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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.

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VENDOR UNSOLICITED PROPOSAL IN SUPPORT OF COVID-19

Form/Template
4/7/2020

Unsolicited Proposal Information Supporting COVID-19

Recommended Content:

Component Acquisition Executive | Coronavirus

Refrigerator Temperature Log - Celsius

Form/Template
3/23/2020

Temperature log for refrigerators storing vaccines, with form for recording vaccine storage troubleshooting.

Recommended Content:

Vaccine Storage and Handling

Freezer Temperature Log - Celsius

Form/Template
3/23/2020

Temperature log for freezers storing vaccines, with form for recording vaccine storage troubleshooting.

Recommended Content:

Vaccine Storage and Handling

Freezer Temperature Log - Fahrenheit

Form/Template
3/23/2020

Temperature log for freezers storing vaccines, with form for recording vaccine storage troubleshooting.

Recommended Content:

Vaccine Storage and Handling

Refrigerator Temperature Log - Fahrenheit

Form/Template
3/23/2020

Temperature log for refrigerators storing vaccines, with form for recording vaccine storage troubleshooting.

Recommended Content:

Vaccine Storage and Handling

DD Form 3111: Routine Immunization Screening Form: Adult

Form/Template
3/17/2020

A screening checklist for contraindications to vaccines for adults.

DD Form 3110: Routine Immunization Screening Form: Pediatric

Form/Template
3/17/2020

A screening checklist for contraindications to vaccines for children and teens.

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 | Office of the Armed Forces Medical Examiner | 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.

Pediatric and Adult Influenza Screening and Immunization Documentation

Form/Template
2/1/2020

A form for screening both children and adults for contraindications to receiving influenza vaccine.

Recommended Content:

Influenza, Northern Hemisphere

DMRTI JOP Nomination Form

Form/Template
1/30/2020

Nomination form for JMOC, JMPT, and JHOC

Recommended Content:

Joint Humanitarian Operations Course (JHOC) | Joint Medical Operations Course (JMOC) | Joint Medical Planning Tool Course | Defense Medical Readiness Training Institute | Combat Support | Defense Medical Readiness Training Institute | Joint Humanitarian Operations Course (JHOC) | Joint Medical Operations Course | Joint Medical Planning Tool Course

DMRTI JOP Student Nomination_JAN20

Form/Template
1/22/2020

Student nomination form for both JMOCs and JMPT.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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