DA Form 2173 "Statement of Medical Examination and Duty Status"

What Is DA Form 2173?

DA Form 2173, Statement of Medical Examination and Duty Status, is a form used during Line of Duty Investigations (LDI) in cases when a Soldier contracts an injury, illness, or disease during Active Duty service, Inactive (IDT) and Active Duty (AD) training or traveling to and from IDT or AD.

The latest version of the form was released by the U.S. Department of the Army (DA) on June 1, 2021. An up-to-date fillable DA Form 2173 is available for download and digital filing down below or can be found on the Army Publishing Directorate (APD) website.

DA Form 2173 must be completed by the authorized personnel no later than 7 days after receiving notice of said injury, illness, or disease unless the injury was not a direct result of Active Duty or IDT. The form expires either in 60 days after the incident (in case of an informal LDI) or in 90 days (in case of a formal LDI). The statement must be submitted within an adequate period of time for all allowances to come into effect within 30 days after reported injury, illness, or disease. The completed DA 2173 must undergo a detailed review and be approved by superiors for the continuation of incapacitation benefits.

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DA Form 2173 Instructions

Regulation AR 600-8-4 contains a detailed overview and instructions for the statement of medical examination and duty status. Detailed instructions are provided below.

How to Fill Out DA Form 2173?

DA Form 2173 and - if applicable - DD Form 261, Report of Investigation Line of Duty and Misconduct Status, are prepared during the LDI.

Five copies of the DA 2173 must be provided for active-duty personnel. The form may only be verified by an MTF commander, an attending physician, or a patient administrator. All personal data must be reviewed and checked. Changes made in pen and ink are allowed. The form must be returned to the unit commander or the MTF commander in case other corrections are needed. An investigation officer can be appointed in case any further investigation is required.

  1. The first lines on the form require basic information about the Soldier and their case. This includes their full name, SSN, grade, organization, station, the date and place of the accident, and the to and from addresses for forwarding the form.
  2. Section I is completed by an attending physician or a hospital patient administrator:
    • Block 6 defines the physical state of the patient - admitted, outpatient, dead;
    • Block 7 requires the name of the civilian or military hospital;
    • Block 8 calls for exact admission hours;
    • Block 9 shows exact examination hours;
    • Block 10 requires a detailed explanation of the nature and extent of injury, disease, or death;
    • Block 11 is for providing a specific medical opinion. Box 11A specifies if the patient was under the influence during the accident. The substance must be specified if known. Box 11B identifies their mental state. Box 11C specifies if the injury may result in a claim against the Government. Box 11D specifies if the injury happened during duty;
    • Block 12 specifies the level of resulting disability;
    • Block 13 is for the results of the blood alcohol test;
    • Block 14 is for specifying the level of alcohol in the blood samples if any is found.
  3. Section II is completed by a Unit commander or adviser:
    • Block 19 shows the duty station at the time of the incident;
    • Block 20 states the period of absence;
    • Block 21 shows if the absence was with or without authority materially interfered with the performance of military duty;
    • Block 22 specifies the duty status (active duty, inactive duty, etc.);
    • Block 23 specifies the period of training if the Soldier was on IDT or Active Duty for training;
    • Block 24 is completed if the reservist died in the time of proceeding directly to or from the training;
    • Blocks 25, 26, 27, and 28 are for specifying the mode of transportation, the time when the trip began, the distance covered, and the normal time for travel;
    • Block 29 specifies if the duty status at the time of death is different from the time when the injury or disease was incurred;
    • Block 30 requires details of the injury;
    • Block 31 specifies if any further investigation is required. Block 32 shows the line of duty determination for injuries.
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STATEMENT OF MEDICAL EXAMINATION AND DUTY STATUS
(Required for Line of Duty Investigation)
For use of this form, see AR 600-8-4, the proponent agency is DCS, G-1.
PRIVACY ACT STATEMENT
AUTHORITY:
To provide information regarding a Soldier’s status when injury, illness, disease or death occurs. It tracks and ensure
Soldiers are receiving proper benefits and proper institutions/agencies are notified regarding payment and benefits. For
additional information see the System of Records Notice A0608-8-1b AHRC, Line of Duty Investigations.
https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570057/a06008-1b-ahrc.aspx/
ROUTINE USES:
There are no specific routine uses anticipated for this form; however it may be subject to a number of proper and
necessary routine uses identified in the system of records notice(s) specified in the purpose Statement above.
DISCLOSURE:
Voluntary, however, failure to provide the information will interfere with the proper adjudication of the Soldier's case in the
best interest of the Soldier and the United States Army.
1. THRU:
2. TO:
3. FROM:
4. NAME OF SOLDIER EXAMINED (Last, First, Middle Initial)
5. SSN
6. GRADE
7. UNIT OF ASSIGNMENT ADDRESS:
8. ACCIDENT/INCIDENT INFORMATION
a. Date/Time:
b. Location:
SECTION I - TO BE COMPLETED BY ATTENDING PHYSICIAN OR HOSPITAL PATIENT ADMINISTRATOR
(UA/READINESS/SARC'S MAY COMPLETE WITH SUBSTANTIATING MEDICAL RECORDS )
9. SOLDIER WAS:
OUT PATIENT
10.
HOSPITAL NAME
ADMITTED
DEAD ON ARRIVAL
11.
HOUR/DATE EXAMINED
12. NATURE AND EXTENT OF
INJURY
ILLNESS
DISEASE
13. ICD-10 CODE:
14. MEDICAL OPINION: (Lines 15-23 Must be completed by a Physician, Physician Assistant or Nurse Practitioner) (UA/Readiness/SARC's
may complete with substantiating medical records)
WAS NOT UNDER
15. SOLDIER
WAS
ALCOHOL
DRUGS (Specify):
UNKNOWN
THE INFLUENCE OF
MAY NOT HAVE RESULTED IN THE SOLDIERS INJURY, ILLNESS,
16. DRUGS OR ALCOHOL
MAY
UNKNOWN
DISEASE OR DEATH
17. BLOOD TEST MADE?
)
YES (If Yes: No. of MG ALCOHOL/100 ML BLOOD
NO
UNKNOWN
DRUG SCREEN DONE?
YES (Attach results)
NO
18. INJURY
IS
IS NOT LIKELY TO REQUIRE FOLLOW-ON CARE.
UNKNOWN
IS NOT LIKELY TO RESULT IN A CLAIM AGAINST THE GOVERNMENT FOR FUTURE
19. INJURY
IS
UNKNOWN
MEDICAL CARE
NO (ONLY CAN BE DETERMINED
20. DID INJURY ILLNESS OR DISEASE EXIST PRIOR TO SERVICE?
YES
UNKNOWN
BY A PHYSICIAN, PA, or NP).
NO (ONLY CAN BE DETERMINED
21. CONDITION EXISTED PRIOR TO START OF CURRENT DUTY?
YES
UNKNOWN
BY A PHYSICIAN, PA, or NP).
23. SIGNATURE
24. DATE
APD AEM v1.01ES
DA FORM 2173, JUN 2021
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 2
STATEMENT OF MEDICAL EXAMINATION AND DUTY STATUS
(Required for Line of Duty Investigation)
For use of this form, see AR 600-8-4, the proponent agency is DCS, G-1.
PRIVACY ACT STATEMENT
AUTHORITY:
To provide information regarding a Soldier’s status when injury, illness, disease or death occurs. It tracks and ensure
Soldiers are receiving proper benefits and proper institutions/agencies are notified regarding payment and benefits. For
additional information see the System of Records Notice A0608-8-1b AHRC, Line of Duty Investigations.
https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570057/a06008-1b-ahrc.aspx/
ROUTINE USES:
There are no specific routine uses anticipated for this form; however it may be subject to a number of proper and
necessary routine uses identified in the system of records notice(s) specified in the purpose Statement above.
DISCLOSURE:
Voluntary, however, failure to provide the information will interfere with the proper adjudication of the Soldier's case in the
best interest of the Soldier and the United States Army.
1. THRU:
2. TO:
3. FROM:
4. NAME OF SOLDIER EXAMINED (Last, First, Middle Initial)
5. SSN
6. GRADE
7. UNIT OF ASSIGNMENT ADDRESS:
8. ACCIDENT/INCIDENT INFORMATION
a. Date/Time:
b. Location:
SECTION I - TO BE COMPLETED BY ATTENDING PHYSICIAN OR HOSPITAL PATIENT ADMINISTRATOR
(UA/READINESS/SARC'S MAY COMPLETE WITH SUBSTANTIATING MEDICAL RECORDS )
9. SOLDIER WAS:
OUT PATIENT
10.
HOSPITAL NAME
ADMITTED
DEAD ON ARRIVAL
11.
HOUR/DATE EXAMINED
12. NATURE AND EXTENT OF
INJURY
ILLNESS
DISEASE
13. ICD-10 CODE:
14. MEDICAL OPINION: (Lines 15-23 Must be completed by a Physician, Physician Assistant or Nurse Practitioner) (UA/Readiness/SARC's
may complete with substantiating medical records)
WAS NOT UNDER
15. SOLDIER
WAS
ALCOHOL
DRUGS (Specify):
UNKNOWN
THE INFLUENCE OF
MAY NOT HAVE RESULTED IN THE SOLDIERS INJURY, ILLNESS,
16. DRUGS OR ALCOHOL
MAY
UNKNOWN
DISEASE OR DEATH
17. BLOOD TEST MADE?
)
YES (If Yes: No. of MG ALCOHOL/100 ML BLOOD
NO
UNKNOWN
DRUG SCREEN DONE?
YES (Attach results)
NO
18. INJURY
IS
IS NOT LIKELY TO REQUIRE FOLLOW-ON CARE.
UNKNOWN
IS NOT LIKELY TO RESULT IN A CLAIM AGAINST THE GOVERNMENT FOR FUTURE
19. INJURY
IS
UNKNOWN
MEDICAL CARE
NO (ONLY CAN BE DETERMINED
20. DID INJURY ILLNESS OR DISEASE EXIST PRIOR TO SERVICE?
YES
UNKNOWN
BY A PHYSICIAN, PA, or NP).
NO (ONLY CAN BE DETERMINED
21. CONDITION EXISTED PRIOR TO START OF CURRENT DUTY?
YES
UNKNOWN
BY A PHYSICIAN, PA, or NP).
23. SIGNATURE
24. DATE
APD AEM v1.01ES
DA FORM 2173, JUN 2021
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 2
SECTION II - TO BE COMPLETED BY THE IMMEDIATE COMMANDER OR SARC
25. NAME OF SOLDIER EXAMINED (Last, First, Middle Initial)
26. SSN
27. GRADE
31. DATE AND TIME OF DUTY
32. DUTY STATUS LOCATION
28. DUTY STATUS:
PRESENT
EXCUSED
29. ABSENT WITHOUT LEAVE (DOCUMENTED?)
YES
NO
30. SOLDIER WAS INJURED IN AUTHORIZED
YES
NO
TRAVEL STATUS PER JTR
33. SOLDIER WAS ON FEDERAL ORDERS:
30 DAYS OR LESS
> 30 DAYS
34. SOLDIER WAS IN INACTIVE DUTY TRAINING STATUS:
DATE/TIME IDT BEGAN:
ENDED:
35. SOLDIER DIED OF INJURIES RECEIVED PROCEEDING DIRECTLY:
TO
FROM
DURING TRAINING
NA
36. DETAILS OF INCIDENT - REMARKS (If additional space is needed, attach enclosures as necessary).
NO (*NOTE-An informal investigation can only result in an ILD finding)
37. FORMAL LINE OF DUTY INVESTIGATION REQUIRED
YES
38. INJURY IS TO HAVE BEEN INCURRED IN LINE OF DUTY (Not applicable on deaths)
YES
NO
39. NAME/GRADE OF IMMEDIATE/UNIT COMMANDER OR SARC
40. SIGNATURE
41. DATE
APD AEM v1.01ES
DA FORM 2173, JUN 2021
Page 2 of 2
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