Da Form 4036 R

NAME OF MPD/PSC REPRESENTATIVE B. TITLE C. D. GRADE SIGNATURE DA FORM 4036-R MAY 90 E. DATE USAPPC V1. U.S. DOD Form dod-da-4036-r MEDICAL AND DENTAL PREPARATION FOR OVERSEAS MOVEMENT For use of this form see AR 600-8-11 the proponent agency is DCSPER PRIVACY ACT STATEMENT Authority Principal Purpose Routine Uses Disclosure Title 10 USC Sections 3010 8012 and 5031 and Title 5 USC Section 301. Information is required on all soldiers being reassigned overseas to determine if they meet medical and dental standards for such assignment. 1 For personnel service support and 2 Information is primarily obtained from review of records unless assignment is to be an isolated area which requires evaluation and personal interview. Disclosure of information is voluntary. If family members are required to complete medical and dental evaluation and personal interview but refuse to do so they will not be permitted to accompany the soldier to the oversea assignment. TO NAME Last Middle First PRESENT UNIT OF ASSIGNMENT PROJECTED UNIT OF ASSIGNMENT Include location/country PROJECTED DUTY MOS OR AOC 9 Position Code ANTICIPATED DATE OF LOSS FROM SSN 5A. GRADE OR RANK 5B. PMOS OR AOC 10. IS MEMBER BEING ASSIGNED TO AN ISOLATED AREA AS DEFINED BY AR 40-501 PARA 5-13C Yes No 11. IF ANSWER TO ITEM 10 IS YES AND IF MEMBER IS REQUESTING FAMILY TRAVEL ALL FAMILY MEMBERS WILL BE SCREENED BY THE LOCAL MEDICAL TREATMENT FACILITY FOR SPECIAL MEDICAL AND FUNCTIONAL NEEDS* ENTER NAMES OF ALL ACCOMPANYING FAMILY MEMBERS OTHERWISE ENTER N/A. NAME LIST ANY OTHER SPECIAL MEDICAL OR DENTAL INSTRUCTIONS CONTAINED IN THE ASSIGNMENT INSTRUCTIONS 13A. 00 Complete the medical and dental status portions below return the original and one copy to the MDP/PSC within 21 calendar days of the date shown in item 13E and forward one copy to the address in item 6. MEDICAL STATUS 14A. PHYSICAL PROFILE SERIAL CODE PULHES YES NO PHYSICAL CATEGORY CODE N/A MEDICAL RECORDS REVEAL THE FOLLOWING ASSIGNMENT LIMITATIONS ITEM IF CONDITION IS TEMPORARY EXPECTED DATE MEMBER WILL BE ELIGIBLE FOR ASSIGNMENT Does the member meet the medical fitness standards outlined in AR 40-501 If no explain briefly. 16A. Has member completed HIV screening 17A. Is the member pregnant DATE TIME AND LOCATION OF APPOINTMENT IF YES EXPECTED DATE OF DELIVERY IF YES INDICATE DATE TIME AND LOCATION OF APPOINTMENT All active duty and reserve personnel of PCS 18A. assignment to Korea will be vaccinated with hepatitis B vaccine. Does the member require immunization 19A. 20A. Is the member currently undergoing alcohol or drug abuse rehabilitation THE REHABILITATION PROGRAM If item 10 is checked yes can the member be 21A. assigned to an area where medical facilities are limited or nonexistent IF YES THE MEMBER and family members if applicable MUST BE SCHEDULED FOR A FOLLOW-UP EVALUATION OF MEDICAL STATUS WITHIN 30 CALENDAR DAYS OF THE ANTICIPATED DATE OF LOSS Item 9. INDICATE DATE TIME AND LOCATION OF APPOINTMENT S 22. Medical Records Indicate the Member Requires the Following Check those appropriate REQUIRES HAS MISSING A.