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Get DA 2173 1972

DATE 32. INJURY IS CONSIDERED TO HAVE BEEN INCURRED IN LINE OF DUTY Not applicable on deaths 34. TYPED NAME AND GRADE OF UNIT COMMANDER OR UNIT ADVISER DA FORM 2173 OCT 1972 REPLACES DA FORM 2173 1 JUN 66 WHICH IS OBSOLETE. APD PE v2. STATEMENT OF MEDICAL EXAMINATION AND DUTY STATUS For use of this form see AR 600-8-4 the proponent agency is DCS G-1. THRU Include ZIP Code TO Include ZIP Code FROM Include ZIP Code 1. NAME OF INDIVIDUAL EXAMINED Last First and Middle Initial 2. SSN 4. ORGANIZATION AND STATION 3. GRADE ACCIDENT INFORMATION b. PLACE City and State a* DATE SECTION I - TO BE COMPLETED BY ATTENDING PHYSICIAN OR HOSPITAL PATIENT ADMINISTRATOR OUT PATIENT DEAD ON ARRIVAL 6. INDIVIDUAL WAS ADMITTED 7. NAME OF HOSPITAL OR TREATMENT FACILITY 8. HOUR AND DATE ADMITTED INJURY a* b. INDIVIDUAL c* IS d. W AS RESULTING IN DEATH Explain DISEASE DRUGS Specify Attach Psychiatric evaluation if appropriate. IS NOT LIKELY TO RESULT IN A CLAIM AGAINST THE GOVERNMENT FOR FUTURE MEDICAL CARE* WAS NOT INCURRED IN LINE OF DUTY. PERMANENT PARTIAL BASIS FOR OPINION 13. BLOOD ALCOHOL TEST MADE PERMANENT TOTAL 15. DETAILS OF ACCIDENT OR HISTORY OF DISEASE YES 14. NO. OF MG ALCOHOL/100 ML BLOOD NO how where when 17. TYPED OR PRINTED NAME OF ATTENDING PHYSICIAN OR PATIENT ADMINISTRATOR 16. DATE ALCOHOL WAS NOT UNDER THE INFLUENCE OF WAS NOT MENTALLY SOUND 12. THE FOLLOWING DISABILITY MAY RESULT TEMPORARY MILITARY 9. HOUR AND DATE EXAMINED 10. NATURE AND EXTENT OF 11. MEDICAL OPINION CIVILIAN 18. SIGNATURE 19. DUTY STATION PRESENT FOR DUTY ABSENT WITHOUT AUTHORITY ABSENT WITH AUTHORITY ON PASS HOUR AND DATE OF ABSENCE FROM b. TO ON LEAVE 21. ABSENCE WITHOUT AUTHORITY MATERIALLY INTERFERRED WITH THE PERFORMANCE OF MILITARY DUTY Explain in Item 30 type of duty missed hours of duty and how it did or did not interfere with performance ACTIVE DUTY ACTIVE DUTY FOR TRAINING HOUR AND DATE TRAINING a* BEGAN b. ENDED INACTIVE DUTY TRAINING 24. RESERVIST DIED OF INJURIES RECEIVED PROCEEDING 25. MODE OF TRANSPORTATION 26. HOUR BEGINNING TRAVEL DIRECTLY TO TRAINING DIRECTLY FROM TRAINING 27. DISTANCE INVOLVED 28. NORMAL TIME FOR TRAVEL 29. DUTY STATUS AT TIME OF DEATH IF DIFFERENT FROM TIME OF INJURY OR CONTRACTION OF DISEASE 31. FORMAL LINE OF DUTY INVESTIGATION REQUIRED 33. STATEMENT OF MEDICAL EXAMINATION AND DUTY STATUS For use of this form see AR 600-8-4 the proponent agency is DCS G-1. THRU Include ZIP Code TO Include ZIP Code FROM Include ZIP Code 1. NAME OF INDIVIDUAL EXAMINED Last First and Middle Initial 2. THRU Include ZIP Code TO Include ZIP Code FROM Include ZIP Code 1. NAME OF INDIVIDUAL EXAMINED Last First and Middle Initial 2. SSN 4. ORGANIZATION AND STATION 3. GRADE ACCIDENT INFORMATION b. PLACE City and State a* DATE SECTION I - TO BE COMPLETED BY ATTENDING PHYSICIAN OR HOSPITAL PATIENT ADMINISTRATOR OUT PATIENT DEAD ON ARRIVAL 6. SSN 4. ORGANIZATION AND STATION 3. GRADE ACCIDENT INFORMATION b. PLACE City and State a* DATE SECTION I - TO BE COMPLETED BY ATTENDING PHYSICIAN OR HOSPITAL PATIENT ADMINISTRATOR OUT PATIENT DEAD ON ARRIVAL 6. INDIVIDUAL WAS ADMITTED 7. NAME OF HOSPITAL OR TREATMENT FACILITY 8. HOUR AND DATE ADMITTED INJURY a* b. .

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