Dd Form 2796 Draft - Post-Deployment Health Assessment (Pdha) Page 9
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10This form must be completed electronically. Handwritten forms will not be accepted.
Deployer’s SSN (Last 4 digits): _______________________
16. Suicide risk evaluation.
a. Ask “Over the PAST MONTH, have you been bothered
Yes
by thoughts that you would be better off dead or of
No (go to block 17)
hurting yourself in some way?”
b. If 16.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 16.a. was yes, ask: “Have you had thoughts of
Yes (If yes, ask questions 16d. through 16g.)
actually hurting yourself?”
No (If no thoughts of self-harm, go to block 17)
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
acting on a thought. How likely do you think it is that you will
Somewhat likely
act on these thoughts about hurting yourself or ending
Very likely
your life over the next month?”
f. Ask “Is there anything that would prevent or
Yes What? ___________________________________
keep you from harming yourself?”
No
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
S A M P L E
psychiatric disorder, recent loss, financial stress,
______________________________________________
legal disciplinary problems, or serious physical illness).
i. Does deployer pose a current risk for harm to self?
Yes (complete blocks 19 and 20)
No
17. 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 18)
If yes, ask additional questions to determine
extent of problem (target, plan, intent, past history) Comments:
_____________________________________________________
b. Does member pose a current risk to others?
Yes (complete blocks 19 and 20)
No (briefly state reason): _________________________
DD FORM 2796, OCT 2015
Page 9 of 10 Pages
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