This form must be completed electronically. Handwritten forms will not be accepted.
POST DEPLOYMENT HEALTH ASSESSMENT (PDHA)
PRIVACY ACT STATEMENT
This statement serves to inform you of the purpose for collecting the personal information required by the DD Form 2796, Post Deployment Health
Assessment (PDHA), and how it will be used.
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; DoDD 1404.10, DoD Civilian Expeditionary Workforce; DoDD 6490.02E, Comprehensive Health Surveillance; and E.O. 9397
(SSN), as amended.
PURPOSE: To collect information on your physical and mental health status after a deployment in a combat, contingency, or other operation
outside of the United States, and to assist health care providers in administering present or future care.
ROUTINE USES: Use and disclosure of your records outside of DoD may occur in accordance with the DoD Blanket Routine Uses published at
, and as permitted by the Privacy Act of 1974, as amended (5 U.S.C.
552a(b)). 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. Permitted uses and disclosures of PHI include, but are not limited to, treatment,
payment, and healthcare operations.
DISCLOSURE: Voluntary. However, if you choose not to provide the requested information comprehensive health care services may not be
possible or administrative delays may occur. 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 and where
you deployed. If you do not understand a question, please discuss the question with a health care provider.
DEMOGRAPHICS
Last Name __________________________
First Name ______________________
Middle Initial ____
Social Security Number ______________________
Today’s Date (dd/mmm/yyyy) ____________________
Date of Birth (dd/mmm/yyyy) ___________________ Gender Male Female
Service Branch
Component
Pay Grade
S A M P L E
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
Home station/unit: _________________________________
Current contact information:
Point of contact who can always reach you:
Phone: ______________________________
Name: ________________________________
Cell: ________________________________
Phone: _______________________________
DSN: _______________________________
Email: ________________________________
Email: _______________________________
Address: ______________________________
Address: _____________________________
______________________________
_____________________________
______________________________
_____________________________
PLEASE ANSWER ALL QUESTIONS BASED ON YOUR MOST RECENT DEPLOYMENT
Date arrived theater (dd/mmm/yyyy) ________________
Date departed theater (dd/mmm/yyyy) _____________
Location of operation
To what areas were you mainly deployed?
(Please list all that apply, including the number of months spent at each location.)
Country 1 __________________________________________
Time at location (months) __________________
Country 2 __________________________________________
Time at location (months) __________________
Country 3 __________________________________________
Time at location (months) __________________
Country 4 __________________________________________
Time at location (months) __________________
Country 5 __________________________________________
Time at location (months) __________________
DD FORM 2796, OCT 2015
Page 1 of 10 Pages
PREVIOUS EDITION IS OBSOLETE.