Navmed 1300 Form – 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 medical, dental or educational conditions for the purpose of making a suitability recommendation for an overseas, remote duty, or operational assignment.

Routine uses: This form is completed by a military/civilian physician, nurse practioner, physician assistant, or independent duty corpsman. The medical treatment facility (MTF) Suitability Screening Coordinator will place the completed original form in the service or family member's MTF medical 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 1300.2A for implementing guidance. Complete one form for each service and family member screened.

SERVICE MEMBER NAME

GRADE / RATE

SSN

PART I

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.Physical examinations (aviation, submarine, radiation, asbestos, etc.) current and documented?

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

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

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 all service members, annual preventive health assessment (PHA) current and documented?

12.For servicewomen:

a.Annual health assessment current and documented?

b.Pregnancy screening (verbal inquiry)?

		c. If pregnant? (EDC:	)
13.		For family members, U.S. Preventive Services Task Force screening test recommendations current and documented?
	14.	If a Special Duty assignment, is there a condition, which by MANMED, chapter 15, section IV, is disqualifying?

15.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 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, adjustment/personality disorder, ADD/ADHD, anxiety, psychosis)

g.Recurrent or frequent medications not on the standard formulary (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:

16. For service/family members requiring medication in excess of 90 days: (if not applicable, check block and skip to #18)

a. Is the patient in the maintenance phase of treatment?

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.Is the medical staff at the gaining MTF/operational platform capable of managing the medication manipulation(s) if the underlying condition exacerbates?

d.Has the service/family member registered with the TRICARE Mail Order Pharmacy program?

NAVMED 1300/1 (Rev. 9-2010), Part I - Front

Yes	No N/A	ITEM

17. For service/family members with underlying medical conditions: (if not applicable, check block and skip to #18)

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.Can the gaining MTF/operational platform provide the current required medical support?

d.Can the gaining MTF/operational platform provide required medical support (diagnostic and therapeutic) if the underlying condition is exacerbated?

e.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)

f.If required, were potential environmental concerns and possible health effects communicated to each service and family member? (document on appropriate SF 600)

18.For infants and toddlers (birth through 2 years, inclusive) with a disability, is the child receiving or eligible to receive early intervention services as evidenced by an Individualized Family Service Plan (IFSP)?

19.For preschool and school children (ages 3 through 21, inclusive) with a disability, is the child receiving or eligible to receive special education and related services as evidenced by an Individualized Education Program (IEP) and DD 2792, Addendum B?

20.Specify other concerns:

IF ANY OF THE ABOVE SHADED BLOCKS ARE CHECKED, QUERY THE GAINING MEDICAL TREATMENT FACILITY OR MEDICAL DEPARTMENT SUPPORTING THE OVERSEAS, REMOTE DUTY OR OPERATIONAL LOCATION CONCERNING LOCAL CAPABILITIES TO PROVIDE REQUIRED SUPPORT. (Attach Reply)

NAVMED 1300/1 (Rev. 9-2010), Part I - Back

PART II

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.

Yes No N/A

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.Specify other concerns:

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.

IF ANY OF THE ABOVE SHADED BLOCKS ARE CHECKED, FORWARD A SUITABILITY INQUIRY TO THE GAINING MEDICAL TREATMENT FACILITY OR MEDICAL DEPARTMENT SUPPORTING THE OVERSEAS, REMOTE DUTY, OR OPERATIONAL LOCATION TO DETERMINE IF THE REQUIRED DENTAL SUPPORT IS AVAILABLE. (attach reply)

NAVMED 1300/1 (Rev. 9-2010), Part II