MEDICAL, DENTAL, AND EDUCATIONAL SUITABILITY SCREENING
CHECKLIST AND WORKSHEET
Privacy Act Statement: OPNAVINST 1300.14D authorizes collection of this information. The following information and documents, as applicable, are required to
conduct medical, dental, and educational screening to determine suitability for an overseas, remote duty, or operational assignment. Complete and current
information is essential for completion of screening. Disclosure is voluntary, however, missing or incomplete information may delay the screening process, result in
orders held in abeyance until completion of screening, or affect the amount of leave in transit. Refer to BUMEDINST 1300.2B for implementing guidance.
The Suitability Screening Coordinator (SSC) at the military treatment facility (MTF) can assist in obtaining and completing the required information. The SSC will
ensure required information and documents are complete and current before referral to a MTF provider for screening and a suitability recommendation. The SSC
will place the completed original from in the individual’s Service Treatment Record/Non-Service Treatment Record and retain a copy for audit. Medical, dental, and
educational suitability screening is valid for 12 months from the date of completion if there were no significant changes in the medical, dental, or educational status of
the service or family member. The service member must notify his or her commanding officer or officer in charge of any change in status (including pregnancy).
Complete one form for each Service and family member screened.
SERVICE MEMBER NAME
NEXT DUTY STATION LOCATION & UNIT IDENTIFICATION CODE (UIC)
TYPE DUTY CLASSIFICATION CODE (Navy Enlisted Code Only)
FAMILY MEMBER NAME
FAMILY MEMBER PREFIX
A. FOR SERVICE MEMBERS:
1. Legible copy of orders or an Overseas Screening Notification. (For operational assignments, orders should
indicate the platform to which assigned and a description of the duty assignment.)
2. Each family member name, family member prefix, social security number, address and telephone number, if other
than the service member’s.
SERVICE TREATMENT RECORD TO INCLUDE:
3. All Physical Exams (to include special duty aviation, submarine, radiation, asbestos, etc.) are current and filed in
the Service Treatment Record?
a. Type of Physical ____________________________
b. Completion Date of Physical __________________
4. Annual Periodic Health Assessment (PHA) current and documented?
5. Current medical history (DD Form 2807-1)
6. Hearing (Audiogram)
7. Vision Examination
8. G-6P-D Test
9. PPD Test
10. Sickle Cell Trait Test
11. Negative HIV results current to 1 year of transfer
Date Drawn: ________________________
Roster Number: ________________________________
12. Blood Type: ____________________
13. DNA Testing completed and documented?
14. Required Immunizations (Assignment Specific)
15. Military Dental Records
16. Copies of civilian medical, dental, or mental health care records to include narrative summaries of any inpatient
admissions in civilian facilities.
17. Mammogram current and documented.
18. Pregnancy screen (verbal inquiry). (Also, command will refer for pregnancy test 30 days prior to departure date.)
B. FOR FAMILY MEMBERS:
1. Non-Service Treatment Record (medical and dental) and include a completed DD Form 2807-1
2. Copies of civilian medical, dental, or mental health care records to include narrative summaries of any inpatient
admissions in civilian facilities. Include a completed DD Form 2807-1
3. Recommended ACIP and required country specific immunizations (check current country specific immunization
requirements issued by the Centers for Disease Control and Prevention (CDC) i.e. yellow fever)
NAVMED 1300/2 (Rev.12-2015)