E ZIP Code) TO: (Include ZIP Code) FROM: (Include ZIP Code) 1. NAME OF INDIVIDUAL EXAMINED (Last, First, and Middle Initial) 2. SSN 5. 4. ORGANIZATION AND STATION 3. GRADE ACCIDENT INFORMATION a. DATE b. PLACE (City and State) SECTION I - TO BE COMPLETED BY ATTENDING PHYSICIAN OR HOSPITAL PATIENT ADMINISTRATOR 6. INDIVIDUAL WAS OUT PATIENT ADMITTED DEAD ON ARRIVAL 7. NAME OF HOSPITAL OR TREATMENT FACILITY 8. HOUR AND DATE ADMITTED 10. NATURE AND EXTENT OF 11. MEDICAL OPINION: INJURY.
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the Da 2173 online
The DA 2173 form, also known as the statement of medical examination and duty status, is essential for documenting medical evaluations and duty statuses. This guide provides clear, step-by-step instructions on how to complete the form accurately and efficiently online.
Follow the steps to fill out the form correctly.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling in the personal information of the individual examined. Enter their name, social security number, organization, station, and grade in the appropriate fields.
- Provide the accident information, including the date and place (city and state) where the incident occurred.
- In Section I, completed by the attending physician or hospital patient administrator, specify whether the individual was an outpatient, admitted, or dead on arrival. Provide the name of the hospital or treatment facility, as well as the hour and date admitted and examined.
- Detail the nature and extent of the injury or disease, and give the medical opinion on the case. Indicate if the individual was under the influence of drugs or alcohol and include additional notes if necessary.
- Complete Section II, which is for the unit commander or unit adviser. Document the duty station, whether the individual was present for duty, absent with or without authority, and details about any training.
- Provide details of the accident or the history of the disease, including explanations of how the incident interfered with military duty if applicable. Make sure to indicate if a formal line of duty investigation is required.
- Finalize the form by typing or printing the names and signatures of the attending physician or patient administrator, and unit commander or unit adviser in the designated spaces.
- Once all fields are completed, review the information for accuracy before saving any changes, downloading, printing, or sharing the form.
Complete the DA 2173 form online to ensure accurate documentation and compliance with requirements.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
Jun 16, 2022 — ... DA-2173 form. If the officer cannot make this request or if the...
Nov 13, 2006 — Effective immediately, for approved projects within your respective...
This manual was prepared to help you un- derstand the operation and maintenance of your...
Get answers to your most pressing questions about US Legal Forms API.
What is a DA form 2173 used for?
The DA form 2173 serves to document injuries or medical incidents that occur while on active duty. This form is essential for processing claims related to medical treatment and disability benefits. By utilizing the DA 2173, service members can ensure their injuries are officially recorded, enabling them to access the appropriate support. Explore our platform at uslegalforms for helpful tools that simplify understanding how to use the DA 2173 effectively.
How to fill out DA 2142?
To fill out the DA 2142, start by reviewing the instructions that accompany the form. Collect all necessary information before beginning, such as identification details and particulars of the situation being reported. Make sure to follow each section carefully, as accuracy is crucial. If you need additional assistance, uslegalforms provides templates and tips to facilitate the process.
How to fill out 2173?
Filling out the DA 2173 requires careful attention to detail. First, gather all relevant information, including your personal details and the circumstances surrounding the incident. Use clear and concise language when describing the events. For extra guidance, you can use resources available on the uslegalforms platform to ensure your DA 2173 is completed accurately.
How to get a lod in the army?
Obtaining a Line of Duty (LOD) determination in the Army involves completing the DA 2173 to document your injury or illness. Clearly outline the specifics of the incident as well as witness statements if applicable. This process may require submitting the form to your unit’s personnel officer for review and approval. Leverage the resources available on the US Legal Forms platform to ensure you submit everything correctly and efficiently.
How to fill out a 2173?
To fill out a 2173 correctly, start by providing your personal information clearly. Next, detail the nature of the injury or illness, including the date and circumstances surrounding the event. Finally, ensure all signatures are completed as required. For added guidance, the US Legal Forms platform can offer templates and resources related to the DA 2173, simplifying the process.
What is DA form 2173?
The DA form 2173 is an official document used by the U.S. Army to document an injury or illness sustained while on active duty or during inactive duty training. This form is crucial for claiming benefits and providing necessary information to military authorities. Understanding the purpose of the DA 2173 can ensure that service members receive the support they deserve in case of an injury.
How to fill out an APO form?
Filling out an APO form is a straightforward process. First, gather all relevant personal information, such as your name, address, and service details. Next, clearly complete each section of the form, following the provided instructions. If you need assistance, consider using the US Legal Forms platform, which offers reliable resources to help you with various military forms, including the DA 2173.
What is a DA 2173?
A DA 2173 is an official form used by the army to document injuries or illnesses that occur during duty. It serves as the foundation for initiating a Line of Duty investigation. Properly completing and submitting this form ensures that the service member can access necessary benefits and support related to the incident.
How to start an lod army?
To start a Line of Duty (LOD) investigation in the army, you need to complete a DA form 2173 accurately. Submit the completed form through your chain of command, providing any required documentation that supports your case. Early initiation of this process can lead to timely benefits and support for your situation.
What is the line of duty process?
The Line of Duty (LOD) process involves investigating whether an injury or illness occurred while a service member was on active duty. This process begins with the submission of a DA form 2173 and includes collecting evidence and testimonies. Ultimately, the army determines if the incident is service-connected, impacting benefits and assistance.
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.