Da Form 7655 PDF Details

The Department of the Army Form 7655, also known as the Soldier's Report of Separation, is a document that soldiers must complete in order to officially leave the military. This form records important information about the soldier's service and separation, such as dates of service, rank, type of discharge, and more. The completion of this form is critical for separating soldiers and their families, so it's important to understand what information is required and how to complete it correctly. In this blog post, we'll provide an overview of the DA Form 7655 and explain how to fill it out correctly. Stay tuned!

QuestionAnswer
Form NameDa Form 7655
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesa7655 fjso form 7566 april 2010

Form Preview Example

DEPARTMENT OF THE ARMY

ARMED FORCES EYE AND VISION READINESS SUMMARY

For use of this form, see DA Pam 40-506; the proponent agency is OTSG.

PRINCIPLE PURPOSE (S): Army personnel are required to have a periodic assessment of visual health and refractive status by an optometrist or ophthalmologist to determine fitness for prolonged duty without ready access to eye and vision care. If the Soldier has had an eye examination within the past 24 months, this form may be completed by the eye care provider to capture the spectacle prescription and eye history data without having to repeat the examination. Measurement of visual acuity is an annual requirement and may be conducted by the unit or in conjunction with the Periodic Health Assessment.

ROUTINE USE (S): Periodic Health Assessment and Vision Readiness Classification.

DISCLOSURE: Voluntary; however, failure to provide the information may result in delays in assessing refractive and vision health needs for military service. Information on this form may also be used to determine Vision Readiness Classification.

1.SERVICE MEMBER'S NAME (Last, First, Middle Initial)

2. DATE OF BIRTH

3. BRANCH OF SERVICE

4. UNIT OF ASSIGNMENT

5. UNIT ADDRESS

EXAMINATION RESULTS:

To the Doctor: The individual that you are examining is an Active Duty/National Guard/Reserve member of the United States Armed Forces. We request your assessment of his/her eye and vision health for potential worldwide duty. Please complete the following information, using visual acuity determination, ocular history review, biomicroscopy and refraction as a suggested minimum clinical examination. This form is meant to determine fitness for prolonged duty without ready access to eye and vision care and is not intended to address the member’s comprehensive ophthalmologic or optometric needs.

6. DATE OF VISION SCREENING (YYYYMMDD):

DATE OF SPECTACLE RX (YYYYMMDD):

 

 

(1) UNCORRECTED DISTANCE VISUAL ACUITY

(2) BEST CORRECTED DISTANCE VISUAL ACUITY

Right Eye

20/

Right Eye

20/

Left Eye

20/

Left Eye

20/

Both Eyes

20/

Both Eyes

20/

(3) IF > 45, UNCORRECTED NEAR VISUAL ACUITY

(4) IF > 45, BEST CORRECTED NEAR VISUAL ACUITY

Both Eyes

20/

Both Eyes

20/

(5) SPECTACLE PRESCRIPTION (MINUS CYLINDER FORMAT, IF NEAR VISION ONLY ANNOTATE IN BIFOCAL FORM):

 

Right Eye

SPHERE

CYLINDER -

 

AXIS

 

 

 

ADDITION +

PRISM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Left Eye

SPHERE

CYLINDER -

 

AXIS

 

 

 

ADDITION +

PRISM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(6)

PUPILLARY DISTANCE:

FAR

mm

NEAR

mm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(7)

Does the patient have any ocular condition(s) that may present problems in austere environments far removed from routine medical care?

 

YES

 

If yes, please state condition(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(8)

Will the patient require a 180-day supply of medication(s) to treat an ophthalmologic condition(s)?

 

 

 

 

 

YES

 

If yes, please provide medication(s) and dosage(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(9)

Has the patient undergone a refractive surgical procedure(s) in the past?

 

 

 

 

 

 

 

 

 

 

 

YES

 

If yes, please provide month, year and type of procedure(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. DOCTOR'S PRINTED NAME

 

 

8. STATE LICENSE NUMBER

9. DOCTOR'S ADDRESS & TELEPHONE OR E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. DOCTOR'S SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DA FORM 7655, JUN 2009

APD LC v1.00

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1. Firstly, when filling in the Da Form 7655, beging with the page with the next fields:

Part no. 1 for submitting Da Form 7655

2. Right after finishing the previous section, go on to the subsequent step and enter the essential particulars in all these blank fields - Right Eye, SPHERE, Left Eye, SPHERE, CYLINDER, CYLINDER, AXIS, AXIS, ADDITION, ADDITION, PRISM, PRISM, PUPILLARY DISTANCE, FAR, and NEAR.

Writing segment 2 of Da Form 7655

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