Da 2173 Form – Fill Out and Use This PDF

The DA Form 2173, known as the Statement of Medical Examination and Duty Status, serves a crucial role in documenting an individual's medical condition and duty status following an incident or illness within the military context. This form, governed by AR 600-8-4 with the proponent agency being DCS, G-1, captures detailed information including the accident details, medical opinions, and ultimately, the impact on duty status. Ensure your DA Form 2173 is accurately filled out by clicking the button below.

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Da 2173 Form PDF Details

The DA Form 2173, titled "Statement of Medical Examination and Duty Status," serves a crucial function in the documentation and management of medical and duty status within the military. Designated for use as prescribed by AR 600-8-4, with the Department of the Army G-1 as the proponent agency, this form encapsulates critical information ranging from personal identification, including the individual's name and Social Security Number, to the specifics of an accident or disease. It delves into the details of medical examination outcomes, such as the diagnosis, nature, and extent of injuries or diseases, and considerations about whether the condition might result in a claim against the government. Furthermore, it addresses the question of whether an injury occurred in the line of duty and the potential permanence of any disability arising from it. The form is comprehensive, requiring inputs from attending physicians or hospital patient administrators, and also covers administrative aspects, such as duty status at the time of injury or disease, handled by unit commanders or advisers. This collaborative approach ensures a meticulous review process, guiding the accurate determination of duty status and aligning medical evaluations with military requirements. Through its structured sections, the DA Form 2173 bridges the critical gap between medical assessment and military duty status, providing a systematic method for recording and assessing the implications of medical conditions on service members' duty capabilities.

Question	Answer
Form Name	DA Form 2173
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	da form 2173 line of duty, lod army form, army lod form, da form 2173 pdf fillable, da form 2173 line of duty, da form 2173 2021

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STATEMENT OF MEDICAL EXAMINATION AND DUTY STATUS

For use of this form, see AR 600-8-4, the proponent agency is DCS, G-1.

THRU: (Include ZIP Code)

TO: (Include ZIP Code)

FROM: (Include ZIP Code)

1. NAME OF INDIVIDUAL EXAMINED (Last, First, and Middle Initial)

2. SSN

3. GRADE

4. ORGANIZATION AND STATION

5.ACCIDENT INFORMATION

a. DATE	b. PLACE (City and State)

SECTION I - TO BE COMPLETED BY ATTENDING PHYSICIAN OR HOSPITAL PATIENT ADMINISTRATOR

6.	INDIVIDUAL WAS	OUT PATIENT	7. NAME OF HOSPITAL OR TREATMENT FACILITY		CIVILIAN	MILITARY
	ADMITTED	DEAD ON ARRIVAL

8.	HOUR AND DATE ADMITTED			9. HOUR AND DATE EXAMINED

10. NATURE AND EXTENT OF

INJURY

DISEASE

RESULTING IN DEATH (Explain)


11. MEDICAL OPINION:		a.	INDIVIDUAL		WAS	WAS NOT UNDER THE INFLUENCE OF		ALCOHOL	DRUGS (Specify) :

b.	INDIVIDUAL	WAS		WAS NOT MENTALLY SOUND			(Attach Psychiatric evaluation if appropriate).
c.	INJURY	IS	IS NOT LIKELY TO RESULT IN A CLAIM AGAINST THE GOVERNMENT FOR FUTURE MEDICAL CARE.
d.	INJURY	WAS	WAS NOT INCURRED IN LINE OF DUTY.				BASIS FOR OPINION:

12.THE FOLLOWING DISABILITY MAY RESULT TEMPORARY PERMANENT PARTIAL

PERMANENT TOTAL

13.BLOOD ALCOHOL TEST MADE

YES

14. NO. OF MG ALCOHOL/100 ML BLOOD

15. DETAILS OF ACCIDENT OR HISTORY OF DISEASE (how, where, when)

16. DATE

17.TYPED OR PRINTED NAME OF ATTENDING PHYSICIAN OR PATIENT ADMINISTRATOR

18. SIGNATURE

SECTION II - TO BE COMPLETED BY UNIT COMMANDER OR UNIT ADVISER

19. DUTY STATION

PRESENT FOR DUTY

ABSENT WITH AUTHORITY:

ABSENT WITHOUT AUTHORITY

ON PASS

ON LEAVE

20.HOUR AND DATE OF ABSENCE

a. FROM	b. TO

21.ABSENCE WITHOUT AUTHORITY MATERIALLY INTERFERRED WITH THE PERFORMANCE OF MILITARY DUTY (Explain in Item 30 type of duty missed, hours of duty, and how it did or did not interfere with performance)

YES

22. INDIVIDUAL WAS ON

ACTIVE DUTY

ACTIVE DUTY FOR TRAINING

INACTIVE DUTY TRAINING

23.HOUR AND DATE TRAINING

a. BEGAN	b. ENDED

24.	RESERVIST DIED OF INJURIES RECEIVED PROCEEDING		DIRECTLY TO TRAINING		DIRECTLY FROM TRAINING
25. MODE OF TRANSPORTATION		26. HOUR BEGINNING TRAVEL		27. DISTANCE INVOLVED		28. NORMAL TIME FOR TRAVEL

29.	DUTY STATUS AT TIME OF DEATH IF DIFFERENT FROM TIME OF INJURY OR CONTRACTION OF DISEASE
	PRESENT FOR DUTY	ABSENT WITH AUTHORITY			ABSENT WITHOUT AUTHORITY

30.DETAILS OF ACCIDENT - REMARKS (If additional space is needed, continue on reverse) (Attach inclosures as necessary)

31.	FORMAL LINE OF DUTY INVESTIGATION REQUIRED			32. INJURY IS CONSIDERED TO HAVE BEEN INCURRED IN LINE OF
	YES	NO		DUTY (Not applicable on deaths)		YES	NO

33.	DATE		34. TYPED NAME AND GRADE OF UNIT COMMANDER OR		35. SIGNATURE
			UNIT ADVISER

DA FORM 2173, OCT 1972

REPLACES DA FORM 2173, 1 JUN 66, WHICH IS OBSOLETE.

APD PE v2.01ES

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YES, SECTION II TO BE COMPLETED BY, and ABSENT WITH AUTHORITY in da form 2173 pdf fillable

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Da 2173 Form – Fill Out and Use This PDF

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