Dd Form 2795 - Privacy Act Statement (Sample) - Pre-Deployment Health Assessment
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7This form must be completed electronically. Handwritten forms will not be accepted.
PRE-DEPLOYMENT HEALTH ASSESSMENT
PRIVACY ACT STATEMENT
This statement serves to inform you of the purpose for collecting personally identifiable information through the DD Form 2795 (Pre-Deployment Health Assessment).
AUTHORITY:
10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. 1074f, Medical Tracking System for Members Deployed Overseas;
DoDI 1404.10, DoD Civilian Expeditionary Workforce; DoDI 6490.02E, Comprehensive Health Surveillance, and E.O. 9397 (SSN), as amended.
PURPOSE:
To obtain information from an individual in order to assess the state of the individual’s health before possible deployment outside the United States, its
territories and possessions as part of a contingency, combat, or other operation and to assist health care providers in identifying and providing present and
future medical care to the individual. The information provided may result in a referral for additional health care that may include medical, dental, or
behavioral health care or diverse community support services.
ROUTINE USES:
Your records may be disclosed to other Federal and State agencies and civilian health care providers, as necessary, in order to provide medical care and
treatment. Use and disclosure of you records outside of DoD may also occur 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: Any protected
health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as
implemented within DoD by DoD 6025.18-R. Permitted uses and discloses of PHI include, but are not limited to, treatment, payment, and healthcare
operations.
DISCLOSURE:
Voluntary. If you chose not to provide information, comprehensive healthcare services may not be possible or administrative delays may occur.
HOWEVER, CARE WILL NOT BE DENIED.
INSTRUCTIONS:
You are encouraged to answer all questions. You must at least complete the first portion on who you are and when you will deploy. If you do not
understand a question, please discuss the question with a health care provider.
DEMOGRAPHICS
Last Name __________________________
First Name ______________________
Middle Initial ____
Today’s Date (dd/mmm/yyyy) ____________________
Social Security Number ______________________
Date of Birth (dd/mmm/yyyy) ___________________ Gender Male Female
Service Branch
Component
Pay Grade
Air Force
Active Duty
E1
O1
W1
Army
National Guard
E2
O2
W2
Navy
Reserves
E3
O3
W3
Marine Corps
Civilian Government Employee
E4
O4
W4
Coast Guard
E5
O5
W5
Civilian Expeditionary Workforce (CEW)
E6
O6
USPHS
E7
O7
Other
Other Defense Agency List: _________________
E8
O8
E9
O9
O10
Current contact information:
Point of contact who can always reach you:
Phone: ______________________________
Name: ________________________________
Cell: ________________________________
Phone: _______________________________
DSN: _______________________________
Email: ________________________________
Email: _______________________________
Address: ______________________________
Address: _____________________________
______________________________
_____________________________
______________________________
_____________________________
Estimated date of upcoming deployment (dd/mmm/yyyy) ________________
List country you are deploying to (if known): ________________________________________
Name of operation (if known): __________________________
None
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6 or more
How many deployments have you done before?
(if previous question was answered as one or more)
___________________
When did you return from your last deployment? (Mmm yyyy)
DD FORM 2795, SEP 2012
Page 1 of 7 Pages
PREVIOUS EDITION IS OBSOLETE
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