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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 | Forensic Pathology Investigations (FPI) | 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 Student Nomination_JAN20

Form/Template
1/22/2020

Student nomination form for both JMOCs and JMPT.

Form 543

Form/Template
1/2/2020

DMRTI JOP Student Nomination

Form/Template
12/11/2019

Student nomination form for all DMRTI Joint Operations Program courses, to include, JMOC-B/A, JMPT, and JHOC.

AFHSB 501 Request Form

Form/Template
11/26/2019

Armed Forces Health Surveillance Branch (AFHSB) Epidemiology and Analysis AFHSB 501 Request Form

DHA-GL Worksheet 41: DoD/VA MOA Inpatient-Outpatient Continued Stay Review

Form/Template
11/20/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

EACE Data Request Form

Form/Template
11/20/2019

Form for users to fill out to request information/data from EACE

DHA-GL Worksheet : Discharge Summary

Form/Template
11/14/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

DHA-GL Worksheet 07: DVA/DoD MOA Initial Referral & Authorization VAMC Richmond Only

Form/Template
11/14/2019

To collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

Data Sharing Agreement (DSA) - Renewal Request Template 2019.10.28

Form/Template
10/25/2019

The Data Sharing Agreement Renewal Request template is used when requesting the renewal of an executed DSA.

Recommended Content:

Submit a Data Sharing Application
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