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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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Offsite Clinic FROZEN Vaccine Inventory Issue Return Receipt and Temp Log Celsius

Form/Template
3/15/2019

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Celsius

Form/Template
3/15/2019

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Fahrenheit

Form/Template
3/15/2019

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

TRICARE Retail Refund Appendix A Change Request Form

Form/Template
3/5/2019

Use this form to transfer or make changes to your current Appendix A

Request for Autopsy Report and Supplemental Information

Form/Template
2/15/2019

Use this form to obtain records/reports/photos of remains by persons legally authorized access to this information.

Recommended Content:

Office of the Armed Forces Medical Examiner

Defense Health Agency J7 Continuing Education Program Office Continuing Education Application

Form/Template
2/11/2019

Defense Health Agency J7 Continuing Education Program Office Continuing Education Application v1-5

DHAJ7 Event Planning Intake Form

Form/Template
2/11/2019

DHAJ7_Event Planning Intake Form_v7-15 (003)

Potentially Compromised Temperature Sensitive Medical Products (PC TSMP) Worksheet

Form/Template
1/7/2019

This worksheet is used when vaccines have been potentially compromised and a disposition is required.

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

PC TSMP Worksheet (Continuation Sheet)

Form/Template
1/7/2019

This is a continuation sheet for the PC TSMP worksheet when additional worksheets are required.

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

Request for DoD P&T Committee Consideration of Potential Changes to the Uniform Formulary, Basic Core Formulary or Extended Core Formulary

Form/Template
1/2/2019

Please attach MTF P&T Committee comments & meeting minutes, an explanation of the rationale for the request, copies of supporting clinical evidence, and anything else that needs to be considered by the DoD P&T Committee.

Recommended Content:

TRICARE Formulary

Guidelines for Reporting Breaches

Form/Template
11/27/2018

This document outlines the DoD reporting and notification requirements for breaches.

Recommended Content:

Breaches of PII and PHI

TRICARE Retail Pharmacy Program Questionnaire

Form/Template
10/23/2018

Please complete the TRICARE Retail Pharmacy Refunds Manufacturer Questionnaire and email to UFVARR_Requests@mail.mil.

OIG DD2949 Whistleblower Complaint Form

Form/Template
7/26/2018

This is a form that users will download and either FAX or mail to file a complaint to the DHA IG office.

Freezer Temperature Log - Celsius

Form/Template
7/12/2018

Temperature log for freezers storing vaccines.

Recommended Content:

Vaccine Storage and Handling

Freezer Temperature Log - Fahrenheit

Form/Template
7/12/2018

Temperature log for freezers storing vaccines.

Recommended Content:

Vaccine Storage and Handling
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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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