Back to Top Skip to main content

Forms & Templates

On this page, you will find various forms that Military Health System uses to support its programs. Please scroll down the page or use the search box to find specific forms and templates.

Please note that files more than two years old may not be compliant with Section 508 of the Rehabilitation Act. If you need an accessible version of a particular file, please contact us and we will provide one for you.

If you're having trouble finding what you're looking for, consider using fewer words in your search criteria. Results are limited to content that matches all terms in the search field.

We found - potentially matching ""

Specify Date Range (Optional):
Select Content Types (Optional):
Current Filters. Click a Filter to Remove It
Date Range:

Freezer Temperature Log - Celsius

Form/Template
3/23/2020

Temperature log for freezers storing vaccines, with form for recording vaccine storage troubleshooting.

Recommended Content:

Vaccine Storage and Handling

Freezer Temperature Log - Fahrenheit

Form/Template
3/23/2020

Temperature log for freezers storing vaccines, with form for recording vaccine storage troubleshooting.

Recommended Content:

Vaccine Storage and Handling

Refrigerator Temperature Log - Celsius

Form/Template
3/23/2020

Temperature log for refrigerators storing vaccines, with form for recording vaccine storage troubleshooting.

Recommended Content:

Vaccine Storage and Handling

Refrigerator Temperature Log - Fahrenheit

Form/Template
3/23/2020

Temperature log for refrigerators storing vaccines, with form for recording vaccine storage troubleshooting.

Recommended Content:

Vaccine Storage and Handling

DD Form 3110: Routine Immunization Screening Form: Pediatric

Form/Template
3/11/2020

A screening checklist for contraindications to vaccines for children and teens.

DD Form 3111: Routine Immunization Screening Form: Adults

Form/Template
3/11/2020

A screening checklist for contraindications to vaccines for adults.

Smallpox Vaccine Screening Form

Form/Template
3/2/2020

Each potential recipient of smallpox vaccine must complete this official screening form and it must be signed by a licensed health care provider prior to vaccination.

Recommended Content:

Smallpox (ACAM2000) | Smallpox Vaccine-Associated Adverse Events

AFRSSIR Supply Order Request

Form/Template
2/12/2020

Fill out this request to place and order with the Armed Forces Repository of Specimen Sample for the Identification of Human Remains

Recommended Content:

Armed Forces Medical Examiner System | Office of the Armed Forces Medical Examiner | DoD DNA Operations | Repository of Specimen Samples for the Identification of Remains

340b Verification Form

Form/Template
2/7/2020

340b Verification Form to be completed by the manufacturer and pharmacy for any 340b claim disputes.

Pediatric and Adult Influenza Screening and Immunization Documentation

Form/Template
2/1/2020

A form for screening both children and adults for contraindications to receiving influenza vaccine.

Recommended Content:

Influenza, Northern Hemisphere

DMRTI JOP Nomination Form

Form/Template
1/30/2020

Nomination form for JMOC, JMPT, and JHOC

Recommended Content:

Joint Humanitarian Operations Course (JHOC) | Joint Medical Operations Course (JMOC) | Joint Medical Planning Tool Course | Defense Medical Readiness Training Institute | Combat Support | Defense Medical Readiness Training Institute | Joint Humanitarian Operations Course (JHOC) | Joint Medical Operations Course | Joint Medical Planning Tool Course

DMRTI JOP Student Nomination

Form/Template
12/11/2019

Student nomination form for all DMRTI Joint Operations Program courses, to include, JMOC-B/A, JMPT, and JHOC.

AFHSB 501 Request Form

Form/Template
11/26/2019

Armed Forces Health Surveillance Branch (AFHSB) Epidemiology and Analysis AFHSB 501 Request Form

DHA-GL Worksheet 41: DoD/VA MOA Inpatient-Outpatient Continued Stay Review

Form/Template
11/20/2019

Used to collect information from Military Health System beneficiaries in order to determine their eligibility for coverage under the TRICARE Program.

EACE Data Request Form

Form/Template
11/20/2019

Form for users to fill out to request information/data from EACE

<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 23

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing: Download a PDF Reader or learn more about PDFs.