, lymphatics

39. Neurologic

40. Psychiatric (Specify any personality deviation)

41. Pelvic (Females only)

42. Endocrine

43. DENTAL DEFECTS AND DISEASE

35. FEET (Continued) (Circle category)

Normal Arch

Pes Cavus

Pes Planus

Mild

Moderate

Severe

Asymptomatic

Symptomatic

DD FORM 2808, OCT 2005 Page 1 of 3 Pages

CLINICAL EVALUATION (Check each item in appropriate column. Enter "NE" if not evaluated.)

b. COMPONENT Coast Guard

PRIVACY ACT STATEMENT

AUTHORITY: 10 USC 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397.

PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.

ROUTINE USE(S): None.

DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status.

Class

Acceptable

Not Acceptable

(Please explain. Use dental form if completed by dentist. If dental examination not done by dental officer, explain in Item 44.)

Native Hawaiian or Other Pacific Islander Hispanic/Latino

Not Hispanic/ Latino

b. ETHNIC CATEGORY

Adobe Professional X

MEASUREMENTS AND OTHER FINDINGS

53. HEIGHT 54. WEIGHT 56. TEMPERATURE

58. BLOOD PRESSURE

a. 1ST

SYS.

DIAS.

b. 2ND

SYS.

DIAS.

c. 3RD

SYS.

DIAS.

57. PULSE

61. DISTANT VISION

Right 20/

Left 20/

Corr. to 20/

62. REFRACTION BY AUTOREFRACTION OR MANIFEST

63. NEAR VISION

Right 20/

Left 20/

Corr. to 20/

Corr. to 20/ by by

64. HETEROPHORIA (Specify distance)

ES EX R.H. L.H. Prism div. Prism Conv

NPR PD

65. ACCOMMODATION

Right Left

66. COLOR VISION (Test used and result) 67. DEPTH PERCEPTION (Test used and score) AFVT

PIP /14

68. FIELD OF VISION

59. RED/GREEN (Army Only)

71a. AUDIOMETER

Right

Left

500 1000 2000 3000 4000 6000

73. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY (Use additional sheets if necessary.)

60. OTHER VISION TEST

Uncorrected Corrected

69. NIGHT VISION (Test used and score) 70. INTRAOCULAR TENSION

O.D.

72a. READING ALOUD

TEST

DD FORM 2808, OCT 2005 Page 2 of 3 Pages

LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER

Unit Serial Number

Date Calibrated (YYYYMMDD)

a. Albumin

b. Sugar

LABORATORY FINDINGS

TESTS

46. URINE HCG 47. H/H

RESULTS

49. HIV

50. DRUGS

51. ALCOHOL

52. OTHER

a. PAP SMEAR b.

HIV SPECIMEN ID LABEL DRUG TEST SPECIMEN ID LABEL

55. MIN WGT - MAX WGT

O.S.

SAT UNSAT

45. URINALYSIS

MAX BF %

lbs.

Right

Left

500 1000 2000 3000 4000 6000HZ

71b. Unit Serial Number

Date Calibrated (YYYYMMDD)

48. BLOOD TYPE

72b. VALSALVA

SAT UNSAT

b. PHYSICAL PROFILE

P U L H E S X

74.a. EXAMINEE/APPLICANT (check one)

IS QUALIFIED FOR SERVICE

IS NOT QUALIFIED FOR SERVICE

76. SIGNIFICANT OR DISQUALIFYING DEFECTS

DD FORM 2808, OCT 2005 Page 3 of 3 Pages

75. I have been advised of my disqualifying condition.

a. SIGNATURE OF EXAMINEE b. DATE (YYYYMMDD)

LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER

PROFILER INITIALS DATE (YYYYMMDD)

ITEM

NO. MEDICAL CONDITION/DIAGNOSIS ICD

CODE

PROFILE

SERIAL

RBJ DATE

(YYYYMMDD) SERVICE DATE (YYYYMMDD)

EXAMINER

INITIALS

WAIVER RECEIVED

80. MEDICAL INSPECTION DATE HT WT %BF HCG QUAL DISQ PHYSICIAN'S SIGNATUREMAX WT

81.a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER b. SIGNATURE

83.a. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which) b. SIGNATURE

84.a. TYPED OR PRINTED NAME OF REVIEWING OFFICER/APPROVING AUTHORITY b. SIGNATURE

87. NUMBER OF

ATTACHED SHEETS

85. This examination has been administratively reviewed for completeness and accuracy.

a. SIGNATURE c. DATE (YYYYMMDD)b. GRADE

86. WAIVER GRANTED (If yes, date and by whom)

YES

82.a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER b. SIGNATURE

77. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers) (Use additional sheets if necessary.)

78. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify) (Use additional sheets if necessary.)

79. MEPS WORKLOAD (For MEPS use only)

WKID ST DATE (YYYYMMDD) INITIAL WKID ST DATE (YYYYMMDD) INITIAL

QUALI-

FIED

DIS-

QUALI-

FIED

examdate:

homeaddr:

homephone:

grade:

birthdate:

age:

sex: Off

xamerind: Off

xasian: Off

xblack: Off

xwhite: Off

xpacific: Off

xethnic: Off

milyrs:

civyrs:

agency:

org:

rating:

totalfly:

lastsix:

xservice: Off

xcomp: Off

xpurpose: Off

examloc:

x17: Off

x18: Off

x19: Off

x20: Off

x21: Off

x22: Off

x23: Off

x24: Off

x25: Off

x26: Off

x27: Off

x28: Off

x29: Off

x30: Off

x31: Off

x32: Off

x33: Off

x34: Off

x35: Off

x36: Off

x37: Off

x38: Off

x39: Off

x40: Off

x41: Off

x42: Off

xdental: Off

dentclass:

notes:

appname:

ssn:

albumin:

sugar:

URINE_HCG:

HH:

BLOOD_TYPE:

HIVresults:

drugresults:

alcresults:

papresults:

othertest1:

otherresults1:

othertest2:

otherresults2:

HIV_SPECIMEN_ID_LABEL:

DRUG_TEST_SPECIMEN_ID:

HEIGHT:

weight:

MIN_WGT__MAX_WGT:

MAX_BF:

TEMPERATURE:

PULSE:

SYS1:

SYS2:

SYS3:

DIAS1:

DIAS2:

DIAS3:

REDGREEN:

OTHER_VISION_TEST:

Right_20:

Corr_to_20:

Left_20:

Corr_to_2:

By1:

By_S:

CX1:

By2:

By_S1:

CX2:

Right_1:

Corr_to_1:

by3:

Left_1:

Corr_to_3:

by4:

es:

ex:

rh:

lh:

prism:

ct:

npr:

pd:

Right:

Left1:

PIP:

14:

afvt:

Uncorrected:

Corrected:

FIELD_OF_VISION:

NIGHT_VISION:

OD:

OS:

71a_Unit_Serial_Number:

71a_Date_Calibrated:

xqual: Off

signdate:

date1:

qual1: Off

summary:

recommendations:

WKID1:

ST1:

mepsdate1:

WKID4:

ST4:

mepsdate4:

WKID2:

ST2:

mepsdate2:

WKID5:

ST5:

mepsdate5:

WKID3:

ST3:

mepsdate3:

WKID6:

ST6:

mepsdate6:

HT1:

WT1:

BF1:

MAX_WT1:

HCG1:

inspqual1: Off

HT2:

WT2:

BF2:

MAX_WT2:

HCG2:

insp_date3:

HT3:

WT3:

BF3:

MAX_WT3:

HCG3:

insp_date4:

HT4:

WT4:

BF4:

MAX_WT4:

HCG4:

insp_date5:

HT5:

WT5:

BF5:

MAX_WT5:

HCG5:

phys_name1:

phys_name2:

dent_name1:

dent_name2:

revgrade:

revdate:

xwaiver: Off

waiver:

sheets:

insp_date1:

insp_date2:

inspqual3: Off

inspqual4: Off

inspqual5: Off

item1:

P1:

U1:

L1:

H1:

E1:

S1:

X1:

date2:

P2:

U2:

L2:

H2:

E2:

S2:

X2:

P3:

U3:

L3:

H3:

E3:

S3:

X3:

date3:

P4:

U4:

L4:

H4:

E4:

S4:

X4:

date4:

P5:

U5:

L5:

H5:

E5:

S5:

X5:

date5:

item2:

cond1:

icd1:

prof_ser1:

rbjdate1:

svc_1:

waivdate1:

cond2:

icd2:

prof_ser2:

rbjdate2:

svc_2:

waivdate2:

item3:

cond3:

icd3:

prof_ser3:

rbjdate3:

svc_3:

waivdate3:

item4:

cond4:

icd4:

prof_ser4:

rbjdate4:

svc_4:

waivdate4:

item5:

cond5:

icd5:

prof_ser5:

rbjdate5:

svc_5:

waivdate5:

qual2: Off

qual3: Off

qual4: Off

qual5: Off

inspqual2: Off

r_500_a:

r_1000_a:

r_2000_a:

r_3000_a:

r_4000_a:

r_6000_a:

l_500_a:

l_1000_a:

l_2000_a:

l_3000_a:

l_4000_a:

l_6000_a:

71b_Unit_Serial_Number:

71b_Date_Calibrated:

r_500_b:

r_1000_b:

r_2000_b:

r_3000_b:

r_4000_b:

r_6000_b:

l_500_b:

l_1000_b:

l_2000_b:

l_3000_b:

l_4000_b:

l_6000_b:

read_aloud: Off

valsalva: Off

notes_contd:

xnormarch: Off

xcavus: Off

xplanus: Off

xmodfeet: Off

xmildfeet: Off

xsevfeet: Off

xasimfeet: Off

xsymfeet: Off

File details come from the government source that posted it. Updated Jan 21, 2025.