Form Cg 6100 – Fill Out and Use This PDF

U.S. DEPARTMENT OF

Modified Screening For:

HOMELAND SECURITY

Overseas Assignment and/or Sea Duty Health Screening

U.S. COAST GUARD

This form is subject to the Privacy Act Statement of 1974

CG-6100 Rev. 04-09

A. EXAMINEE DATA

LAST NAME - FIRST NAME - MIDDLE INITIAL

RATE/RANK

SOCIAL SECURITY NUMBER

UNIT

EXAMINING FACILITY

PURPOSE OF SCREENING

TRANSFER/DEPLOYMENT LOCATION

DATE

1.

Would you say your health in general is:

Excellent

Good

Fair

Poor

2.

Do you have any medical or dental problems or concerns?

No

Yes

3.

Do you have any health related duty limitations?

No

Yes

4.

Could you be pregnant? (females request HCG if needed)

N/A

Unknown

No

Yes

5.

Are you taking prescription medications? (request refills if needed)

No

Yes

6.

During the past year, have you sought or required counseling or mental health care?

No

Yes

7.

Explain any "fair, poor, yes, or unknown" responses:

8.

Have you been hospitalized since your last Periodic Health Assessment (PHA)? Yes No

If (Yes) explain.

I certify that the responses above are true: (signature of examinee)

C. PERIODIC HEALTH ASSESSMENT (PHA) REVIEW (current approved PHA required)

9.

Date of most recent PHA:

10.

Status of recommendations or further specialist examination:

11.

Summary of significant health history since last PHA:

D. HEALTH RECORD & INDIVIDUAL MEDICAL READINESS REVIEW

12.

Have routine gynecologic (pap) examinations been completed in the past year? (females)

N/A

No

Yes

13.

Does examinee have two pair of glasses? (if required)

N/A

No

Yes

14.

Does deployable member have a gas mask insert? (if required)

N/A

No

Yes

15.

Has DNA sampling been completed and documented? (once per career)

No

Yes

16.

Has G-6PD screening been completed and documented? (once per career)

No

Yes

17.

Are immunizations up-to-date and meet requirements for destination?

No

Yes

18.

Has an HIV test been drawn (with negative results) in the past 6 months? (foreign country PCS only)

N/A

No

Yes

19.

Has a baseline TST been completed and documented?

No

Yes

20.

Have specific force health protection requirements been met (e.g. malaria chemoprophylaxis)?

N/A

No

Yes

21.

Has a Type 2 dental examination been completed in the past year and is examinee “Class 1 or 2”?

No

Yes

22.

Explain any "no" answers: _____________________________________________________________________________________________

Contact the Centers for Disease Control and Prevention at http://www.cdc.gov and the National Center for Medical Intelligence at

https://www.intelink.gov/ncmi/index.php

E. SIGNATURE (Medical and Dental Provider or IDHS)

Medical Provider/IDHS signature/stamp: ___________________________________________________

Date:_______________________

Dental Provider/IDHS signature/stamp: ____________________________________________________

Date:_______________________

F. APPROVAL/DISAPPROVAL (Clinic Administrator)

Reviewing/approving authority: ____________________________________________________________

Approved

Disapproved