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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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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

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

MDR Special Justification Form

Form/Template
4/1/2020

Military Health System Data Repository (MDR) Special Justification Form. MDR Users will use this to request access to special tables in the MDR.

DD Form 3111: Routine Immunization Screening Form: Adults

Form/Template
3/11/2020

A screening checklist for contraindications to vaccines for adults.

DD Form 3110: Routine Immunization Screening Form: Pediatric

Form/Template
3/11/2020

A screening checklist for contraindications to vaccines for children and teens.

Smallpox Vaccine Screening Form

Form/Template
3/2/2020

Each potential recipient of smallpox vaccine must complete this official screening form and it must be signed by a licensed health care provider prior to vaccination.

Recommended Content:

Smallpox (ACAM2000) | Smallpox Vaccine-Associated Adverse Events

AFRSSIR Supply Order Request

Form/Template
2/12/2020

Fill out this request to place and order with the Armed Forces Repository of Specimen Sample for the Identification of Human Remains

Recommended Content:

Armed Forces Medical Examiner System | Office of the Armed Forces Medical Examiner | DoD DNA Operations | Repository of Specimen Samples for the Identification of Remains

340b Verification Form

Form/Template
2/7/2020

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

DMRTI JOP Nomination Form

Form/Template
1/30/2020

Nomination form for JMOC, JMPT, and JHOC

Recommended Content:

Joint Humanitarian Operations Course (JHOC) | Joint Medical Operations Course | Joint Medical Planning Tool Course | Defense Medical Readiness Training Institute | Combat Support | Defense Medical Readiness Training Institute | Joint Humanitarian Operations Course (JHOC) | Joint Medical Operations Course | Joint Medical Planning Tool Course
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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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