Form NAVMED 6100/5 at a glance
What it is: The Abbreviated Medical Evaluation Board Report is NAVMED 6100/5 (Rev. 08-2004).
Who signs: Printed MEB Member Name and Signature/Date; Printed CA Name and Signature/Date; Patient Signature/Date; Patient Administration Officer/Medical Boards Official Printed Name, Signature, and Date.
A filled-in Form NAVMED 6100/5 example: a sailor's medical officers complete Section 1
How to fill out Form NAVMED 6100/5, box by box
Date, patient and limited duty dates
Section 1: Clinical Information is to be completed by medical officers.
Enter the Date, the Patient Name and the Patient SSN.
Enter the Proposed start date for limited duty and the Proposed end date (< 6 months).
This period of limited duty is for
Select one: 1st LIMDU (< 6 months) Enlisted ADSM (no referral to service headquarters necessary).
2nd LIMDU (< 6 months) Enlisted ADSM (no referral to service headquarters necessary). Note that the first and second TLD periods cannot exceed 12 months cumulatively from the date of the first TLD period.
1st LIMDU (< 6 months) Officer ADSM (referral to service headquarters necessary).
2nd LIMDU (< 6 months) Officer ADSM (referral to service headquarters necessary).
3rd or subsequent LIMDU periods on Navy and Marine ADSM involving a distinctly different condition than that responsible for the first and second TLD periods (for referral to service headquarters for "departmental review").
Placement on LIMDU - if the patient is not already in a LIMDU status - at the same time the patient's case is referred to the physical evaluation board for adjudication.
Diagnosis, circumstances, treatment plan, limitations and Section 1 signatures
Under Diagnosis, enter (1), (2) and (3), each with its ICD-9 CM Code.
Enter the Circumstances of injury/illness.
Enter the Treatment plan.
Enter the Limitations from full duty (including whether transfer/TEMDU for treatment is indicated, and any PRT limitations).
The MEB members and the CA sign under SIGN SIGN SIGN, and enter the Printed MEB Member Name and Signature/Date, the Printed MEB Member Name and Signature/Date and the Printed CA Name and Signature/Date.
Section 2: Patient Information
Section 2: Patient Information is to be completed by the patient.
This period of limited duty is not effective until approved by the MTF Convening Authority.
Under SIGN, the patient enters the Patient Signature/Date.
Section 3: Patient Administration Officer/Medical Boards Officer
Section 3 is to be completed by Patient Administration Officer/Medical Boards Officer, who marks the actions completed.
The following actions have been completed: Completion of Patient Information Sheet, Briefing to Patient on Limited Duty/MEBs, Notification to PSD/Personnel Office, Notification to MTF LIMDU Coordinator, LODD Requested from Parent Command (if LODD required), Notification to Parent Command, Entry into MedBOLTT.
Under SIGN, the Patient Administration Officer/Medical Boards Official enters a Printed Name, Signature, and Date.
Common questions about Form NAVMED 6100/5
Where do I file it?
Original to Patient Health Record; copies to Patient, Parent Command, PSD, MEBR Case File, and PERS-4821 or MMSR-4.
Sources
[1] NAVMED 6100/5 (Rev. 08-2004), Abbreviated Medical Evaluation Board Report (the Official source link on this page).