Da Form 12 R PDF Details

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.

QuestionAnswer
Form NameDa Form 12 R
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmp check 190 45d, ae form 190 45d, da pam 25 33 pdf, ae form 190 45b

Form Preview Example

REQUEST FOR ESTABLISHMENT OF A PUBLICATIONS ACCOUNT

For use of this form, see DA PAM 25-33; the proponent agency is ODISC4

1.

ACCOUNT NUMBER

2.

DATE

3. TYPE OF SUBMISSION

 

 

 

 

 

a.

INITIAL b.

CHANGE c.

CLOSE

4.

FROM (Include nine-digit ZIP Code)

5.

THRU (Include nine-digit ZIP Code)

 

6. TO

 

 

 

 

 

 

 

 

 

 

 

SECTION I - GENERAL

7a. REQUEST AN ACCOUNT BE ESTABLISHED FOR THE FOLLOWING SERVICE:

PUBLICATIONS

BLANK FORMS

TEST MATERIAL (see para 2-5, DA PAM 25-33)

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

 

Marine Corps

Navy

DOD Activity

Contractor

Other

 

 

 

b. TOE Number or TDA Number (Army Only)

 

e. Commercial and Government Entity (CAGE) Code

 

 

 

(Contractors)

 

 

 

 

 

 

c. Unit Identification Code

(UIC) (Army Users)

 

f. Contract Number (if applicable)

 

d. Military Assistance Program Address Code (FMS Users)

g. DOD Activity Address Code (Non-Army Users) or Navy UIC

9. PUBLICATIONS OFFICER FOR THIS ORGANIZATION WILL BE:

a. Typed Name, Grade and Title

 

b. Signature

c. Telephone Number

 

 

 

(DSN and Commercial)

 

 

 

 

 

SECTION II - ACCOUNT CLASSIFICATION LEVEL

 

 

 

10. REQUEST THE FOLLOWING CLASSIFICATION LEVEL FOR THIS ACCOUNT:

 

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 9-digit Zip Code)

b. NEW ADDRESS (Include 9-digit Zip Code)

EFFECTIVE DATE:

SECTION IV - AUTHENTICATING OFFICIALS

13a.

Typed Name, Grade and Title of Commander

b. Signature

c. Telephone Number

 

 

 

(DSN and Commercial)

 

 

 

 

14a.

Typed Name, Grade and Title of PCO/PSM

b. Signature

c. Telephone Number

 

 

 

(DSN and Commercial)

 

 

 

 

DA FORM 12-R, APR 96

PREVIOUS EDITIONS ARE OBSOLETE

USAPA V2.01