The DA Form 12 R, "Report of Medical History," is a U.S. Army regulation form that must be completed by all active duty and reserve soldiers prior to any medical examination or treatment. The form collects soldier's personal information, health history, and other relevant data. Completion of the DA Form 12 R is critical for accurate tracking of soldiers' health histories and for ensuring that all necessary precautions are taken during any medical procedures.
Question | Answer |
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Form Name | Da Form 12 R |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | mp check 190 45d, ae form 190 45d, da pam 25 33 pdf, ae form 190 45b |
REQUEST FOR ESTABLISHMENT OF A PUBLICATIONS ACCOUNT
For use of this form, see DA PAM
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ACCOUNT NUMBER |
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DATE |
3. TYPE OF SUBMISSION |
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INITIAL b. |
CHANGE c. |
CLOSE |
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4. |
FROM (Include |
5. |
THRU (Include |
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6. TO |
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SECTION I - GENERAL
7a. REQUEST AN ACCOUNT BE ESTABLISHED FOR THE FOLLOWING SERVICE:
PUBLICATIONS
BLANK FORMS
TEST MATERIAL (see para
7b. JUSTIFICATION FOR BLANK FORMS (Use a separate sheet of paper if more space is needed.)
8.UNIT DESCRIPTION DATA (FAILURE TO COMPLETE THIS BLOCK WILL RESULT IN YOUR REQUEST BEING RETURNED.)
a. Component (Contractors must complete Block 8e and/or 8f.)
Active Army |
Army Reserve |
National Guard |
Air Force |
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Marine Corps |
Navy |
DOD Activity |
Contractor |
Other |
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b. TOE Number or TDA Number (Army Only) |
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e. Commercial and Government Entity (CAGE) Code |
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(Contractors) |
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c. Unit Identification Code |
(UIC) (Army Users) |
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f. Contract Number (if applicable) |
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d. Military Assistance Program Address Code (FMS Users)
g. DOD Activity Address Code
9. PUBLICATIONS OFFICER FOR THIS ORGANIZATION WILL BE:
a. Typed Name, Grade and Title |
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b. Signature |
c. Telephone Number |
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(DSN and Commercial) |
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SECTION II - ACCOUNT CLASSIFICATION LEVEL |
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10. REQUEST THE FOLLOWING CLASSIFICATION LEVEL FOR THIS ACCOUNT: |
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UNCLASSIFIED
CONFIDENTIAL
SECRET
11.THIS ORGANIZATION HAS ADEQUATE EQUIPMENT AND PROPERLY CLEARED PERSONNEL TO RECEIVE AND SAFEGUARD MATERIAL ACCORDING TO THE CLASSIFICATION REQUESTED FOR THIS ACCOUNT. IF CLASSIFIED SERVICE IS APPROVED, THE SECURITY OFFICER WILL BE:
a. Typed Name, Grade and Title
b. Signature
c.Telephone Number
(DSN and Commercial)
SECTION III - CHANGE OF ADDRESS
12a. OLD ADDRESS (Include
b. NEW ADDRESS (Include
EFFECTIVE DATE:
SECTION IV - AUTHENTICATING OFFICIALS
13a. |
Typed Name, Grade and Title of Commander |
b. Signature |
c. Telephone Number |
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(DSN and Commercial) |
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14a. |
Typed Name, Grade and Title of PCO/PSM |
b. Signature |
c. Telephone Number |
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(DSN and Commercial) |
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DA FORM |
PREVIOUS EDITIONS ARE OBSOLETE |
USAPA V2.01 |