The DA 3947 form, also known as the Medical Evaluation Board Proceedings, plays a vital role in the life of military personnel facing medical challenges. Crafted under the provisions of AR 40-400 and overseen by the Office of The Surgeon General, this document serves as a comprehensive record of the medical evaluation process for service members. It meticulously documents everything from personal identification details, including name, grade, and service number, to more specific data regarding military service history, both active and inactive. Crucially, the form enables the board to convey their determinations after reviewing clinical records, laboratory findings, and physical examinations, noting down diagnoses and the medical conditions or defects identified. It outlines whether the individual presented their views, the diagnosis details including the origin, and whether these conditions were aggravated by service, directing the future course of action—a return to duty, limitations on service, referral to a Physical Evaluation Board, among others. Furthermore, it captures the service member's desire to continue active duty under certain provisions and records the action taken by the approving authority, including any appeals made by the patient against the board's findings. This document is more than a form; it's a critical tool in ensuring the welfare of service members, guiding them through the evaluation process and impacting decisions related to their military careers and health care.
| Question | Answer |
|---|---|
| Form Name | Da 3947 Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | da3947, narsum example, da form 3947 pdf fillable, da 3947 |
MEDICAL EVALUATION BOARD PROCEEDINGS
For use of this form, see AR
MEDICAL TREATMENT FACILITY
DATE
(YYYYMMDD)
1. NAME (Last, First, MI) |
2. GRADE |
3. SSN |
4. COMPONENT |
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5. DEPARTMENT |
6. SEX |
7. DATE OF BIRTH 8. ORGANIZATION |
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9. TOTAL YEARS OF MILITARY SERVICE
a. ACTIVE |
b. INACTIVE |
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10.DATE ENTERED CURRENT TOUR OF ACTIVE DUTY (YYYYMMDD)
11.MILITARY OCCUPATIONAL SPECIALTY (include code)
ACTION BY THE BOARD
BY DIRECTION OF THE APPOINTING AUTHORITY,
THE BOARD CONVENED TO EVALUATE THE PATIENT IDENTIFIED ABOVE
12. The patient |
did |
did not present views in own behalf. (When presented, attach a summary of the patient's comments to the report) |
Click here for initials:
13. DIAGNOSIS
AFTER CONSIDERATION OF CLINICAL RECORDS, LABORATORY FINDINGS, AND PHYSICAL EXAMINATION, THE BOARD FINDS THAT THE PATIENT HAS THE FOLLOWING MEDICAL CONDITIONS/DEFECTS. LIST ALL DIAGNOSIS.
a
APPROXIMATE
DATE OF
ORIGIN
b
INCURRED |
EXISTED |
PERMANENTLY |
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WHILE |
PRIOR TO |
AGGRAVATED |
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ENTITLED TO |
SERVICE |
BY SERVICE |
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BASE PAY |
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14. The board recommends that the patient be: Returned to duty
Returned to duty with the following limitations:
Referred to a Physical Evaluation Board (PEB)
Other (specify)
DA FORM 3947, SEP 1983 |
PREVIOUS EDITIONS ARE OBSOLETE. |
Page 1 of 2 |
APD PE v3.03ES
15. The patient does
does not desire to continue on active duty under AR
16.Continuance on active duty under provisions of AR
15 is affirmative) Enter assignment limitations in Item 30.
is
is not medically contraindicated. (Complete when answer to item
17. TYPED NAME AND GRADE OF PHYSICIAN
SIGNATURE
18. TYPED NAME AND GRADE OF PHYSICIAN
SIGNATURE
19. TYPED NAME AND GRADE OF PHYSICIAN
SIGNATURE
ACTION BY THE APPROVING AUTHORITY
20.
21.
22.
The findings and recommendation of the board are approved. |
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The report of the board is returned for reconsideration. |
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The report of the board is forwarded to: |
Comments are attached as inclosure |
23. TYPED NAME, GRADE AND TITLE OF APPROVING AUTHORITY
SIGNATURE
DATE (YYYYMMDD)
ACTION BY PATIENT
24.I have been informed of the approved findings and recommendation of the board.
Click here for initials:
I agree with the board's findings and recommendation.
I do not agree with the board's findings and recommendation. My appeal is attached as inclosure
25. TYPED NAME, GRADE AND SSN
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Grade: , SSN:
SIGNATURE
DATE (YYYYMMDD)
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FURTHER ACTION BY APPROVING AUTHORITY |
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26. |
The appeal has been considered and the original findings and recommendation are confirmed. |
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27. |
The appeal has been considered and the report of the board is returned for reconsideration. Attach further action as inclosure |
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28. |
The appeal has been considered and the report of the board is forwarded to: |
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Comments are attached as Enclosure |
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29. TYPED NAME, GRADE AND TITLE OF APPROVING AUTHORITY |
SIGNATURE |
DATE |
(YYYYMMDD) |
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30.CONTINUATION (Identify by item number)
TRANSITION POINT:
Continuation of Block #24:
I have reviewed the contents of the Medical Evaluation Board (MEB) packet and read the attached DA Form 3947 (Medical Board Proceedings), Narrative Summary (NARSUM), and the Physical Profile (DA Form 3349).
a. In regard to issues relating to fitness for duty and disability compensation, I understand that the PEB will consider and review only those conditions listed on the DA Form 3947.
b. The DA Form 3947 includes all my current medical conditions and whether or not they meet medical retention standards.
c. The conditions which do not meet medical retention standards are properly listed on the following three documents: DA Form 3947; the Narrative Summary; and the Physical Profile (DA Form 3349).
d. All documentation of military medical care in my possession has been provided to the Physical Evaluation Board Liaison Officer for inclusion in this MEB.
e. I agree that this MEB accurately covers all my current medical conditions.
f. If I do not agree with any of these statements and/or I do not agree with the contents of the MEB as reflected in my election at item 24, above, I have provided all my disagreements and concerns in the attached appeal.
DA FORM 3947, SEP 1983 |
Page 2 of 2 |
APD PE v3.03ES
13. DIAGNOSIS (CONT'D.)
AFTER CONSIDERATION OF CLINICAL RECORDS, LABORATORY FINDINGS, |
APPROXIMATE |
INCURRED |
EXISTED |
PERMANENTLY |
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AND PHYSICAL EXAMINATION, THE BOARD FINDS THAT THE PATIENT HAS |
DATE OF |
WHILE |
PRIOR TO |
AGGRAVATED |
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THE FOLLOWING MEDICAL CONDITIONS/DEFECTS. LIST ALL DIAGNOSIS. |
ORIGIN |
ENTITLED TO |
SERVICE |
BY SERVICE |
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DA FORM 3947, SEP 1983 |
APD PE v3.03ES |