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 received an injury, illness or disease during Active Duty, inactive-duty training or traveling to and from IDT.  

The latest version of the form was released by the Department of the Army in October 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 website.

The DA form 2173 must be completed no later than 7 days after receiving a 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 formal one).

The form must be submitted within the adequate period of time for all allowances to come into effect within 30 days after reported injury, illness or disease. The completed form must undergo a detailed review and be approved for continuation of incapacitation benefits.

STATEMENT OF MEDICAL EXAMINATION AND DUTY STATUS
For use of this form, see AR 600-8-4, the proponent agency is DCS, G-1.
THRU: (Include ZIP Code)
TO: (Include ZIP Code)
FROM: (Include ZIP Code)
1. NAME OF INDIVIDUAL EXAMINED (Last, First, and Middle Initial)
2. SSN
3. GRADE
5.
ACCIDENT INFORMATION
4. ORGANIZATION AND STATION
a. DATE
b. PLACE (City and State)
SECTION I - TO BE COMPLETED BY ATTENDING PHYSICIAN OR HOSPITAL PATIENT ADMINISTRATOR
6. INDIVIDUAL WAS
OUT PATIENT
7. NAME OF HOSPITAL OR TREATMENT FACILITY
CIVILIAN
MILITARY
ADMITTED
DEAD ON ARRIVAL
8. HOUR AND DATE ADMITTED
9. HOUR AND DATE EXAMINED
10. NATURE AND EXTENT OF
INJURY
DISEASE
RESULTING IN DEATH
11. MEDICAL OPINION:
a.
WAS
WAS NOT UNDER THE INFLUENCE OF
ALCOHOL
DRUGS (Specify):
INDIVIDUAL
WAS NOT MENTALLY SOUND
(Attach Psychiatric evaluation if appropriate).
INDIVIDUAL
WAS
b.
IS
IS NOT LIKELY TO RESULT IN A CLAIM AGAINST THE GOVERNMENT FOR FUTURE MEDICAL CARE.
INJURY
c.
BASIS FOR OPINION:
INJURY
WAS
WAS NOT INCURRED IN LINE OF DUTY.
d.
12. THE FOLLOWING DISABILITY MAY RESULT
14. NO. OF MG ALCOHOL/100 ML BLOOD
13. BLOOD ALCOHOL
TEST MADE
TEMPORARY
PERMANENT PARTIAL
PERMANENT TOTAL
YES
NO
15. DETAILS OF ACCIDENT OR HISTORY OF DISEASE (how, where, when)
18. SIGNATURE
16. DATE
17. TYPED OR PRINTED NAME OF ATTENDING
PHYSICIAN OR PATIENT ADMINISTRATOR
SECTION II - TO BE COMPLETED BY UNIT COMMANDER OR UNIT ADVISER
19 DUTY STATION
20.
HOUR AND DATE OF ABSENCE
PRESENT FOR DUTY
ABSENT WITHOUT AUTHORITY
a. FROM
b. TO
ABSENT WITH AUTHORITY:
ON PASS
ON LEAVE
21. ABSENCE WITHOUT AUTHORITY MATERIALLY INTERFERRED WITH THE PERFORMANCE OF MILITARY DUTY (Explain in Item 30
type of duty missed, hours of duty, and how it did or did not interfere with performance)
YES
NO
22. INDIVIDUAL WAS ON
23.
HOUR AND DATE TRAINING
ACTIVE DUTY
ACTIVE DUTY FOR TRAINING
a. BEGAN
b. ENDED
INACTIVE DUTY TRAINING
24. RESERVIST DIED OF INJURIES RECEIVED PROCEEDING
DIRECTLY TO TRAINING
DIRECTLY FROM TRAINING
26. HOUR BEGINNING TRAVEL
27. DISTANCE INVOLVED
28. NORMAL TIME FOR TRAVEL
25. MODE OF TRANSPORTATION
29. DUTY STATUS AT TIME OF DEATH IF DIFFERENT FROM TIME OF INJURY OR CONTRACTION OF DISEASE
PRESENT FOR DUTY
ABSENT WITH AUTHORITY
ABSENT WITHOUT AUTHORITY
30. DETAILS OF ACCIDENT - REMARKS (If additional space is needed, continue on reverse) (Attach inclosures as necessary)
INJURY IS CONSIDERED TO HAVE BEEN INCURRED IN LINE OF
31. FORMAL LINE OF DUTY INVESTIGATION REQUIRED
32.
DUTY (Not applicable on deaths)
YES
NO
YES
NO
33. DATE
35. SIGNATURE
34.
TYPED NAME AND GRADE OF UNIT COMMANDER OR
UNIT ADVISER
REPLACES DA FORM 2173, 1 JUN 66, WHICH IS OBSOLETE.
DA FORM 2173, OCT 72
APD V2.01

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DA Form 2173 Instructions

Regulation AR 600-8-4, released on September 4th, 2008, 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?

The DA Form 2173 and - if applicable - the 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 is verified by the MTF commander, attending physician or patient administrator only. All personal data must be reviewed and checked. Pen and ink changes are allowed to be made. The form must be returned to the unit or MTF commander in case corrections are needed. An investigation officer can be appointed in case any further investigation is needed.

The DA Form 2173 consists of two Sections with around 10 to 15 Blocks in each.

  1. Basic information is required at the top of the form: the full name, SSN, grade, organization, and station of the soldier, the date and place of the accident and the to and from addresses for forwarding the form.
  2. Section I is completed by the attending physician or hospital patient administrator. 
    • Block 6 defines the state of the patient - admitted, outpatient, dead.
    • Block 7 requires the name of the civilian or military hospital.
    • Block 8 shows 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 provides 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 shows if the injury may result in a claim against the Government. Box 11D specifies if the injury happened during duty. An explanation is required. 
    • 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 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 traveling started, 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.