Da Form 2173 - Statement Of Medical Examination And Duty Status, Oct 1972
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1STATEMENT OF MEDICAL EXAMINATION AND DUTY STATUS
For use of this form, see AR 600-8-4, the proponent agency is DCS, G-1.
THRU: (Include ZIP Code)
TO: (Include ZIP Code)
FROM: (Include ZIP Code)
1. NAME OF INDIVIDUAL EXAMINED (Last, First, and Middle Initial)
2. SSN
3. GRADE
5.
ACCIDENT INFORMATION
4. ORGANIZATION AND STATION
a. DATE
b. PLACE (City and State)
SECTION I - TO BE COMPLETED BY ATTENDING PHYSICIAN OR HOSPITAL PATIENT ADMINISTRATOR
6. INDIVIDUAL WAS
OUT PATIENT
7. NAME OF HOSPITAL OR TREATMENT FACILITY
CIVILIAN
MILITARY
ADMITTED
DEAD ON ARRIVAL
8. HOUR AND DATE ADMITTED
9. HOUR AND DATE EXAMINED
10. NATURE AND EXTENT OF
INJURY
DISEASE
RESULTING IN DEATH
11. MEDICAL OPINION:
a.
WAS
WAS NOT UNDER THE INFLUENCE OF
ALCOHOL
DRUGS (Specify):
INDIVIDUAL
WAS NOT MENTALLY SOUND
(Attach Psychiatric evaluation if appropriate).
INDIVIDUAL
WAS
b.
IS
IS NOT LIKELY TO RESULT IN A CLAIM AGAINST THE GOVERNMENT FOR FUTURE MEDICAL CARE.
INJURY
c.
BASIS FOR OPINION:
INJURY
WAS
WAS NOT INCURRED IN LINE OF DUTY.
d.
12. THE FOLLOWING DISABILITY MAY RESULT
14. NO. OF MG ALCOHOL/100 ML BLOOD
13. BLOOD ALCOHOL
TEST MADE
TEMPORARY
PERMANENT PARTIAL
PERMANENT TOTAL
YES
NO
15. DETAILS OF ACCIDENT OR HISTORY OF DISEASE (how, where, when)
18. SIGNATURE
16. DATE
17. TYPED OR PRINTED NAME OF ATTENDING
PHYSICIAN OR PATIENT ADMINISTRATOR
SECTION II - TO BE COMPLETED BY UNIT COMMANDER OR UNIT ADVISER
19 DUTY STATION
20.
HOUR AND DATE OF ABSENCE
PRESENT FOR DUTY
ABSENT WITHOUT AUTHORITY
a. FROM
b. TO
ABSENT WITH AUTHORITY:
ON PASS
ON LEAVE
21. ABSENCE WITHOUT AUTHORITY MATERIALLY INTERFERRED WITH THE PERFORMANCE OF MILITARY DUTY (Explain in Item 30
type of duty missed, hours of duty, and how it did or did not interfere with performance)
YES
NO
22. INDIVIDUAL WAS ON
23.
HOUR AND DATE TRAINING
ACTIVE DUTY
ACTIVE DUTY FOR TRAINING
a. BEGAN
b. ENDED
INACTIVE DUTY TRAINING
24. RESERVIST DIED OF INJURIES RECEIVED PROCEEDING
DIRECTLY TO TRAINING
DIRECTLY FROM TRAINING
26. HOUR BEGINNING TRAVEL
27. DISTANCE INVOLVED
28. NORMAL TIME FOR TRAVEL
25. MODE OF TRANSPORTATION
29. DUTY STATUS AT TIME OF DEATH IF DIFFERENT FROM TIME OF INJURY OR CONTRACTION OF DISEASE
PRESENT FOR DUTY
ABSENT WITH AUTHORITY
ABSENT WITHOUT AUTHORITY
30. DETAILS OF ACCIDENT - REMARKS (If additional space is needed, continue on reverse) (Attach inclosures as necessary)
INJURY IS CONSIDERED TO HAVE BEEN INCURRED IN LINE OF
31. FORMAL LINE OF DUTY INVESTIGATION REQUIRED
32.
DUTY (Not applicable on deaths)
YES
NO
YES
NO
33. DATE
35. SIGNATURE
34.
TYPED NAME AND GRADE OF UNIT COMMANDER OR
UNIT ADVISER
REPLACES DA FORM 2173, 1 JUN 66, WHICH IS OBSOLETE.
DA FORM 2173, OCT 72
APD V2.01
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