Dd Form 2795 - Privacy Act Statement (Sample) - Pre-Deployment Health Assessment Page 6
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7This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
6.
Major life stressor as reported on deployer question 13.
Yes Deployer’s concern:
a. Did deployer mark they have a concern or a
________________________
No (go to block 7)
difficulty with a major life stressor?
Not answered by deployer
b. If yes, ask additional questions to determine level of problem: ________________________________________________________
Yes
c. Consider need for referral. Referral indicated?
(complete blocks 11 and 12)
No
Already under care
Already has referral
No significant impairment
Other reason (explain): _________________________
7.
Suicide risk evaluation.
a. Ask “Over the PAST MONTH, have you been bothered
Yes
No (go to block 8)
by thoughts that you would be better off dead or of
hurting yourself in some way?”
b. If 7.a. was yes, ask: “How often have you
Few or several days
been bothered by these thoughts?”
More than half of the time
Nearly every day
c. If 7.a. was yes, ask: “Have you had thoughts of
Yes (If yes ask questions 7d. through 7g.)
No (If no thoughts of self-harm, go to block 8)
actually hurting yourself?”
d. Ask “Have you thought about how you might actually hurt yourself?”
Yes How? ____________________________________
No
e. Ask “There’s a big difference between having a thought and
Not at all likely
Somewhat likely
acting on a thought. How likely do you think it is that you will
Very likely
act on these thoughts about hurting yourself or ending
your life over the next month?”
f. Ask “Is there anything that would prevent or
Yes What? ____________________________________
No
keep you from harming yourself?”
g. Ask “Have you ever attempted to harm yourself in the past?”
Yes How?
___________________________________
No
h. Conduct further risk assessment (e.g., interpersonal conflicts,
social isolation, alcohol/substance abuse, hopelessness,
Comments: _______________________________________
severe agitation/anxiety, diagnosis of depression or other
psychiatric disorder, recent loss, financial stress,
________________________________________________
legal disciplinary problems, or serious physical illness).
Yes (complete blocks 11 and 12)
i. Does deployer pose a current risk for harm to self?
No
8.
Violence/harm risk evaluation.
a. Ask, “Over the past month have you had thoughts or
Yes
concerns that you might hurt or lose control with someone?”
No (go to block 9)
If yes, ask additional questions to determine
extent of problem (target, plan, intent, past history) Comments: ______________________________________________________
Yes (complete blocks 11 and 12)
b. Does member pose a current risk to others?
No (briefly state reason): __________________________
Medical History Review – if available, hard copy and/or electronic
Completed
9.
No health records available
health records (including DD2766 and SF-600 entries, and most
recent past deployment health assessments).
a. Significant findings related to ability to deploy: ______________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Yes
b. Evidence of deployment limiting conditions or medications?
No
DD FORM 2795, SEP 2012
Page 6 of 7 Pages
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