Da Form 5840 PDF Details

On July 3, 2014, the United States Army released DA Form 5840, "Enlisted Record and Report of Medical History." The new form is used to document enlisted service members' medical history from cradle to grave. It supersedes the previous version, DA Form 4856, which was last updated in 1997. Service members are required to complete and submit a copy of DA Form 5840 with their separation papers. The new form is more comprehensive than its predecessor and includes sections on allergies, immunizations, health care providers, and family medical history. It also has a section for recording medical incidents during military service.

You'll find information about the type of form you intend to prepare in the table. It can show you how much time it will take to fill out da form 5840, what fields you will have to fill in and several additional specific details.

QuestionAnswer
Form NameDa Form 5840
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesform 5840 da, da form 5840 family care plan, da form 5840 fillable, da form 5840 pdf

Form Preview Example

CERTIFICATE OF ACCEPTANCE AS GUARDIAN OR ESCORT

For use of this form, see AR 600-20; the proponent agency is DCS, G-1.

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE:

PRIVACY ACT STATEMENT

10 U.S.C. Section 3013, Secretary of the Army: Army Regulation 600-20, Army Command Policy.

Guardian's agreement to care for a soldier's child(ren) in his or her absence.

None.

Voluntary; However, failure to provide all the requested information could lead to rejection of a soldier's Family Care Plan.

I

 

was provided an original DA Form 5841

(Power of Attorney) or other legally sufficient authority naming me as guardian/escort for:

NAME (s) / AGE (s) OF FAMILY MEMBERS

family members of:

NAME (s)

I agree to accept responsibility for these family members. I have received all necessary documents required to provide financial, medical, educational, quarters, and subsistence support for these family members. I have been briefed on procedures for accessing military/civilian facilities, services, benefits, and entitlements on behalf of these family members.

TYPED OR PRINTED NAME OF GUARDIAN

ADDRESS (Include ZIP Code)

SIGNATURE

DATE (YYYY/MM/DD)

TELEPHONE NUMBER (Include Area Code)

E-MAIL ADDRESS

NOTARY:

STATE OF

COUNTY OF

Acknowledged before me this

 

day of

,

 

.

 

 

 

 

 

 

 

(Notary Public)

My commission expires:

DA FORM 5840, JUN 2010

PREVIOUS EDITIONS ARE OBSOLETE.

APD PE v1.00ES

How to Edit Da Form 5840 Online for Free

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da form 5840 family care plan gaps to complete

The software will require you to fill out the TELEPHONE NUMBER Include Area Code, EMAIL ADDRESS, NOTARY, STATE OF, COUNTY OF, Acknowledged before me this, day of, Notary Public, My commission expires, DA FORM JUN, PREVIOUS EDITIONS ARE OBSOLETE, and APD PE vES field.

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