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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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Toxicology Submission Guidelines

Form/Template
4/4/2016

Guidelines for the collection and shipment of toxicology specimens

DHA Form 61, Privacy Threshold Analysis (PTA)

Form/Template
3/31/2016

The purpose of the PTA is to identify if a system contains personally identifiable information (PII); and determine whether a Privacy Impact Assessment (PIA) is required, whether a System of Records Notice (SORN) is required, and if any other privacy requirements apply to the information system.

Recommended Content:

Privacy Impact Assessments | Privacy and Civil Liberties

Report of Medical Assessment, DD Form 2697

Form/Template
3/30/2016

This form is used by the Medical Services to provide a comprehensive medical assessment for active and reserve component service members separating or retiring from active duty.

DHA PIA Desk Reference Guide

Form/Template
3/21/2016

The DHA PIA Guide addresses the common issues encountered during the completion of a PIA. This PIA Guide enhances the assessment process and helps the DHA Privacy and Civil Liberties Office efficiently conduct a PIA review to completion.

Recommended Content:

Privacy Impact Assessments

FCC Request Form

Form/Template
3/9/2016

Student nomination form for the FCC/PRA Basic Operations Course

EPRC Course for Operator/Responder: Evaluation Form

Form/Template
3/8/2016

must be completed to get a certificate

EPRC Course for Executives/Commanders: Evaluation Form

Form/Template
3/8/2016

must be completed to get a certificate

EPRC Course for Clinicians: Evaluation Form

Form/Template
3/8/2016

must be completed to get a certificate

EPRC Course for Executives/Commanders: Attestation Statement

Form/Template
3/8/2016

Must be completed and signed to get a certificate.

EPRC Course for Clinicians: Attestation Statment

Form/Template
3/8/2016

Must be completed and signed to get a certificate.

EPRC Course for Operator/Responders: Attestation Statement

Form/Template
3/8/2016

Must be completed and signed to get a certificate.

Joint Medical Operations Course/Joint Medical Planning Tool Nomination Request Form

Form/Template
3/7/2016

Submission of this request indicates that the nominee is available for training and has the full endorsement of the nominating command.

Faculty Disclosure Form

Form/Template
3/4/2016

All faculty participating in a sponsored activity are expected to disclose to the activity audience any significant financial interest or other relationship (1) with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in an educational presentation and (2) with any commercial supporters of the activity.

Biographic Data Form

Form/Template
3/4/2016

Information for each faculty member must be typed directly on this form. The information you provide may be used for your introduction and/or publication in course materials.

Reserve Heath Readiness Program Historical Update Request Form

Form/Template
3/2/2016

This form allows Service Members to present RHRP with the latest services obtained through a private health care provider.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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