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Forms & Templates

On this page, you will find various forms that Military Health System uses to support its programs. Please scroll down the page or use the search box to find specific forms and templates.

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Research Repository Template

Form/Template
1/20/2021

The RRT asks researchers whether they intend to put data into a repository, and if yes, what data and under what governance terms.

Recommended Content:

Privacy and Civil Liberties

Data Sharing Agreement Application (DSAA)

Form/Template
1/12/2021

The Data Sharing Agreement Application (DSAA) is used when requesting data from systems that are owned and/or managed by DHA.

Recommended Content:

Submit a Data Sharing Application

EWSC Student Enrollment Form

Form/Template
1/8/2021

Fillable student enrollment form for EWSC registration.

JOP Nomination Form

Form/Template
11/24/2020

Student/nominee JOP course request form.

DHA Privacy Office Standard Contract Language

Form/Template
10/27/2020

This Section addresses the Contractor’s requirements under The Privacy Act of 1974 (Privacy Act), The Freedom of Information Act (FOIA), and The Health Insurance Privacy and Accountability Act (HIPAA) as set forth in applicable statutes, implementing regulations and DoD issuances.

Recommended Content:

Privacy and Civil Liberties | DHA Privacy Contract Language

Pediatric and Adult Influenza Screening and Immunization Documentation

Form/Template
10/21/2020

A form for screening both children and adults for contraindications to receiving influenza vaccine.

Recommended Content:

Influenza, Northern Hemisphere

HIPAA Safeguard Review of Non-Federal Systems (HSR)

Form/Template
10/1/2020

The HIPAA Safeguard Review of Non-Federal Systems (HSR) is used when data obtained through a DSAA will be stored, transmitted, processed, or otherwise maintained on a non-federal information system.

Recommended Content:

Submit a Data Sharing Application

Dental Common Access System

Form/Template
9/2/2020

Dental Common Access System (DENCAS)

Initial/Annual Competency Assessment Checklist: INFLUENZA VACCINE ADMINISTRATION

Form/Template
8/11/2020

A checklist to evaluate competency in administering the influenza vaccine, to include customer service, patient screening and education, and administration technique and procedures.

Recommended Content:

Influenza, Northern Hemisphere

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Celsius

Form/Template
8/4/2020

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

Offsite Clinic FROZEN Vaccine Inventory Issue Return Receipt and Temp Log Celsius

Form/Template
8/4/2020

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Fahrenheit

Form/Template
8/4/2020

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

VENDOR UNSOLICITED PROPOSAL IN SUPPORT OF COVID-19

Form/Template
5/21/2020

Unsolicited Proposal Information Supporting COVID-19

Recommended Content:

Component Acquisition Executive | Coronavirus

Refrigerator Temperature Log - Celsius

Form/Template
3/23/2020

Temperature log for refrigerators storing vaccines, with form for recording vaccine storage troubleshooting.

Recommended Content:

Vaccine Storage and Handling

Freezer Temperature Log - Celsius

Form/Template
3/23/2020

Temperature log for freezers storing vaccines, with form for recording vaccine storage troubleshooting.

Recommended Content:

Vaccine Storage and Handling
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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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