Active Duty/Reserve/Guard/Civilian Forces Dental Examination Form
This form is used by the Department of Defense to assess the dental health of Active Duty, Reserve, Guard, and Civilian members of the United States Armed Forces. The form helps determine fitness for prolonged duty without ready access to dental care. It includes sections for personal information, dental examination results, and dentist's details.
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How do I fill this out?
To fill out this form, provide personal information including your name, social security number, branch of service, unit of assignment, and unit address. The dentist will need to record the results of the dental examination and provide any additional information regarding your dental health. Make sure to review the information before submission.
How to fill out the Active Duty/Reserve/Guard/Civilian Forces Dental Examination Form?
1
Provide your personal information.
2
The dentist will assess your oral health condition.
3
Dentist records the examination results.
4
Include additional comments if necessary.
5
Review the form for accuracy before submission.
Who needs the Active Duty/Reserve/Guard/Civilian Forces Dental Examination Form?
1
Active Duty Members to assess their dental health for worldwide duty.
2
Reserve Members to determine fitness for prolonged duty without ready access to dental care.
3
Guard Members to ensure dental readiness for potential deployment.
4
Civilian Members to document their dental health status for military service.
5
Dentists to provide assessment and record examination results for military members.
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Enter your personal information and examination results.
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What are the instructions for submitting this form?
To submit this form, ensure all required fields are accurately filled out. You can email the form to the designated email address, fax it to the provided fax number, or use the online submission form if available. Alternatively, you can send it to the physical address specified. Review all details before submission to avoid any delays in processing.
What are the important dates for this form in 2024 and 2025?
The form is typically updated and revalidated periodically by the Department of Defense. Ensure to check for any updates or changes in form requirements.
What is the purpose of this form?
The purpose of this form is to record an assessment of an individual's dental health, as required by the Department of Defense. It helps to determine fitness for prolonged duty without ready access to dental care and potential deployment outside the United States and its territories. This form is used to ensure that Active Duty, Reserve, Guard, and Civilian members of the United States Armed Forces maintain good oral health and are free from dental emergencies that could affect their ability to perform their duties effectively. The form must be completed by a licensed dentist who will assess the service member's dental health and provide necessary information to guide medical care and possible referrals. Ensuring the accuracy and completeness of this form is crucial for maintaining the dental readiness and overall health of military personnel.
Tell me about this form and its components and fields line-by-line.
- 1. SERVICE MEMBER'S NAME: Requires the full name (Last, First, Middle Initial) of the service member.
- 2. SOCIAL SECURITY NUMBER: Requires the social security number of the service member.
- 3. BRANCH OF SERVICE: Indicate the branch of the service to which the member belongs.
- 4. UNIT OF ASSIGNMENT: Specify the unit of assignment for the service member.
- 5. UNIT ADDRESS: Provide the full address of the unit of assignment.
- 6. EXAMINATION RESULTS: Dentist's assessment of the service member's dental health, categorized into four blocks based on the condition and expected dental treatment needs.
- 7. DENTIST'S NAME: Full name of the dentist conducting the examination.
- 8. DENTIST'S ADDRESS: Complete address of the dentist, including street, city, state, and ZIP code.
- 9. DENTIST'S TELEPHONE NUMBER: Contact telephone number of the dentist, including area code.
- 10. DENTIST'S SIGNATURE/STATE LICENSE NUMBER: Dentist's signature and state license number verifying the accuracy of the examination results.
- 11. DATE OF EXAMINATION: The date on which the dental examination was conducted, in YYYYMMDD format.
What happens if I fail to submit this form?
Failure to submit this form may result in delays in assessing dental health needs and determining fitness for duty or deployment. It is important to submit the form to avoid potential consequences.
- Delay in Dental Health Assessment: Failure to submit may lead to delays in obtaining a dental health assessment for military service.
- Deployment Readiness: Incomplete submission could affect deployment readiness and fitness for duty.
How do I know when to use this form?
- 1. Active Duty Assessment: To evaluate the dental health of Active Duty members for worldwide duty.
- 2. Reserve Assessment: Used by Reserve members to determine fitness for prolonged duty.
- 3. Guard Assessment: For Guard members to ensure dental readiness for deployment.
- 4. Civilian Assessment: Required by Civilian members to document their dental health status.
- 5. Dental Examination Record: Dentists use this form to record examination results and provide additional comments.
Frequently Asked Questions
How can I fill out the form on PrintFriendly?
Upload the form, enter your personal information, have your dentist fill out the examination results, and review for accuracy before finalizing.
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Yes, you can share the completed form directly via email or download it to share later.
Who needs to use this form?
Active Duty, Reserve, Guard, and Civilian members of the United States Armed Forces, as well as dentists, need this form to assess and document dental health.
What is the purpose of the dental examination form?
The form is used to assess dental health and determine fitness for prolonged duty or deployment without ready access to dental care.
How can I ensure the accuracy of the form?
Review all information provided before finalizing and submitting the form.
Can I add additional comments on the form?
Yes, there is a section for the dentist to add additional comments regarding dental health.
Is the form available for download?
Yes, you can download the completed and edited form directly from PrintFriendly.
How do I submit the form?
Follow the submission instructions provided, which include emails, fax numbers, online submission forms, and physical addresses.
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