Dd Form 2795 - Privacy Act Statement (Sample) - Pre-Deployment Health Assessment Page 5
ADVERTISEMENT
1
2
3
4
5
6
7This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
4.
PTSD screening as reported in deployer question 11.
Yes
a. Did deployer mark yes on two or more of
No (go to block 5)
questions 11a. through 11d.?
Not answered by deployer
b. If yes, deployer’s responses to questions 11e. through 11u. resulted in a PCL-C score of _________ and the deployer’s response to level
of impairment with life events (11v.) is indicated in the table below.
11e. through 11v. were not answered or are incomplete.
Based on the PCL-C score, the deployer’s level of functioning, and your exploration of responses, follow the guidance below:
Post-Traumatic Stress Disorder Intervention Matrix
PCL-C Score <30
Self-Reported
PCL-C Score 30-39
PCL-C Score 40-49
PCL-C Score ≥ 50
(Sub-threshold or
Level of Functioning
(Mild Symptoms)
(Moderate Symptoms)
(Severe Symptoms)
no Symptoms)
Consider referral for
Not Difficult at All
further evaluation
or
No intervention
Provide PTSD education*
AND
Somewhat Difficult
provide PTSD education*
Assess need for further
Very Difficult
Consider referral for further evaluation
Refer for further evaluation
evaluation
to
AND
AND
AND
Extremely Difficult
provide PTSD education*
provide PTSD education*
provide PTSD education*
* PTSD Education = Reassurance/supportive counseling, provide literature on PTSD, encourage self-management activities, and counsel
deployer to seek help for worsening symptoms.
Yes (complete blocks 11 and 12)
c. Referral indicated?
No
Already under care
Already has referral
No significant impairment
Other reason (explain): _____________________________
5.
Depression screening as reported in deployer question 12.
a. Did deployer mark “More than half the days” or
Yes
“Nearly every day” on question 12a. or 12b.?
No (go to block 6)
Not answered by deployer
b. If yes, deployer’s responses to questions 12a. through 12h. resulted in a total PHQ-8 score of _________ and the deployer’s response to
level of impairment with life events (12i.) is indicated in the table below.
12c. through 12i. were not answered or incomplete.
Based on the PHQ-8 score, deployer’s level of functioning, and exploration of responses, follow the guidance below:
Depression Intervention Matrix
Self-Reported
PHQ-8 Score 1-4
PHQ-8 Score 5-9
PHQ-8 Score 10-14
PHQ-8 Score 15-18
PHQ-8 Score 19-24
Level of Functioning
(No Symptoms)
(Sub-Threshold Symptoms)
(Mild Symptoms)
(Moderate Symptoms)
(Severe Symptoms)
Consider referral for
Consider referral for
Not Difficult at All
further evaluation
further evaluation
or
No intervention
Depression education*
AND
AND
Somewhat Difficult
provide depression
provide depression
education*
education*
Consider referral for
Consider referral for
Refer for further
Very Difficult
Assess need for further evaluation
further evaluation
further evaluation
evaluation
to
AND
AND
AND
AND
Extremely Difficult
provide depression education*
provide depression
provide depression
provide depression
education*
education*
education*
* Depression Education = Reassurance/supportive counseling, provide literature on depression, encourage self-management activities,
and counsel deployer to seek help for worsening symptoms.
Yes (complete blocks 11 and 12)
c. Referral indicated?
No
Already under care
Already has referral
No significant impairment
Other reason (explain): ________________________
DD FORM 2795, SEP 2012
Page 5 of 7 Pages
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business