Form 220 PDF Details

In the panorama of documentation crucial for individuals stepping into active duty, the 220 form stands out as a vital instrument. As mandated by privacy statutes such as 10 USC 275 and Executive Order 9397 dating back to November 1943, this form primarily serves to convey crucial information to individuals reporting for active duty, while also facilitating the computation of date of rank for officers and warrant officers embarking on active duty for durations extending 12 months or more. Its usage encompasses a broad spectrum, reporting periods of active duty, physical condition at both entry and release points, and notably, serves as a medical statement to pinpoint any health alterations since the last examination, potentially triggering further medical review should significant changes be observed. It’s imperative to note the form's reliance on the Social Security Number as a unique identifier for the service member, underscoring the form’s critical role not just as a procedural necessity but as a gateway to ensuring the well-being and proper placement of military personnel according to their physical and service readiness. With voluntary completion, albeit with implications for non-compliance, the form embodies a key facet of military administration, meticulously designed to safeguard the personal and professional trajectory of those in service.

QuestionAnswer
Form NameForm 220
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform duty, dd 220 printable, 220 report, form duty pdf

Form Preview Example

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACTIVE DUTY REPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Privacy Act Statement

 

 

 

 

 

 

 

 

 

 

 

AUTHORITY:

 

 

10 USC 275, EO 9397, November 1943 (SSN).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRINCIPAL

 

 

Used to report items of information to individuals reporting for active duty. Also used to compute date of rank for officers and

 

PURPOSE:

 

 

warrant officers ordered to active duty for 12 or more months.

 

 

 

 

 

 

 

 

 

 

 

ROUTINE USES:

 

 

Information is used to report periods of active duty and physical condition upon entry and release from active duty. Medical

 

 

 

statement is used to identify defects or conditions which have arisen since the member was last medically examined. If any

 

 

 

 

 

 

 

 

 

 

 

 

significant changes are noted, the member is given a medical examination. The SSN is used to identify the member.

 

 

 

 

 

 

 

 

 

 

 

 

Voluntary; however, if an individual refuses to complete ITEM 15, he/she will be scheduled for a medical examination.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. RESERVE COMPONENT (X one)

 

 

 

 

 

 

 

 

 

 

 

 

2. DATE (YYMMDD)

 

 

 

 

 

 

ARNGUS

 

 

 

 

 

 

 

 

ANGUS

 

 

 

USAR

 

 

 

 

AFRES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. TO (Appropriate Military Department)

 

 

 

 

 

4. FROM (Initial Active Duty Station)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. NAME (Last, First, MI)

 

 

 

 

 

6. SSN

 

 

 

7. GRADE OR

8. BRANCH OF

9. RETIREMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RANK

ARMED SVC

YR ENDING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. EFFECTIVE DATE OF ENTRY ON ACTIVE DUTY (Determined by personnel

officer at

 

 

 

 

YEAR

 

MONTH

DAY

 

 

 

first duty station IAW criteria outlined in AR 37-104 or AFR 35-3)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. REPORTING DATE (Date specified in orders or the actual reporting date if later than

 

 

 

 

 

 

 

 

 

 

 

 

 

date specified)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. DATE DEPARTED FROM DUTY STATION TO HOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. AUTHORITY FOR ACTIVE DUTY

 

 

 

 

 

 

 

 

 

 

 

 

14. LENGTH OF

TOUR (Less than

 

ORDERS NO.

 

 

 

 

 

 

PARAGRAPH NO.

 

 

 

 

 

DATED

 

 

 

 

 

 

90 days if ARNGUS or USAR)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HQ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(YYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Designation and location of HQ issuing orders)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. STATEMENT OF PHYSICAL CONDITION (In lieu of medical examination)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I, the undersigned, underwent a complete medical examination for military service on or about

 

 

 

 

 

which was accomplished at

 

 

 

 

 

 

 

 

 

 

 

 

 

(YYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Name and location of hospital or medical treatment facility)

 

 

 

 

 

and since that time:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I have not been treated by clinics, physicians, healers or other practitioners.

 

 

 

 

 

 

 

 

I have been treated by

 

 

 

 

 

 

during the period from

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Name of physician) (Last, First, MI)

 

 

 

 

 

 

 

(YYMMDD)

 

to

 

 

 

 

 

for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(YYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Description of injury or illness)

 

 

 

 

 

 

 

 

I was hospitalized in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Name and location of hospital or medical treatment facility)

 

 

 

 

 

The attending physician was

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Last, First, MI)

 

 

 

 

 

Diagnosis was

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Description of injury or disease)

 

 

 

 

 

 

 

 

I do

 

 

do not believe that I am now medically qualified to perform satisfactory military service.

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

Signed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(YYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. (ARMY USE ONLY) Upon mobilization this item will be filled in for members of units of reserve components of the Army and copies of orders will be attached to this form.

Entered on active duty as a member of

(Unit and unit home station)

Ordered to active duty from

(Home of record or home address) (Include ZIP code)

DD Form 220, AUG 89

Previous editions may be used until supply is exhausted.

ADOBE PROFESSIONAL 8.0

17.(ARMY USE ONLY) DA FORM 67-8 (US Army Officer Evaluation Report) OR DA FORM 1059 (Academic Evaluation Report)

PREPARED AND FORWARDED:

 

 

YES, FORWARDED TO

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

(Address of Reserve or NG unit) (Include ZIP Code)

 

 

(YYMMDD)

 

 

 

NO, REPORT WILL BE FORWARDED ON OR ABOUT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(YYMMDD)

 

 

 

 

 

NOT APPLICABLE

 

 

 

 

 

 

 

 

18.(ARMY USE ONLY) DATE OF RANK (YYMMDD) (For officers and warrant officers ordered to active duty for 12 or more months, enter computation below)

19a. TYPED NAME OF ADJUTANT OR OTHER OFFICER b. GRADE OR

REPRESENTING COMMANDER (Last, First, MI)

RANK

c. SIGNATURE

20.ENCLOSURES (List enclosures, if any)

21.REMARKS (Explain reason for delay, if any, in complying with orders)

DD Form 220 Reverse, AUG 89

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2. Your next part is usually to submit these particular fields: STATEMENT OF PHYSICAL CONDITION, Nameand location ofhospital or, YYMMDD, and since that time, I have not been treated by clinics, during the period from, Name ofphysician Last First MI, YYMMDD, for, YYMMDD, I was hospitalized in, The attending physician was, Diagnosis was, Descriptionof injury or illness, and Nameand location ofhospital or.

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3. Completing ARMY USE ONLYDA FORM USArmy, PREPARED AND FORWARDED, YES FORWARDED TO, DATE, Address ofReserve orNGunit Include, YYMMDD, NO REPORT WILL BE FORWARDED ON OR, YYMMDD, NOT APPLICABLE, ARMY USE ONLY DATE OF RANK, computation below, a TYPED NAME OF ADJUTANT OR OTHER, REPRESENTING COMMANDER Last FirstMI, b GRADE OR, and RANK is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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