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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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Freezer Temperature Log - Celsius

Form/Template
3/25/2021

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

Recommended Content:

Vaccine Storage and Handling

Refrigerator Temperature Log - Fahrenheit

Form/Template
3/25/2021

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

Recommended Content:

Vaccine Storage and Handling

Steps to take for Potentially Compromised Vaccine Event

Form/Template
3/25/2021

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

DHA Form 207: COVID-19 Vaccine Screening and Immunization Document, v19

Form/Template
3/25/2021

The purpose of this form is to determine if the COVID-19 vaccine can be administered to the patient. (v19, April 2022)

Recommended Content:

Coronavirus | COVID-19 Vaccine Efforts | Coronavirus and the COVID-19 Vaccine | COVID-19 Information for Military Treatment Facility Directors

Refrigerator Temperature Log - Celsius

Form/Template
3/25/2021

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

Recommended Content:

Vaccine Storage and Handling

Emergency Vaccine Retrieval and Storage Plan Worksheet

Form/Template
3/24/2021

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

Sample WISDOM Agenda 5 Day

Form/Template
2/11/2021

Recommended Content:

M2 Functional Specifications | MDR, M2, ICDs Functional Support

aCME Disclosure FY20 Fillable

Form/Template
1/29/2021

Instructor CME Disclosure form

Recommended Content:

Defense Medical Readiness Training Institute | DMRTI Course Information | Emergency War Surgery Course (EWSC)

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

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)

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Last Updated: April 03, 2020

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

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