How to Fill Out DA Form 3365

DA Form 3365 at a glance

What it is: DA Form 3365 is the Authorization for Medical Warning Tag under AR 40-66.

Who signs: The REQUESTING MEDICAL OR DENTAL OFFICER signs, with the TYPED NAME AND SIGNATURE, and enters the DATE. The Responsible Officer signs on the Signature of Responsible Officer line and enters the DATE DELIVERED.

A filled-in DA Form 3365 example: a clinic officer requests a warning tag

DA Form 3365 example filled out, example: a clinic officer requests a warning tag
A clinic medical officer requests a patient's warning tag. The tag needs 1 line of text, so Tag content lines 2 to 5 stay empty. The picture shows the request before delivery; every value in it is made up. Nothing goes in Tag delivered to patient because the tag is not yet delivered. Remarks is left blank because nothing else needs saying. Person to call if other than patient is left blank because the patient is the contact. The patient is a made-up sergeant named John A. Sample, so Patient identification holds his unit, home address, phone number, name, grade and a made-up number.

How to fill out DA Form 3365, box by box

To and from

DA Form 3365 example filled out, to and from

Under TO, include the ZIP Code. Under FROM, enter the Medical Treatment Facility (Specify Clinic, Ward, etc.).

Typed name, signature and date of the requesting officer

DA Form 3365 example filled out, typed name, signature and date of the requesting officer

The REQUESTING MEDICAL OR DENTAL OFFICER signs, with the TYPED NAME AND SIGNATURE, and enters the DATE.

Tag content lines

DA Form 3365 example filled out, tag content lines

Under TAG CONTENT, enter the content of the tag by LINE NO. and SPACE NUMBER.

Remarks

DA Form 3365 example filled out, remarks

Write any REMARKS in the REMARKS box.

Tag delivered to patient

DA Form 3365 example filled out, tag delivered to patient

The Responsible Officer signs on the Signature of Responsible Officer line and enters the DATE DELIVERED.

Person to call if other than patient

DA Form 3365 example filled out, person to call if other than patient

If the PERSON TO CALL is other than the patient, enter the NAME AND RELATIONSHIP TO PATIENT, ADDRESS and PHONE NUMBER.

Patient identification

DA Form 3365 example filled out, patient identification

Under PATIENT IDENTIFICATION, enter the PATIENT'S NAME (Last, first, middle), GRADE OR STATUS and IDENTIFICATION NUMBER.

Under PATIENT IDENTIFICATION, enter the ORGANIZATION, UNIT, LOCATION (Military Pers ONLY), HOME ADDRESS (Include Zip Code) and PHONE NUMBER.

Sources

[1] DA Form 3365 (AUG 1968), Authorization for Medical Warning Tag, Office of The Surgeon General (the Official source link on this page).

Da 3365 Form PDF Details

What Is DA Form 3365?

DA Form 3365, titled "Authorization for Medical Warning Tag," is an official US Army medical document governed by Army Regulation AR 40-66 under the Office of The Surgeon General. Medical treatment facilities use this form to authorize and document the issuance of a medical warning tag to a patient who has a specific health condition, allergy, or treatment requirement that emergency responders must know about.

What the Authorization Form Records

When completing this form, the following details are captured:

Role of This Form in Army Medical Records

Under AR 40-66, all medical warning tags issued at Army facilities must be formally authorized through this pdf form. The completed authorization is filed as part of the patient's official Army health record, ensuring the chain of custody for the tag is properly documented. This standard process upholds the Army's commitment to patient safety and accurate medical documentation across all military treatment facilities.

QuestionAnswer
Form NameDa 3365 Form
Form Length1 page
Fillable?Yes
Fillable fields108
Avg. time to fill out15 sec
Other namesPers, V1, da form 3365, form

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