DA Form 3437 "Department of the Army Nonappropriated Funds Certificate of Medical Examination"

What Is DA Form 3437?

DA Form 3437, Department of the Army Nonappropriated Funds - Certificate of Medical Examination is an official form used to record the results of a pre-employment physical examination of NAF employees. The certificate can also be used during periodic job-related physical tests. An up-to-date DA Form 3437 fillable version is available for filing and download below or can be found through the Army Publishing Directorate website.

The certificate is necessary for positions that may require the employee to:

  • Operate motor vehicles;
  • Have direct physical contact with people (especially when applying for childcare-related positions);
  • Work underground, in dangerous conditions, or around power-driven machinery;
  • Undergo exertion, dangerous duty, or excessive physical demands;
  • Be in contact with food that will be consumed by others.

The most recent version of the form - sometimes incorrectly referred to as the DD Form 3437 - was released by the Department of the Army (DA) on August 1, 2019, with the previous editions obsolete.

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How to Fill Out DA Form 3437?

The medical certificate, in general, is a written statement from a medical work that describes results of a medical examination. It can be used as a sick note or as evidence of a certain health condition.

Procedural guidelines and additional information can be found in the AR 215-3, Nonappropriated Funds Instrumentalities Personnel Policy, released in September 2015. Specific DA Form 3437 instructions are as follows:

  1. Personnel working in childcare-related positions must undergo annual medical assessments that include a TB skin test, a chest X-ray, be vaccinated for measles, mumps, rubella, diphtheria, tetanus, and polio with all results recorded on their DA 3437.
  2. Along with the original certificate, the civil employee's personnel folder must contain the following forms:
  3. A DA Form 3437 is authorized for filing in the Civilian employee medical records folder. The Civilian employee medical records folder - or CEMR, for short - may be maintained either in the terminal digit filing system DA 3444 Forms or the Standard Form 66D during the entire course of working with the Department of the Army.
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Download DA Form 3437 "Department of the Army Nonappropriated Funds Certificate of Medical Examination"

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DEPARTMENT OF THE ARMY
NONAPPROPRIATED FUNDS
CERTIFICATE OF MEDICAL EXAMINATION
For use of this form, see AR 215-3; the proponent agency is DCS, G1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974 (5 USC 552a)
AUTHORITY: Title 5 USC Section 3301, Section 3312, and AR 215-3.
PRINCIPAL PURPOSE: The primary use of this information will be to determine the nature of a medical or physical condition that may
affect safe and efficient performance of the work described.
ROUTINE USES: This form is used to collect medical information about individuals who are incumbents of positions in the Department of
Defense which require physical fitness testing and medical examinations, or individuals who have been selected for such a position
contingent upon successful completion of physical fitness testing and medical examinations as a condition of their employment. The
primary use of this information will be to determine the nature of a medical or physical condition that may affect safe and efficient
performance of the work described. In addition to those disclosures generally permitted under 5 USC 552a (b) (Privacy Act), the
information contained therein may specifically be disclosed outside the Department of Defense as routine pursuant to 5 U.S.C 552a (b) 3
as follows:
- To Department of Labor and the Equal Employment Opportunity Commission, to resolve and/or adjudicate matters falling within their
jurisdiction.
- To labor organizations in response to requests for names of employees and identifying information.
- DoD Health Information Privacy Regulation, (DOD 6025.18-R) may place additional procedural requirements on the uses and
disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in this system of records notice.
DISCLOSURE: Completion of this form is voluntary; however, failure to complete the form may result in no further consideration of an
applicant, or a determination that an employee is no longer qualified for his or her position. In addition, incomplete, misleading, or
untruthful information provided on the form may result in delays in processing the form for employment, or termination of employment.
CITATION: A0215-3 SAMR, NAF Personnel Records (June 01, 2000, 65 FR 35054).
INSTRUCTIONS
There are five parts in this form:
Part A - To be completed by applicant or employee. Signature of the applicant or employee certifies that the information provided is
complete and accurate; and that the applicant or employee consents to the release of the examination results to the servicing Human
Resources Division.
Part B - To be completed by the appointing officer (management) before the medical examination: identifies the purpose of the examination;
the position title, series and grade; generally describes the position; and shows the specific functional requirements and environmental
factors that the work requires.
Part C - To be completed and signed by the examining physician, and returned to the servicing Human Resources Division.
Part D - To be completed by the medical officer who reviews the examination results and recommends action.
Part E - To be completed by the human resources officer in order to document the personnel action that is rendered by management.
PREVIOUS EDITONS ARE OBSOLETE.
PAGE 1 OF 7
DA FORM 3437, AUG 2019
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DEPARTMENT OF THE ARMY
NONAPPROPRIATED FUNDS
CERTIFICATE OF MEDICAL EXAMINATION
For use of this form, see AR 215-3; the proponent agency is DCS, G1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974 (5 USC 552a)
AUTHORITY: Title 5 USC Section 3301, Section 3312, and AR 215-3.
PRINCIPAL PURPOSE: The primary use of this information will be to determine the nature of a medical or physical condition that may
affect safe and efficient performance of the work described.
ROUTINE USES: This form is used to collect medical information about individuals who are incumbents of positions in the Department of
Defense which require physical fitness testing and medical examinations, or individuals who have been selected for such a position
contingent upon successful completion of physical fitness testing and medical examinations as a condition of their employment. The
primary use of this information will be to determine the nature of a medical or physical condition that may affect safe and efficient
performance of the work described. In addition to those disclosures generally permitted under 5 USC 552a (b) (Privacy Act), the
information contained therein may specifically be disclosed outside the Department of Defense as routine pursuant to 5 U.S.C 552a (b) 3
as follows:
- To Department of Labor and the Equal Employment Opportunity Commission, to resolve and/or adjudicate matters falling within their
jurisdiction.
- To labor organizations in response to requests for names of employees and identifying information.
- DoD Health Information Privacy Regulation, (DOD 6025.18-R) may place additional procedural requirements on the uses and
disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in this system of records notice.
DISCLOSURE: Completion of this form is voluntary; however, failure to complete the form may result in no further consideration of an
applicant, or a determination that an employee is no longer qualified for his or her position. In addition, incomplete, misleading, or
untruthful information provided on the form may result in delays in processing the form for employment, or termination of employment.
CITATION: A0215-3 SAMR, NAF Personnel Records (June 01, 2000, 65 FR 35054).
INSTRUCTIONS
There are five parts in this form:
Part A - To be completed by applicant or employee. Signature of the applicant or employee certifies that the information provided is
complete and accurate; and that the applicant or employee consents to the release of the examination results to the servicing Human
Resources Division.
Part B - To be completed by the appointing officer (management) before the medical examination: identifies the purpose of the examination;
the position title, series and grade; generally describes the position; and shows the specific functional requirements and environmental
factors that the work requires.
Part C - To be completed and signed by the examining physician, and returned to the servicing Human Resources Division.
Part D - To be completed by the medical officer who reviews the examination results and recommends action.
Part E - To be completed by the human resources officer in order to document the personnel action that is rendered by management.
PREVIOUS EDITONS ARE OBSOLETE.
PAGE 1 OF 7
DA FORM 3437, AUG 2019
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PART A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE
1. NAME (LAST - FIRST - MIDDLE INITIAL)
3. SEX
2. BIRTH DATE (MONTH, DAY, YEAR)
MALE
FEMALE
4. DO YOU HAVE ANY MEDICAL DISORDER OR PHYSICAL IMPAIRMENT WHICH WOULD INTERFERE IN ANY WAY WITH THE FULL PERFORMANCE OF
THE DUTIES SHOWN IN PART B, NO. 3?
YES
NO
(IF YOUR ANSWER IS YES, EXPLAIN FULLY TO THE PHYSICIAN PERFORMING THE EXAMINATION)
Including City, State, and Zip Code)
5. ADDRESS
(
(With Area Code)
7. TELEPHONE NUMBERS
6. E-MAIL ADDRESS
8. APPLICANT OR EMPLOYEE CONSENT AND CERTIFICATION
I certify that all of the information I have provided on this form is complete and accurate to the best of my knowledge, and that submitting information that is
incomplete, misleading, or untruthful may result in termination criminal sanctions, or delays in processing this form for employment. Furthermore, consistent with the
Privacy Act Statement, I authorize the release to my servicing Human Resources Division of all information contained on this examination form and all other forms
generated as a direct result of my examination.
9. SIGNATURE
(Do not print)
10. DATE
(Month, Day, Year)
DA FORM 3437, AUG 2019
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PART B. TO BE COMPLETED BEFORE EXAMINATION BY APPIONTING OFFICER
1. PURPOSE OF EXAMINATION
2. POSITION TITLE, SERIES, AND GRADE
PRE-PLACEMENT
OTHER (SPECIFY)
3. BRIEF DESCRIPTION OF WHAT THE POSITION REQUIRES THE EMPLOYEE TO DO.
DA FORM 3437, AUG 2019
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PART B. CONTINUED - TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER
4. CHECK THE BOX FOR EACH FUNCTIONAL REQUIREMENT IN SECTION 4a. AND EACH ENVIRONMENTAL FACTOR IN SECTION 4b. ESSENTIAL TO
THE DUTIES OF THIS POSITION. LIST ANY ADDITIONAL ESSENTIAL FACTORS IN THE BLANK SPACES.
4a. FUNCTIONAL REQUIREMENTS
REPEATED BENDING (
HOURS)
BOTH EYES REQUIRED
HEAVY LIFTING, 45 POUNDS AND OVER
CLIMBING, LEGS ONLY (
HOURS)
DEPTH PERCETION
MODERATE LIFTING, 15-44 POUNDS
CLIMBING, USE OF LEGS AND ARMS
ABILITY TO DISTINGUISH BASIC COLORS
ABILITY TO DISTINGUISH SHADES OF
BOTH LEGS REQUIRED
LIGHT LIFTING, UNDER 15 POUNDS
COLORS
OPERATION OF CRANE, TRUCK, TRACTOR,
OR MOTOR VEHICLE
HEAVY CARRYING, 45 POUNDS AND OVER
HEARING (AID PERMITTED)
ABILITY FOR RAPID MENTAL AND MUSCULAR
HEARING WITHOUT AID
MODERATE CARRYING, 15-44 POUNDS
COORDINATION SIMULTANEOUSLY
SPECIFIC VISUAL REQUIREMENT
LIGHT CARRYING, UNER 15 POUNDS
ABILITY TO USE AND DESIRABILITY OF USING
(SPECIFY)
FIREARMS
HOURS)
STRAIGHT PULLING (
NEAR VISION CORRECTABLE AT 13" TO 16"
PULLING HAND OVER HAND (
HOURS)
TO JAEGER 1 TO 4
HOURS)
PUSHING (
FAR VISION CORRECTABLE IN ONE EYE TO
20/20 AND TO 20/40 IN THE OTHER
REACHING ABOVE SHOULDER
SPECIFIC VISUAL REQUIREMENT (SPECIFY)
WALKING (
HOURS)
USE OF FINGERS
KNEELING (
HOURS)
BOTH HANDS REQUIRED
STANDING (
HOURS)
HOURS)
CRAWLING (
4b. ENVIRONMENTAL FACTORS
WORKING ALONE
OUTSIDE
ELECTRICAL ENERGY
PROTRACTED OR IRREGULAR HOURS OF
OUTSIDE AND INSIDE
SLIPPERY OR UNEVEN WALKING SURFACES
WORK
EXCESSIVE HEAT
OTHER
WORKING AROUND MACHINERY WITH MOVING PARTS
EXCESSIVE DAMPNESS OR CHILLING
EXCESSIVE HUMIDITY
WORKING ON LADDERS OR SCAFFOLDING
WORKING BELOW GROUND
DRY ATMOSPHERIC CONDITIONS
UNUSUAL FATIGUE (SPECIFY)
EXCESSIVE NOISE, INTERMITTENT
WORKING WITH HANDS IN WATER
DUST
CONSTANT NOISE
EXPLOSIVES
VIBRATION
SILICA, ASBESTOS, ETC.
FUMES, SMOKE, OR GASES
SOLVENTS
WORKING CLOSELY WITH OTHER
GREASE AND OILS
RADIANT ENERGY
PART C. TO BE COMPLETED BY EXAMINING PHYSICIAN
NOTE TO EXAMINING PHYSICIAN: The person you are about to examine will have to cope with the functional requirements and environmental factors checked in
Part 4 of this form. Please take these, and the brief description of the job duties, into consideration as you make your examination and report your findings and
conclusions. Limit the examination, findings, and conclusions to those elements that are relevant to the requirements and factors of the position held by, or being
considered for, the individual.
FEET
FEET
1. HEIGHT
POUNDS
WEIGHT
2. EYES:
left
a. Distant vision (Snellen): without corrective lenses: right
left
; with corrective lenses, if worn;
b. Depth perception
Type of test:
Seconds of Arc
tested
of
Number correct:
Interpretation
Normal
Abnormal
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PART C. CONTINUED - TO BE COMPLETED BY EXAMINING PHYSICIAN
degrees
degrees
c. Peripheral vision
Right Nasal
Temporal
degrees
degrees
Left Nasal
Temporal
d. Color vision: Is color vision normal by Ishihara or other color plate test?
YES
NO
If not, can applicant pass lantern test?
YES
NO
Can see red/green/yellow?
YES
NO
3. EARS: (Consider denominators indicated here as normal. Record as numerators the greatest distance heard)
Ordinary conversation:
Right Ear
:
20 ft.
Audiometer in dB (if given) for Right Ear:
250
500
2000
4000
6000
7000
1000
3000
5000
8000
Left Ear
:
20 ft.
Audiometer in dB (if given) for Left Ear:
250
500
2000
4000
6000
7000
1000
3000
5000
8000
4. Other Finding: Describe any abnormality (including diseases, scars, and disfigurations). Include brief pertinent history. If normal, so indicate.
a. Eyes, ears, nose, and throat (including tooth and oral hygiene)
b. Abdomen
c. Head and neck (including face, hair, scalp, and range of motion)
d. Peripheral blood vessels
e. Speech (note any malfunction)
f. Extremities (Including strength, range of motion)
g. Skin and lymph nodes (including thyroid gland)
h. Urinalysis (if indicated) SP. Gr.
Sugar
Blood
Albumin
Casts
Pus
i. Respiratory tract (X-ray if indicated)
Pulse
j. Heart (size, rate, rhythm, function) Blood pressure
EKG (if indicated)
k. Back (special consideration for positions involving heavy lifting and other strenuous duties)
l. Neurological (including reflexes, sensation) and mental health
DA FORM 3437, AUG 2019
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