Da Form 2985 – Fill Out and Use This PDF

1.

REPORTING MTF

2.

MTF LOCATION

(State or

ADMISSION AND CODING INFORMATION

1

2

3

4

5

6

7

8

Country

For use of this form, see AR 40-400; the proponent agency is OTSG

A

Code.)

3.

REGISTER NUMBER

NAME (Last, First, Middle Initial)

4. PAY GRADE

5.

SEX

9

10

11

12

13

14

15

16

17

18

6. DATE OF BIRTH (Y Y Y Y M M D D)

7.

AGE AT ADMISSION

8.

RACE

9.

ETHNIC

RELIGION

19

20

21

22

23

24

25

26

27

28

29

30

31

BACK-

GROUND

10.

LENGTH OF SERVICE

ETS

11.

FMP

12.

SOCIAL SECURITY NUMBER

32

33

34

35

36

37

38

39

40

41

42

43

44

45

ORGANIZATION (Active Duty Only)

13.

MARITAL STATUS

HOUR OF

BRANCH / CORPS

ADMISSION

46

14.

FLYING STATUS

15.

BENEFICIARY CATEGORY

16. ZIP CODE OF RESIDENCE

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

17.

UNIT LOCATION (State or

18.

MOS

19.

TRAUMA

PREV. ADMISSION

Country Code)

62

63

64

65

66

67

68

69

70

71

YEAR

NO

20. SOURCE OF ADMISSION/ AUTHORITY FOR

WARD

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

ADMISSION

72

ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

21.

TYPE OF DISPOSITION

22.

MTF TRANSFERRED TO

23. DATE OF DISPOSITION (Y Y Y Y M M D D)

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

24.

CLINIC SVC - ADMITTING

25.

MTF TRANSFERRED FROM

26.

DATE THIS ADMISSION (Y Y Y Y M M D D)

89

90

91

92

93

94

95

96

97

98

99

100

101

102

103

104

105

106

27.

LOCATION OF OCCURRENCE

28. MTF OF INITIAL ADMISSION

29. DATE INITIAL ADMISSION (Y Y Y Y M M D D)

(Battle Casualty Only)

107

108

109

110

111

112

113

114

115

116

117

118

119

120

121

122

FOR LOCAL USE

ADMITTING OFFICER (Signature, as required)

SIGNATURE OF ADMITTING CLERK