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Military Health System

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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.

Please note that files more than two years old may not be compliant with Section 508 of the Rehabilitation Act. If you need an accessible version of a particular file, please contact us and we will provide one for you.

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DHA Form 116: Pediatric and Adult Influenza Screening and Immunization Documentation

Form/Template
8/25/2023

A form for screening both children and adults for contraindications to receiving influenza vaccine. (v5, August 2023)

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Celsius

Form/Template
8/22/2023

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.

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Fahrenheit

Form/Template
8/22/2023

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.

Vaccine Emergency Storage Plan Worksheet

Form/Template
8/22/2023

Provides guidance on how to maintain vaccine storage requirements during an emergency.

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

Form/Template
8/10/2023

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.

DHA Form 177: Potentially Compromised Temperature Sensitive Medical Product Worksheet

Form/Template
8/1/2023

TSMP collectively refers to: vaccines, some pharmaceuticals, temperature sensitive laboratory supplies, and other temperature sensitive medical items.

340b Verification Form

Form/Template
6/12/2023

340b Verification Form to be completed by the manufacturer and pharmacy for any 340b claim disputes.

DHA DRT Quick Reference Guide

Form/Template
5/31/2023

Revised DSA Form - DSA Data Requests Templates Quick Reference Guide

De Identification Plan Template May 2023

Form/Template
5/31/2023

Use this updated template to provide the de-identification process to be used for your project. The plan should show how MHS sensitive data elements (or quasi-identifiers) will be de-identified as well as how the 18 HIPAA identifiers will be handled.

AFMES Form 42-R: Evidence Chain of Custody

Form/Template
5/23/2023

Armed Forces Medical Examiner System Form 42-R, Evidence Chain of Custody.

AFMES Form 7: AFDIL Casework Request

Form/Template
5/23/2023

Armed Forces Medical Examiner System form 7 - Armed Forces DNA Identification Laboratory Casework Request.

AFMES Form 44: DFT Client Feedback Survey

Form/Template
5/23/2023

AFMES Form 44 Division of Forensic Toxicology Client Feedback Survey.

81st MDG Keesler AFB MEDCOI

Form/Template
5/17/2023

Privacy Impact Assessment, 81st Medical Group (MDG) Keesler Air Force Base (AFB) Medical Community of Interest (MEDCOI).

CIS MIL Enclave PIA

Form/Template
5/17/2023

Privacy Impact Assessment, Clinical Information System (CIS) -.mil Enclave.

66th MDG Hanscom AFB MEDCOI

Form/Template
5/17/2023

Privacy Impact Assessment 66th MDG Hanscom AFB MEDCOI.

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Last Updated: July 11, 2023
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