DA Form 2173 – Army Pubs DA 2173 Fillable – An injury, sickness, or disease that occurs while a Soldier is on active duty while preparing for active duty, or while traveling to and from active duty is documented on DA Form 2173, Statement of Medical Examination and Duty Status.
The Department of the Army (DA) of the United States issued the most recent version of the form on October 1, 1972. An up-to-date fillable DA Form 2173 is available for download and digital filing down below or may be accessed on the Army Publishing Directorate (APD) website.
DA Form 2173 must be completed by authorized personnel no later than 7 days after obtaining notification of the injury, sickness, or disease, unless the injury, illness, or disease was not a direct consequence of Active Duty or IDT in which case it must be done immediately. The form is only valid for 60 days after the occurrence (in the case of an informal LDI) or 90 days after the incident (in the case of a formal LDI) (in the case of a formal LDI). The declaration must be provided within a reasonable amount of time to ensure that all benefits are received within 30 days of the stated injury, sickness, or disease. The completed DA Form 2173 must be subjected to a thorough evaluation and approval by superiors before incapacitation benefits may be continued.
Instructions For The DA Form 2173
Regulation AR 600-8-4 provides a thorough overview as well as specific directions for completing the declaration of medical examination and duty status. Instructions on how to do this task are given below.
How to Complete the DA Form 2173?
During the LDI, the DA Form 2173 and, if relevant, the DD Form 261, Report of Investigation Line of Duty and Misconduct Status, are prepared.
Active-duty employees must be given five copies of DA Form 2173. Only an MTF commander, an attending physician, or a patient administrator are authorized to verify the document. All personal information must be thoroughly inspected and confirmed. Changes done using pen and ink are OK. If any more revisions are required, the form must be submitted to the unit commander or the MTF commander. If more inquiry is necessary, an investigation officer might be appointed.
The Soldier and their situation must be described in detail in the first few paragraphs of the application. This contains their complete name, Social Security number, grade, organization, station, the date and location of the accident, as well as the to and from addresses for sending the form to the appropriate parties.
Section I is performed by an attending physician or a hospital patient administrator and consists of the following sections:
- The patient’s physical status is defined in Block 6 as either “admitted,” “outpatient,” or “dead.”
- The name of the civilian or military hospital is required in Block 7;
- Block 8 requests that entrance hours be specified in detail.
- Block 9 displays the precise examination hours;
- A detailed discussion of the nature and degree of the damage, sickness, or death is required in Block 10.
- A particular medical opinion is required in Block 11 of the application. If the patient was under the influence of drugs or alcohol at the time of the accident, it is indicated in Box 11A. If the drug is known, it must be identified. Box 11B contains information on their mental state. Box 11C indicates whether the harm may give rise to a lawsuit against the government. If the injury occurred while on duty, it is specified in Box 11D.
- Block 12 defines the degree of impairment that will arise as a consequence of the accident.
- A blood alcohol test result is entered into Block 13 of the form.
- If there is any evidence of alcohol in the blood tests, block 14 specifies the amount of alcohol discovered.
Section II is completed by a unit commander or advisor, and it is as follows:
- The duty station at the time of the occurrence is shown in Block 19.
- Block 20 specifies the length of time that the employee will be absent.
- Block 21 indicates whether the absence was authorized or not, and if it caused a serious interference with the execution of military duties.
- It is specified in Block 22 whether or not the duty is active (such as active duty, inactive duty, etc.).
- Block 23 states whether the soldier was on IDT or Active Duty throughout the training period.
- If the reservist died while traveling straight to or from training, Block 24 is completed.
- Blocks 25, 26, 27, and 28 are used to define the form of transportation, the time at which the journey started, the distance traveled, and the typical time for travel.
- Block 29 states if the duty position at the time of death differs from the duty status at the time of the accident or sickness.
- Block 30 requests specifics on the injury.
- Block 31 determines whether or not more research is necessary. Block 32 depicts the decision of the line of duty in the case of an injury.