Department of Defense (DD) forms
- DD 214 (11-88), Certificate of Release or Discharge from Active Duty, S/N
0102-LF-006-5500.
- DD 1172
(8-87), Application for Uniformed Services Identification and Privilege Card
DEERS Enrollment, S/N 0102-LF-001-1723.
- DD 1251
(4C) (7-91), Uniformed Services Medical Treatment Facility Non Availability
Statement, S/N 0102-LF-012-3700.
- DD 1 1934
(7-74), Geneva Convention Card for Medical and Religious Personnel Who
Serve In or Accompany the Armed Forces, S/N 0102-LF-005-8700.
- DD 2161
(10-78), Referral for Civilian Medical Care, S/N 0102-LF-002-1611.
- DD 2493-1
(3-87), Asbestos Exposure Initial Medical Questionnaire - Part 1, S/N
0102-LF-002-4935.
- DD 2493-2
(3-87), Asbestos Exposure Initial Medical Questionnaire - Part 2, S/N
0102-LF-002-4940.
- DD 2697
(2-95), Report of Medical Assessment. Used in conjunction with physical
examination.
Bureau of Medicine and Surgery (NAVMED) forms
- NAVMED 6100/5 (10-89), Abbreviated Limited Duty Medical Board Report, S/N
0105-LF-2800.
- NAVMED 6120/1
(1-82), Competence for Duty Examination, S/N 0105-LF-206-1206.
- NAVMED 6150/2
(4-70), Special Duty Medical Abstract, S/N 0105- 209-5021.
- NAVMED 6150/20
(1-94), Summary of Care, S/N 0105-LF-017-9000. (Replaced by) DD
2766 (3-98) Adult Preventive and Chronic Care Flowsheet, (S/N number not available
yet, should be have soon.)
- NAVMED 6260/5
(5-90), Periodic Health Evaluation, Navy Asbestos Medical Surveillance
Program, History and Physical Examination, S/N 0105-LF-009-9800.
- NAVMED 6260/7
(5-90), Periodic Health Evaluation, Navy Asbestos Medical Surveillance
Program, Roentgenographic Interpretation for Pneumoconiosis, S/N 0105-LF-009-9900.
- NAVMED 6410/1
(6-78), Grounding Notice (Aero Medical), S/N 0105-LF-206-4105.
Chief of Naval Operations (OPNAV) forms
- OPNAV 5100/15 (5-90), Medical Surveillance Questionnaire, S/N 0107-LF-010-1400
- OPNAV 1 650/3
, Personal Award Recommendation (1-94), S/N 0107-LF-017-5800
Navy Comptroller (NAVCOMPT) form
- NAVCOMPT 3065
(2-83), Leave Request/Authorization, S/N 0104-LF-703-0656
Bureau of Naval Personnel (NAVPERS) forms
- NAVPERS 1000/22 (11-81), Acceptance and Oath of Office, S/N 0106-LF-010-0851
- NAVPERS 1 070/66
(8-82), Officer Service Record, Navy, S/N 0106- LF-017-1662
- NAVPERS 1070/74
(9-75), Officer's Report of Home of Record and Place from which
Ordered to a Tour of Active Duty, S/N 0106-LF-010-7320
- NAVPERS 1 070/602
(7-72), Dependency Application/Record of Emergency, S/N
0106-LF-018-6035
- NAYPERS 1210/5
(9-75), Classification Officer Qualifications Questionnaire, S/N
0106-LF-012-1025
- NAVPERS 1 301/1
(10-83), Officer Preference and Personal Information Card, S/N
0106-LF-013-0109
- NAVPERS 1336/3
(9-75), Special Request/Authorization, S/N 0106- LF-063-8633
The following forms are available from the Federal Supply System through normal supply
procurement procedures:
- SF 513
(4-98), Medical Record Consultation Sheet NSN 7540-00-634-4127.
- SF 523
(10-75), Authorization for Autopsy, NSN 7540-00-634-4166.
- SF 600
(6-97), Chronological Record of Medical Care, NSN 7540-00-634-4176.
The following form is available from the Bureau of Naval Personnel:
- NAVPERS 1301/51
, Officer Data Card. (Rev. 6-95).
Reviewed by LCDR Robert A. Rahal, MSC, USN, Assistant Specialty Leader for
Patient Administration, Bureau of Medicine and Surgery, Washington, D.C. (1999).