PWS Attachment 23 DD Form 2808 Report of Medical Examination.pdf

DoD Form PDF 63 KB Posted

Attached to
United States Army Reserve Command (USARC) Physical Exams
Solicitation number
W81K04-22-R-0018
Issued by

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Other versions and copies of DD Form 2808

5 government files on GovTribe name DD Form 2808. Different revisions are separate documents; copies of this exact file point search engines to its first posting.

File Revision Posted Attached to
47QFWA22R0008 Appendix C - DD Form 2808.pdf Same revision and size as this file Revision not stated DoDMERB Medical Services
Attachment_16_DD2808.pdf Revision not stated Occupational Healthcare and Medical Services for NIOSH Morgantown
Attachment 21f DD 2808 Report of Medical Examination.pdf Revision not stated Occupational Health Services
Attachment 16 DD2808.pdf Revision not stated Occupational Healthcare and Medical Services for NIOSH Morgantown

Who attaches DD Form 2808

Agency Files
Department of Health and Human Services Centers for Disease Control and Prevention Pittsburgh 2
General Services Administration Federal Acquisition Service Assisted Acquisition Services Region 7 1
Department of the Army Medical Command 1
Defense Logistics Agency Land and Maritime 1

Other files

File Type Posted
Attachment C Government Furnish Price Model (GFPM)v7.xlsx XLSX spreadsheet
Attachment C Government Furnish Price Model (GFPM)v6.xlsx XLSX spreadsheet
W81K04-22-R-0018-0003 USARC MedExams Services.pdf PDF
Attachment C Government Furnish Price Model (GFPM)v5.xlsx XLSX spreadsheet
Attachment C Government Furnish Price Model (GFPM)v4.xlsx XLSX spreadsheet
KTR QUESTIONS with GOV RESPONSE (24Jun22).xlsx XLSX spreadsheet
Attachment C Government Furnish Price Model (GFPM)v3.xlsx XLSX spreadsheet
KTR QUESTIONS with GOV RESPONSE (22Jun22).xlsx XLSX spreadsheet
W81K04-22-R-0018-0002 USARC MedExams Services.pdf PDF
W81K04-22-R-0018-0001 USARC MedExams Services.pdf PDF
PWS Attachment 06 Respirator Medical Evaluation Questionnaire.pdf PDF
PWS Attachment 03 DD 254 Fillable 1.pdf PDF
Attachment C Government Furnish Price Model (GFPM).xlsx XLSX spreadsheet
PWS Attachment 15 Maintenance Personnel Pre-employment Physical Exam Form.pdf PDF
PWS Attachment 07 Respirator Medical Examination Questionnaire.pdf PDF
PWS Attachment 09 PFAS DOD Firefighter Fact Sheet.pdf PDF
Attachment B Performance Requirements Summary (PRS).docx DOCX document
PWS Attachment 12 Chronological Record of Medical Care Police Security Guard Termination Physical.pdf PDF
PWS Attachment 14 Maintenance Personnel Annual Physical Exam Form.pdf PDF
Attachment E Past Performance Questionnaire.docx DOCX document
PWS Attachment 17 WAMC Form 3021 Respirator Medical Evaluation Questionnaire.pdf PDF
PWS Attachment 16 Maintenance Personnel Termination Physical Exam Form.pdf PDF
PWS Attachment 13 Chronological Record Police Security Pre employment Physical.pdf PDF
PWS Attachment 19 PFAS Guide for Department of Defense Firefighters.pdf PDF
PWS Attachment 21 Cardio Eval MEDCOM MEMO 5June07.pdf PDF
Attachment D Customer Reference Information Sheet.docx DOCX document
PWS Attachment 18 PFAS Occupational Medicine Providers Evaluating DoD Firefighters.pdf PDF
PWS Attachment 02 DD254 Handbook HQDA G-2.pdf PDF
Attachment A QASP.docx DOCX document
PWS Attachment 04 Firefighter Annual Exam Form.pdf PDF
PWS Attachment 05 Chronological Record Firefighter Pre employment.pdf PDF
PWS Attachment 25 MOD15 Tab-A Amplification of the Minimal Stds of Fitness for Deployment CENTCOM AOR.pdf PDF
PWS Attachment 11 Chronological Police Security Guard Annual Physical.pdf PDF
W81K04-22-R-0018 USARC MedExams Services.pdf PDF
PWS Attachment 08 Firefighter Termination Exam Form.pdf PDF
PWS Attachment 27 ACI 4200.09A Force Health Protect Req and Med Guidance for Entry into US Africa Comm Theater.pdf PDF
PWS Attachment 22 DA Form 7708 Personnel Reliability Screening and Evaluation.pdf PDF
PWS Attachment 01 Quality Assurance Surveillance Plan.pdf PDF
PWS Attachment 10 ASDR Memo Blood Testing.pdf PDF
PWS W81K04-22-R-0018 Final (17May22).docx DOCX document
PWS Attachment 26 ECI 4202.01 Health Service Support US European CC Theater Medical Entry Requirements.pdf PDF
PWS Attachment 24 DD Form 2807-1 Report of Medical History.pdf PDF
PWS Attachment 20 MEDCOM Form 829 Initial Entry Tuberculosis Risk Assessment Tool.pdf PDF
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DRAFT

DD FORM 2808, July 2019 Page of Prescribed by: DoDI 1304.2 9.0.0.2.20120627.2.874785

REPORT OF MEDICAL EXAMINATION

REPORT OF MEDICAL EXAMINATION

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 504, Persons not qualified; 10 U.S.C. 505, Regular components: qualifications, term, grade; 10 U.S.C. 507, Extension of enlistment for members needing medical care or hospitalization; 10 U.S.C. 532, Qualifications for original appointment as a commissioned officer; 10 U.S.C. 978, Drug and alcohol abuse and dependency: testing of new entrants; 10 U.S.C. 1201, Regulars and members on active duty for more than 30 days: retirement; 10 U.S.C. 1202, Regulars and members on active duty for more than 30 days: temporary disability retired list; 10 U.S.C. 4346, Cadets: requirements for admission; DoD Directive 1145.2, United States Military Entrance Processing Command; E.O. 9397 (SSN) and 10 U.S.C. 1204, Members on Active Duty for 30 Days or Less or on Inactive Duty Training: Retirement, as amended.

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): The Routine Uses are listed in the applicable system of records notice found at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570661/a0601-270-usmepcom-dod/ 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.

9a. BIRTH SEX 9a. BIRTH SEX 9b. PREFERRED GENDER 9b. PREFERRED GENDER 10a. ETHNIC CATEGORY 10a. ETHNIC CATEGORY 10b. RACIAL CATEGORY (Select one) 10b. RACIAL CATEGORY (Select one)

11. TOTAL YEARS GOVERNMENT SERVICE

11. TOTAL YEARS GOVERNMENT SERVICE

15a. SERVICE 15a. SERVICE 15b. COMPONENT 15b. COMPONENT 15c. PURPOSE OF EXAMINATION 15c. PURPOSE OF EXAMINATION MEDICAL EVALUATION (Check each item in appropriate column. Enter "NE" if not evaluated.)

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

Normal Abnormal

NE

17. Head, face, neck and scalp

18. Nose

19. Sinuses

20. Mouth and throat

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

22. Tympanic Membranes (Perforation)

23. Eyes - General

24. Ophthalmoscopic

25. Pupils (Equality and reaction)

26. Ocular motility (Associated parallel movements, nystagmus)

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 Normal

34. Lower extremities (Except feet)

35. Feet (Check category) 35a.

35b.

35c.

36. Spine, other musculoskeletal

37. Body marks, scars, tattoos

38. Skin, lymphatics

39. Neurologic Normal

40. Psychiatric (Specify any personality disorder)

41. Pelvic (Females only)

42. Endocrine

43. DENTAL DEFECTS AND DISEASE

(Please explain. Use dental form if completed by dentist. If abnormality noted, explain in item 44.)

43. DENTAL DEFECTS AND DISEASE

(Please explain. Use dental form if completed by dentist. If abnormally noted, explain in Item 44.)

LABORATORY FINDINGS

TESTS

RESULTS

49. HIV

50. DRUGS

51. ALCOHOL

52. OTHER

a. PAP SMEAR

b. EKG

c. CXR

MEASUREMENTS AND OTHER FINDINGS

54. WEIGHT (lbs.)

58. BLOOD PRESSURE

58. BLOOD PRESSURE

a. 1ST

a. 1ST

b. 2ND

b. 2ND

c. 3RD

c. 3RD

61. DISTANCE VISION

61. DISTANCE VISION

62. REFRACTION

62. REFRACTION

63. NEAR VISION

63. NEAR VISION

64. HETEROPHORIA

64. HETEROPHORIA

65. ACCOMMODATION

65. ACCOMMODATION

66. COLOR VISION (Pass/Fail and Score)

66. COLOR VISION (pass/Fail and score)

67. DEPTH PERCEPTION (Pass/Fail and Score)

67. DEPTH PERCEPTION (Pas/Fail and Score)

67. DEPTH PERCEPTION (Pas/Fail and Score)

70. INTRAOCULAR PRESSURE

70. INTRAOCULAR PRESSURE

HZ

Left Right

HZ

Left Right 72a. READING ALOUD TEST:

72a. READING ALOUD TEST:

72b. VALSALVA:

72b. VALSALVA:

72c. OTHER TESTING

74. EXAMINEE

75. I have been advised of my disqualifying condition(s).

76. PHYSICAL PROFILE

P U L H E S X D

PROFILER INITIALS

DATE (YYYYMMDD)

77. SIGNIFICANT OR DISQUALIFYING MEDICAL DIAGNOSES

ITEM NO.

MEDICAL DIAGNOSIS

ICD CODE

PROFILE SERIAL

RBJ DATE

(YYYYMMDD)

QUALIFIED

DISQUALIFIED

EXAMINER INITIALS

WAIVER RECEIVED

SERVICE

DATE (YYYYMMDD)

80. MEPS WORKLOAD (For MEPS use only)

WKID

ST

DATE (YYYYMMDD)

INITIALS

WKID

ST

DATE (YYYYMMDD)

INITIALS

81. MEDICAL INSPECTION DATE

HT

WT

%BF

MAX WT

HCG

QUAL

DISQ

EXAMINER'S NAME AND SIGNATURE

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

Click this button to save this form.:
Click this button to print this form.:
Click this Reset button to erase data from all fields.:
CurrentPage:
PageCount:
DATE (YYYYMMDD):
2a. SOCIAL SECURITY

NUMBER:

2b. DoD ID NUMBER (If applicable):

3. LAST NAME - FIRST NAME - MIDDLE NAME

(Suffix):

4. HOME ADDRESS (Street, Apartment Number, City, State and Zip Code):

5.a. HOME TELEPHONE NUMBER (Include Area Code):
5.b. E-MAIL ADDRESS:
6. GRADE/

RANK:

7. DATE OF BIRTH

(YYYYMMDD):

8. AGE:
CYCLO:
a. MILITARY:
b. CIVILIAN:
12. AGENCY (Non-Service Members Only):
13. ORGANIZATION UNIT AND UIC/CODE:
14a. RATING OR SPECIALTY (Aviators Only):
14b. TOTAL FLYING TIME:
14c. LAST SIX MONTHS:
Active Duty:
Reserve:
National Guard:
Navy:
Coast Guard:
Other:
16. NAME OF EXAMINING LOCATION, AND ADDRESS

(Include Zip Code):

Asymptomatic: 0
Asymptomatic: 0
Asymptomatic: 0
Symptomatic: 0
Symptomatic: 0
Symptomatic: 0
c: 0
c: 0
c: 0
Class:
46. URINE HCG:
LAST NAME - FIRST NAME - MIDDLE NAME (Suffix):
SOCIAL SECURITY NUMBER:
DoD ID NUMBER:
45. URINALYSIS:
a. Albumin:
b. Sugar:
47. H/H:
48. BLOOD TYPE:
HZ:
50. DRUGS:
51. ALCOHOL:
52. OTHER:
a. PAP SMEAR:
b. EKG:
c. CXR:
HIV SPECIMEN ID LABEL:
DRUG TEST SPECIMEN ID LABEL:
53. HEIGHT (in.):
54. WEIGHT:
55.a. MIN WGT:
55.b. MAX WGT:
55.d. BMI:
56. TEMPERATURE:
HEART RATE:
Add::
SYS.:
SYS.:
DIAS.:
DIAS.:
DIAS.:
59. RED/GREEN:
60. OTHER VISION TEST:
ES:
EX:
R.H.:
L.H.:
Prism div.:
Prism Conv CT:
NPR:
PD:
Right:
Left:
PIP: Pass/ Fail and Score:
RED / GREEN: Pass/ Fail and Score:
Color Dx: Pass/ Fail and Score:
AFVT: Pass/ Fail and Score:
RANDOT / MCST : Pass/ Fail and Score:
68. FIELD OF VISION:
69. NIGHT VISION:
O.D.:
O.S.:
71a. AUDIOMETER Unit Serial Number:
Date Calibrated (YYYYMMDD):
71b. Unit Serial Number:
SAT:
UNSAT:
72c.OTHER TESTING:
73. NOTES AND/OR INTERVAL HISTORY :
LAST NAME - FIRST NAME - MIDDLE NAME (Suffix):
SOCIAL SECURITY NUMBER:
DoD ID NUMBER:
IS MEDICALLY QUALIFIED : 0
IS NOT MEDICALLY QUALIFIED: 0
75.a. SIGNATURE OF EXAMINEE:
75.b. DATE (YYYYMMDD):
DISQ:
D Entry:
D Entry:
D Entry:
D Entry:
EXAMINER’S NAME AND SIGNATURE:
PROFILER INITIALS:
PROFILER INITIALS:
PROFILER INITIALS:
PROFILER INITIALS:
DATE (YYYYMMDD):
DATE (YYYYMMDD):
DATE (YYYYMMDD):
DATE (YYYYMMDD):
78. SUMMARY OF MEDICAL DIAGNOSES (List diagnoses with item numbers) (Use additional sheets if necessary).:
89. ADDITIONAL REMARKS:
82.a. TYPED OR PRINTED NAME OF PHYSICIAL OR EXAMINER:
82b. Signature:
83.a. TYPED OR PRINTED NAME OF PHYSICIAL OR EXAMINER:
83b. Signature:
87. WAIVER GRANTED (If yes, date and by whom):
85b. Signature:
a. SIGNATURE:
c. DATE (YYYYMMDD):
No: 0
No: 0
88. NUMBER OF ATTACHED SHEETS:

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