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 Department of the Army (DA) on October 1, 1972. 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.