DA Form 2173 at a glance
What it is: DA Form 2173 (JUN 2021), the Statement of Medical Examination and Duty Status, is required for a Line of Duty Investigation.
Who signs: Enter 22. TYPED OR WRITTEN NAME OF PROVIDER/SARC/UA/READINESS, then sign at 23. SIGNATURE and enter 24. DATE. Enter 39. NAME/GRADE OF IMMEDIATE/UNIT COMMANDER OR SARC, then sign at 40. SIGNATURE and enter 41. DATE.
Section I is to be completed by the attending physician or hospital patient administrator (UA/Readiness/SARC's may complete with substantiating medical records). Section II is to be completed by the immediate commander or SARC.
Its principal purpose is to provide information regarding a Soldier's status when injury, illness, disease or death occurs.
A filled-in DA Form 2173 example: a drill-weekend knee injury
How to fill out DA Form 2173, box by box
1. THRU, 2. TO, 3. FROM, 4. NAME OF SOLDIER EXAMINED, 5. SSN and 6. GRADE
Enter 1. THRU, 2. TO and 3. FROM, then 4. NAME OF SOLDIER EXAMINED (Last, First, Middle Initial), 5. SSN and 6. GRADE.
7. UNIT OF ASSIGNMENT ADDRESS and 8. ACCIDENT/INCIDENT INFORMATION
Enter 7. UNIT OF ASSIGNMENT ADDRESS. Under 8. ACCIDENT/INCIDENT INFORMATION, enter a. Date/Time and b. Location.
Section I, 9. SOLDIER WAS, 10. HOSPITAL NAME and 11. HOUR/DATE EXAMINED
For 9. SOLDIER WAS:, mark OUT PATIENT, ADMITTED or DEAD ON ARRIVAL.
Enter 10. HOSPITAL NAME and 11. HOUR/DATE EXAMINED.
12. NATURE AND EXTENT OF INJURY ILLNESS DISEASE RESULTING IN DEATH and 13. ICD-10 CODE
For 12. NATURE AND EXTENT OF, mark INJURY, ILLNESS, DISEASE or RESULTING IN DEATH, and explain (or history of the disease).
Enter 13. ICD-10 CODE.
14. MEDICAL OPINION, 15. alcohol or drugs, 16. result, 17. blood test and drug screen
14. MEDICAL OPINION: Lines 15-23 must be completed by a Physician, Physician Assistant or Nurse Practitioner (UA/Readiness/SARC's may complete with substantiating medical records).
For 15, mark SOLDIER WAS or WAS NOT UNDER THE INFLUENCE OF ALCOHOL or DRUGS (Specify), or mark UNKNOWN.
For 16, mark DRUGS OR ALCOHOL MAY or MAY NOT HAVE RESULTED IN THE SOLDIERS INJURY, ILLNESS, DISEASE OR DEATH, or mark UNKNOWN.
For 17. BLOOD TEST MADE?, mark YES, NO or UNKNOWN. If Yes: enter the No. of MG ALCOHOL/100 ML BLOOD.
For DRUG SCREEN DONE?, mark YES (Attach results) or NO.
18. follow-on care, 19. claim, 20. prior to service and 21. prior to current duty
For 18, mark INJURY IS or IS NOT LIKELY TO REQUIRE FOLLOW-ON CARE, or mark UNKNOWN.
For 19, mark INJURY IS or IS NOT likely to result in a claim against the government for future medical care, or mark UNKNOWN.
For 20. DID INJURY ILLNESS OR DISEASE EXIST PRIOR TO SERVICE?, mark YES or NO (ONLY CAN BE DETERMINED BY A PHYSICIAN, PA, or NP), or mark UNKNOWN.
For 21. CONDITION EXISTED PRIOR TO START OF CURRENT DUTY?, mark YES or NO (ONLY CAN BE DETERMINED BY A PHYSICIAN, PA, or NP), or mark UNKNOWN.
22. provider, 23. SIGNATURE and 24. DATE
Enter 22. TYPED OR WRITTEN NAME OF PROVIDER/SARC/UA/READINESS, then sign at 23. SIGNATURE and enter 24. DATE.
Section II, 25. NAME OF SOLDIER EXAMINED, 26. SSN and 27. GRADE
Enter 25. NAME OF SOLDIER EXAMINED, 26. SSN and 27. GRADE.
28. DUTY STATUS, 29. ABSENT WITHOUT LEAVE, 30. AUTHORIZED TRAVEL STATUS, 31. and 32.
For 28. DUTY STATUS:, mark PRESENT or EXCUSED.
For 29. ABSENT WITHOUT LEAVE (DOCUMENTED?), mark YES or NO.
For 30. SOLDIER WAS INJURED IN AUTHORIZED TRAVEL STATUS PER JTR, mark YES or NO.
Enter 31. DATE AND TIME OF DUTY and 32. DUTY STATUS LOCATION.
33. FEDERAL ORDERS, 34. INACTIVE DUTY TRAINING and 35. DIED OF INJURIES
For 33. SOLDIER WAS ON FEDERAL ORDERS:, mark > 30 DAYS or 30 DAYS OR LESS.
For 34. SOLDIER WAS IN INACTIVE DUTY TRAINING STATUS:, enter the DATE/TIME IDT BEGAN and ENDED.
For 35. SOLDIER DIED OF INJURIES RECEIVED PROCEEDING DIRECTLY:, mark TO, FROM or DURING TRAINING, or mark NA.
36. DETAILS OF INCIDENT - REMARKS
Enter 36. DETAILS OF INCIDENT - REMARKS (If additional space is needed, attach enclosures as necessary).
37. FORMAL LINE OF DUTY INVESTIGATION REQUIRED and 38. INJURY INCURRED IN LINE OF DUTY
For 37. FORMAL LINE OF DUTY INVESTIGATION REQUIRED, mark YES or NO (*NOTE-An informal investigation can only result in an ILD finding).
For 38. INJURY IS TO HAVE BEEN INCURRED IN LINE OF DUTY, mark YES or NO (Not applicable on deaths).
Section II, 39. commander or SARC, 40. SIGNATURE and 41. DATE
Enter 39. NAME/GRADE OF IMMEDIATE/UNIT COMMANDER OR SARC, then sign at 40. SIGNATURE and enter 41. DATE.
More rules for DA Form 2173
For use of this form, see AR 600-8-4. The proponent agency is DCS, G-1.
Disclosure is voluntary, however, failure to provide the information will interfere with the proper adjudication of the Soldier's case in the best interest of the Soldier and the United States Army.
The previous edition is obsolete.
Sources
[1] Form DA 2173 (JUN 2021), Statement of Medical Examination and Duty Status, U.S. Department of the Army (the Official source link on this page).