Form Navmed 1300 1 – Fill Out and Use This PDF

MEDICAL, DENTAL AND EDUCATIONAL SUITABILITY SCREENING FOR SERVICE AND FAMILY

MEMBERS

Privacy Act Statement

Authority: 5 U.S.C. 301, Departmental Regulations; and E. O. 9397 (SSN).

Purpose: To identify special, medical, dental or educational needs for the purpose of making a suitability recommendation for an overseas, remote duty, or operational assignment.

Routine uses: This form is completed by a medical treatment facility (MTF)/non-MTF dentist and physician, nurse practitioner, physician assistant, or independent duty corpsman (Service members only). An MTF Medical Screener must counter sign all screenings completed by non-Navy MTF Providers. The MTF Suitability Screening Coordinator (SSC) will place the completed original form in the individual’s Service Treatment Record/Non-Service Treatment Record and retain a copy for audit.

Disclosure: Voluntary; however, failure to provide this information may delay the screening process, result in orders held in abeyance until completion of screening or affect the amount of leave in transit.

Refer to BUMEDINST 1300.2B for implementing guidance. Complete one form for each Service and family member screened.

SERVICE MEMBER NAME

GRADE / RATE

AGE

SSN

PART I

SECTION A. Medical Screening. Completed by the medical provider to identify special needs and determine if a Service or family member is suitable for an overseas, remote duty, or operational assignment. Attach the completed Report of Medical History (DD 2807-1) to this form.

Yes No N/A

ITEM

1. All current health records (military and civilian) reviewed?

2.All physical exams (to include special duty, aviation, submarine, radiation, asbestos, etc.) are current and filed in the Service

Treatment Record? a. Type of Physical ___________________________ b. Completion date of physical______________

3.G-6P-D, PPD and Sickle Cell trait test and Blood Type completed & documented?

4a. Immunizations are up-to-date and meet destination country requirements?

4b. Has the individual elected to decline any ACIP recommended immunizations or country required Immunizations? If yes (circle): ACIP Country Specific Date Counselled: _____________________

5.Reference audiogram documented on DD 2215?

6.Latest audiogram (DD 2216) reviewed?

7.HIV testing completed or drawn?

8.DNA testing completed and documented?

9. Are there pending consults or tests that have a bearing on assignment suitability?

10. Any past limited duty or medical board(s)? (document on DD 2807-1)

11. For Service members:

a. Annual periodic health assessment current and documented?

b. Pregnancy screening (verbal inquiry)? (Also, Command will refer for pregnancy test 30 days prior to departure date)

c. If pregnant? (EDC:_____________ )

12. For family members, U.S. Preventive Services Task Force screening test recommendations current and documented?

13. If a Special Duty assignment, is there a condition, which by MANMED, chapter 15, section IV, is disqualifying?

14. Are there any conditions requiring ongoing care in the following areas? (document on DD 2807-1)

a. Orthopedic conditions (e.g., chronic back, knee, joint pain or weakness)

b. Cardiovascular conditions (e.g., chest pain/angina, arrhythmia, valve disease, infarction)

c. Gynecologic/Urologic conditions (e.g., chronic pelvic pain, abnormal PAP, breast mass)

d. Neurologic conditions (e.g., seizure, pinched nerve, migraine, neuropathy)

e. Respiratory conditions (e.g., asthma, RAD, chronic sinus, allergies)

f. Mental health or behavioral conditions (e.g., mood, personality disorder, ADD/ADHD, anxiety, psychosis, autism)

g. Recurrent or frequent medications not on the standard formulary or require special attention (e.g., injections/infusions every 6-12 months, medication requiring Risk Evaluation and Mitigation Strategies per FD regulations, hormone replacement therapy, or medications requiring close monitoring of therapeutic blood level)? (list on DD 2807-1)

h. Alcohol or substance abuse or dependence

i. Developmental concerns (e.g., motor, cognitive, communication, social/emotional, or adaptive development)

j. Specify other conditions or concerns:

15. For Service/family members requiring medication.

a. Does the patient’s medication maintenance require a dose adjustment?

b.Should medication use cease, could the underlying condition become life threatening, pose a risk for dangerous or disruptive behavior or result in a limited duty, MEDEVAC, or early return situation?

c.Are there concerns about medication management capabilities at the gaining MTF/operational platform if the underlying condition is exacerbated?

d.Has the service/family member registered with the mail order pharmacy program through TRICARE?

NAVMED 1300/1 (Rev. 1-2016), Part I - Front

Yes	No N/A	ITEM

16. For service/family members with underlying medical conditions:

a.Is there a requirement for special medical supplies, adaptive equipment, assistive technology devices, special accommodations, etc.?

b.If exposed to a physically or emotionally demanding environment, could the underlying condition become life threatening, pose a risk for dangerous or disruptive behavior, or result in a limited duty or MEDEVAC situation?

c.Are there any chronic medical or mental health conditions requiring routine or continuing access to care or access to specialized medical care? (document on DD 2807-1)

d.Are there any potential environmental concerns or possible health effects at the gaining location? (if yes, communicate to family and document on appropriate SF 600)

17.For infants and toddlers (birth to 36 months), is the child receiving or undergoing eligibility to receive early intervention services as evidenced by an Individualized Family Service Plan (IFSP)?

18.For preschool and school age children, is the child receiving or undergoing eligibility to receive special education

and/or related services as evidenced by an Individualized Education Program (IEP)?

19.Explanation of “yes” responses in shaded boxes (include #):

Are there any concerns about the gaining MTF/operational platform’s capabilities to meet the individual’s needs? Specify below:

Navy MTF SSC Name, Signature, Stamp, and Date: ________________________________________________________________

Non-Navy Medical Providers: STOP and proceed to SECTION C

SECTION B. Medical and Educational Screening Disposition. Completed by the screening Navy MTF medical provider to determine if a Service or family member is suitable for an overseas, remote duty, or operational assignment.

Yes No

ITEM

1. Are any of the above shaded blocks in Section A checked?

If “yes”, submit a suitability inquiry to the gaining MTF or medical department supporting the overseas/remote duty/operational location to determine local capabilities to provide required support. (Attach Reply and answer questions 1a and 1b.)

If “no”, proceed to question 2.

a. Does the gaining location have the capabilities to provide the current required medical support?(Service MTFs/TRICARE, etc.)

b.Does the gaining location have the capabilities to provide the required medical support (diagnostic and therapeutic) if the underlying condition is exacerbated? (To include all Service MTFs/operational platform, TRICARE, etc.)

2.Is the shaded block of question 18 checked “yes”?

If yes, Submit the DD 2792-1 and IEP to the gaining DoDEA Special Education Overseas Screening Coordinator and gaining MTF to determine local

capabilities to provide required support. (Attach Reply with POC info and answer question 2a.) If no, proceed to question 3.

		a. Is the DoDEA Special Education Overseas Screening Coordinator recommending travel?
Yes		No	3. IS THE SERVICE/FAMILY MEMBER SUITABLE FOR THE OVERSEAS, REMOTE DUTY OR OPERATIONAL
			ASSIGNMENT? (Must be completed by an MTF medical screener. Answered after the inquiry is completed.)

SECTION C. Contact Information. Completed by the MTF/non-MTF civilian providers who completed PART I. The Navy MTF medical screener shall review and countersign all suitability screenings completed by non-Navy MTF civilian providers, denoting accountability for a complete and thorough suitability screening document review for each Service/family member.

NAVMED 1300/1 (Rev. 1-2016), Part I - Back

PART II

SECTION A. Dental Screening. Completed by a dental officer/privileged dentist prior to an overseas, remote duty, or operational assignment for the purpose of assessing and matching the dental needs of a service/family member to the support capabilities of the gaining medical treatment facility. NOTE: If child does not have teeth -AND- is under the age of 24 months, a pediatrician may perform an oral dental screening.

Yes No

ITEM

1.All current dental records (military and civilian) reviewed?

2.All dental examinations are current? (If more than 180 days since last T-1 or T-2 dental exam, a dental officer/privileged dentist must, at a minimum, review the dental record and interval medical and dental history.)

3.Is a reexamination required by a Navy MTF if examined or treated at a non-Navy facility?

4. If service/family member is in Dental Class 3 or 4, can dental treatment or examination be completed before the transfer?

5. Is there a requirement for follow-on care such as orthodontics, implants, specialty prosthetics, etc.?

6. Are there any chronic dental conditions requiring routine or continuing access to care or access to specialized dental care?

7. Are there any concerns about the gaining MTF/operational platform’s capabilities to meet the individual’s needs? Specify below:

Navy MTF SSC Name, Signature, Stamp, and Date: ___________________________________________________________________

8.Specify Dental Class: (required for service members) Dental Classifications: (Per DoDI 6025.19)

Normally considered worldwide deployable:

Class 1 - Patients with a current dental examination, who do not require dental treatment or re-evaluation.

Class 2 - Patients with a current dental examination, who require non-urgent dental treatment or re-evaluation for oral conditions unlikely to result in a dental emergency within 12 months.

Normally not considered worldwide deployable:

Class 3 - Patients who require urgent or emergent dental treatment for oral conditions with a high potential to cause a dental emergency in the next 12 months.

Class 4 - Patients who require a dental examination either because: (1) No type 1 (comprehensive) or type 2 (annual or periodic oral) dental examination was completed by a dental officer/privileged dentist within the past 12 months; (2) A patient's dental record does not exist or;

(3) The dental record is not held by the responsible dental treatment facility or Medical Department activity.

SECTION B. Dental Screening Disposition. Completed by the screening MTF provider to determine if a service or family member is suitable for an overseas, remote duty, or operational assignment. Non-Navy Medical Providers: STOP and proceed to SECTION C.

Yes	No		ITEM
	1.		Are any of the above shaded blocks checked?
			If yes, submit a suitability inquiry to the gaining MTF or medical department supporting the overseas/remote duty/operational
			location to determine local dental capabilities to provide required support. (Attach Reply and answer question 2)
			If no, proceed to question 3.
		2.	Does the gaining MTF/operational platform have the capabilities to provide the current required dental support?

Yes	No	3. IS THE SERVICE/FAMILY MEMBER SUITABLE FOR THE OVERSEAS, REMOTE DUTY OR OPERATIONAL
		ASSIGNMENT? (Must be completed by an MTF dental screener. Answered after the inquiry is completed.)

SECTION C. Contact Information. Completed by the MTF/non-MTF civilian providers who completed PART II. The Navy MTF dental screener shall review and countersign all suitability screenings completed by non-Navy MTF civilian providers, denoting accountability for a complete and thorough suitability screening document review for each Service/family member.

NAVMED 1300/1 (Rev. 1-2016), Part II