Attachment 21e DD FORM 771 EYEWEAR PRESCRIPTION.pdf

DoD Form PDF 78 KB Posted Jul 29, 2011

Attached to: Occupational Health Services
Solicitation number: SP4702-11-R-0001
Issued by: Defense Logistics Agency Land and Maritime

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Attachment 21e

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Other versions and copies of DD Form 771

2 government files on GovTribe name DD Form 771. Different revisions are separate documents; copies of this exact file point search engines to its first posting.

File	Revision	Posted	Attached to
DD FORM 771-20220411124039 (1).pdf	Revision not stated	Aug 10, 2022	Prescription Safety Eyewear

Who attaches DD Form 771

Agency	Files
GSA Federal Acquisition Service	1
Defense Logistics Agency Land and Maritime	1

Other files

File	Type	Posted
SP4702-11-R-0001 Amend 0002 pg 1_Page_1.jpg	JPG image	Aug 22, 2011
SP4702-11-R-0001 Amendment 0002 pgs 2-11.pdf	PDF	Aug 22, 2011
Amend 0001 11-R-0001 Pg1.pdf	PDF	Aug 15, 2011
Attachment 21d OF178 Example for Deployment.pdf	PDF	Aug 15, 2011
Attachment 26 Health Promotions Screenings.doc	DOC document	Aug 15, 2011
Attachment 7 DLA inj.docx	DOCX document	Aug 15, 2011
Amendment 0001 Replacement pages.pdf	PDF	Aug 15, 2011
Amendment 0001 SP4702-11-R-0001.pdf	PDF	Aug 15, 2011
Attachment 18 Radiation monitoring.pdf	PDF	Aug 15, 2011
Attachment 33 Foreign Travel Vacination Review.pdf	PDF	Aug 15, 2011
Attachment 2 Govt Property.xls	XLS spreadsheet	Aug 15, 2011
Attachment 31 WD05-2417(Rev.14) Amend 0001.pdf	PDF	Aug 15, 2011
Attachment 6 DFAS inj.docx	DOCX document	Aug 15, 2011
Attachment 8 DISA inj.docx	DOCX document	Aug 15, 2011
Attachment 21d OF 178 Example for Pre-employment Medical Surveillance.pdf	PDF	Aug 15, 2011
Attachment 7 DLA inj.docm	DOCM document	Jul 29, 2011
Attachment 8 DISA inj.docm	DOCM document	Jul 29, 2011
Attachment 25 DA Form 5006-R Authorization for Disclosure of Information.pdf	PDF	Jul 29, 2011
Attachment 23 DoDI 6200.03 Public Health Emergency Mgmt within DoD.pdf	PDF	Jul 29, 2011
Attachment 6 DFAS inj.docm	DOCM document	Jul 29, 2011
Attachment 30.xlsx	XLSX spreadsheet	Jul 29, 2011
Attachment 5 Refusal of Medical Services.pdf	PDF	Jul 29, 2011
Attachment 14 CA16.pdf	PDF	Jul 29, 2011
Attachment 13 CLIN sheet .docx	DOCX document	Jul 29, 2011
Attachment 19 Mod 10 to USCENTCOM Indiv Protectection Indiv Unit Deployment.pdf	PDF	Jul 29, 2011
Attachment 4 Potential exposure to BBP.pdf	PDF	Jul 29, 2011
Attachment 21a DD2795 Pre Deployment Health Assessment.pdf	PDF	Jul 29, 2011
Attachment 11 CA1.pdf	PDF	Jul 29, 2011
Attachment 20 PPG-Tab A To accompany Mod 10.pdf	PDF	Jul 29, 2011
Attachment 29.xls	XLS spreadsheet	Jul 29, 2011
Attachment 21h BMI for Deploying DoD Civilians to SWA.pdf	PDF	Jul 29, 2011
Attachment 31-DOL 05-2417 dtd 9.14.10.pdf	PDF	Jul 29, 2011
List of Attachments.docx	DOCX document	Jul 29, 2011
Attachment 10 CA20.pdf	PDF	Jul 29, 2011
Attachment 21c DD2766 Adult Prevention and Chronic Care Flowsheet.pdf	PDF	Jul 29, 2011
Attachment 21g OSHA Respirator medical Evaluation Questionnaire.pdf	PDF	Jul 29, 2011
Attachment 28 Privacy Act Statement - Health Care Records.pdf	PDF	Jul 29, 2011
Attachment 16 Equipment Supplement.doc	DOC document	Jul 29, 2011
Attachment 22 CENTCOM Medical waiver Request Documentation.pdf	PDF	Jul 29, 2011
Attachment 1 Security Safety Fire.doc	DOC document	Jul 29, 2011
Attachment 24 Government Records.doc	DOC document	Jul 29, 2011
Attachment 21b DD2813 DoD Active Reserve Forces Dental Examination.pdf	PDF	Jul 29, 2011
Attachment 21f DD 2808 Report of Medical Examination.pdf	PDF	Jul 29, 2011
Attachment 17 Police Officers.pdf	PDF	Jul 29, 2011
Attachment 9 Medical Officer Report.pdf	PDF	Jul 29, 2011
Attachment 27 DSCC 2278-AED Class Registration Form.pdf	PDF	Jul 29, 2011
Attachment 21i DD2807-1 Report of Medical History.pdf	PDF	Jul 29, 2011
SF 1449 PAGE 1.pdf	PDF	Jul 29, 2011
Attachment 3 Weather Emergencies.doc	DOC document	Jul 29, 2011
Attachment 21d SF78 Certificate of Medical Examination.pdf	PDF	Jul 29, 2011

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Text version

The file's text, extracted by GovTribe without its formatting.

(THIS FORM IS SUBJECT TO THE

PRIVACY ACT OF 1974 -

Use DD Form 2005.)

FRAME

EYEWEAR

PRESCRIPTION

DATE ORDER NUMBER

TO: (Lab) FROM:

NAME (Last, First) GRADE

ADDRESS/UNIT

AD NG A CGNOTHER* AF PHS

PATIENTCLINIC

SHIP TO:

SPHERE CYLINDER AXIS DECENTER H PRISM H BASE

MULTIVISION

NEAR ADD SEG HT TOTAL DECENTER

SPECIAL COMMENTS/JUSTIFICATION (*Use this space to specify blocks marked "Other.")

PRESCRIBING OFFICER/AUTHORITY SIGNATURE

ACCOUNT NUMBER

SSN

PHONE

ADDRESS CONTINUED

CITY, STATE, ZIP

RES RET MC OTHER*

EYE BRIDGE TEMPLE COLOR

DIST

NEAR LENS TINT MATERIAL PAIR CASE

V PRISM V BASE

LAB USE

PRIORITY TECH INITIALS

DISTRIBUTION: ORIGINAL - Retained by Lab. COPY 1 - Returned with eyewear. COPY 2 - Entered in health record.

DD FORM 771, JUL 96 PREVIOUS EDITION IS OBSOLETE.

DATE:

ACCOUNT_NUMBER:

ORDER_NUMBER:

TO_Lab:

FROM:

NAME_Last_First:

SSN:

GRADE:

ADDRESSUNIT:

ADDRESS_CONTINUED:

CITY_STATE_ZIP:

PHONE:

Check1a: Off

Check1b: Off

Check 2a: Off

Check 2b: Off

Check 2c: Off

Check 2d: Off

Check 2e: Off

Check 3a: Off

Check 3b: Off

Check3c: Off

Check3d: Off

Check3e: Off

Check3f: Off

Check3g: Off

FRAME:

BRIDGE:

TEMPLE:

COLOR:

a_1:

LENS:

TINT:

MATERIAL:

PAIR:

CASE:

SPHERE1:

CYLINDER1:

AXIS1:

DECENTER1:

H_PRISM:

H_BASE:

V_PRISM:

V_BASE:

SPHERE2:

CYLINDER2:

AXIS2:

DECENTER2:

H_PRISM1:

H_BASE1:

V_PRISM1:

V_BASE1:

NEAR_ADD:

SEG_HT:

TOTAL_DECENTER:

FillText3:

FillText4:

FillText5:

lab use21:

PRIORITY:

TECH_INITIALS:

SPECIAL_COMM_ENTSJUSTI_Fl:

PRESCRIBING_OFFICERAUTHOR:

SIGNATURE:

Reset:

Eye:

File details come from the government source that posted it. Updated Nov 14, 2017.