Dd Form 2796 Draft - Post-Deployment Health Assessment (Pdha) Page 8
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
12. Environmental and exposure concern/assessment as reported in deployer questions 17 and 18.
a. Did deployer indicate a worry or possible exposure?
Yes
No (go to block 13)
If yes, mark deployer’s exposure
concern(s)
Animal bites
Paints
Animal bodies (dead)
Pesticides
Chlorine gas
Radar/Microwaves
Depleted uranium
Sand/dust
Excessive vibration
Smoke from burning trash or feces
Fog oils (smoke screen)
Smoke from oil fire
Garbage
Solvents
Human blood, body fluids, body parts, or dead bodies
Tent heater smoke
Industrial pollution
Vehicle or truck exhaust fumes
Insect bites
Chemical, biological, radiological warfare agent
Ionizing radiation
Other exposures to toxic chemicals or materials, such as
ammonia, nitric acid, etc. Please list:
JP8 or other fuels
Lasers
Loud noises
b. If yes, referral indicated?
Yes (complete blocks 19 and 20)
No (provide risk education)
When an individual’s medical condition(s) or concern may be associated
Already under care
with possible occupational or environmental exposures during a deployment,
Already has referral
a Periodic Occupational and Environmental Monitoring Summary (POEMS)
No significant impairment
document may be available for review online at https://mesl.apgea.army.mil/mesl/ .
Other reason (explain):__________________
13. Depleted uranium (DU) as reported in deployer question 19.
S A M P L E
a. Did deployer mark either “yes” or
Yes
“don’t know to questions19?
No (go to block 14)
b. If yes, based on details of event and extent
Yes (complete blocks 19 and 20)
of exposure is referral to PCM for completion
No (provide risk education)
of DD Form 2872 (DU Questionnaire) and
Already under care
possible 24-hour urinalysis indicated?
Already has referral
No significant impairment
Other reason (explain):
_______________________
14. Malaria prophylaxis review as reported in deployer question 20.
Deployer reports having deployed to: _________________________
a. Deployment location required malaria prophylaxis?
Yes
No (go to block 15)
b. Did deployer receive anti-malarial prophylaxis
Yes (go to block 15)
No
AND report compliance?
c. If no, determine need for prophylaxis. Prescription indicated?
Yes (complete blocks 19 and 20)
No (briefly state reason):
_________________________________
15. Animal bite (rabies risk) as reported on deployer question 21.
a. Did deployer mark “yes” on animal bite/scratch?
Yes
No (go to block 16)
b. If yes, based on details of event and care received
Yes (complete blocks 19 and 20)
is a referral and/or follow-up indicated?
No (provide risk education)
Note: Rabies incubation period can be months to
Was appropriately treated
years. Rabies prophylaxis can begin at anytime.
Already under care
Already has referral
Situation was not a risk for rabies
Other reason (explain):
_______________________
DD FORM 2796, OCT 2015
Page 8 of 10 Pages
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business