Da 2173 Form PDF Details

The 2173 form is used to apply for a replacement Social Security card. The form can be filled out and submitted online, or you can print it out and mail it in. You will need to provide your name, date of birth, Social Security number, and other information. There is a fee associated with the application process, which you can pay online or by check or money order. Make sure to follow all the instructions carefully so that your request is processed as quickly as possible.

QuestionAnswer
Form NameDa 2173 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
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Form Preview Example

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

NO

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

NO

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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2. Once your current task is complete, take the next step – fill out all of these fields - DATE, TYPED OR PRINTED NAME OF, SIGNATURE, SECTION II TO BE COMPLETED BY, DUTY STATION, PRESENT FOR DUTY, ABSENT WITHOUT AUTHORITY, ABSENT WITH AUTHORITY, ON PASS, ON LEAVE, HOUR AND DATE OF ABSENCE a FROM, b TO, ABSENCE WITHOUT AUTHORITY, YES, and INDIVIDUAL WAS ON with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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

A lot of people frequently make mistakes while filling out YES in this area. You need to review whatever you type in right here.

3. In this part, examine TYPED NAME AND GRADE OF UNIT, DA FORM OCT, REPLACES DA FORM JUN WHICH IS, and APD PE vES. Each one of these will need to be filled in with highest accuracy.

Tips to fill in da form 2173 pdf fillable part 3

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