DA Form 7574-1 Military Physician's Statement of Soldier's Incapacitation/Fitness for Duty

What Is DA Form 7574-1?

DA Form 7574-1, Military Physician's Statement of Soldier's Incapacitation/Fitness For Duty is a form used for documenting a military physician’s conclusions regarding either the ability or inability of a service member to perform their duties.

A new version of the document – sometimes incorrectly referred to as the DD Form 7574-1 – was released by the Department of the Army in March 2008. An up-to-date DA Form 7574-1 fillable version is available for download below or can be found through the Army Publishing Directorate online library.

The DA 7574-1 must be completed once every three months along with statements from employers regarding non-military employment status. Service members are discouraged from performing any military work until a determination of fitness for duty is made by a military physician.

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MILITARY PHYSICIAN'S STATEMENT OF SOLDIER'S INCAPACITATION / FITNESS FOR DUTY
For use of this form, see DA PAM 135-381; the proponent agency is DCS, G-1.
PRIVACY ACT STATEMENT
AUTHORITY:
5 U.S.C. 301, Department Regulations, 10 U.S.C 3013, Secretary of the Army; 37 U.S.C. 204, Entitlement,
A R 135-381, Incapacitation of Reserve Component Soldiers and EO 9397 (SSN)
This information will be used for the physician to verify eligibility for military duties.
PRINCIPAL PURPOSE:
None. The "Blanket Routine Uses" set forth at the beginning of the Army's Compilations of System of Records
ROUTINE USES:
Notices apply to this system.
Voluntary. However, failure to provide all the requested information may delay or prevent the payment of
DISCLOSURE:
compensation.
SOLDIER IDENTIFICATION (Completed by Soldier - PLEASE PRINT)
1. LAST NAME
2. FIRST NAME
3. MI
4. SSN
5. RANK
6. DUTY MOS/AOC
7. CIVILIAN JOB TITLE (S) (include copy of job description)
INCAPACITATION/FITNESS FOR DUTY VERIFICATION
8. INCAPACITATION FOR MILITARY DUTIES: (Must be completed by U.S. government/military physician)
a. On
, I examined the above-named Reserve Component Soldier or his/her records and found that he/she: (Check One)
(enter date YYYYMMDD)
b.
IS NOT FIT to perform military duties from
to
(Date - YYYYMMDD)
(Date - YYYYMMDD)
c.
IS FIT to perform military duties.
(Check One)
d.
initiated on
(provide supporting documentation).
MEB
PEB
(Date - YYYYMMDD)
9. INCAPACITATION FOR CIVILIAN JOB: (Must be completed by any licensed physician)
a. On
, I examined the above-named Reserve Component Soldier and found that he/she:
(enter date YYYYMMDD)
(Check One)
b.
IS NOT FIT to perform civilian duties from
to
(Date - YYYYMMDD)
(Date - YYYYMMDD)
c.
IS FIT to perform civilian duties.
10. GOVERNMENT PHYSICIAN'S VERIFICATION
a. DIAGNOSIS AND PROGNOSIS (Please Print)
b. SOLDIER'S NEXT MEDICAL
c. NAME OF GOVERNMENT/MILITARY TREATMENT FACILITY AND ADDRESS
APPOINTMENT IS ON OR ABOUT:
d. PHYSICIAN'S NAME
e. RANK
f. DAY-TIME PHONE NUMBER
g. FAX NUMBER
h. PHYSICIAN'S SIGNATURE
i. E-MAIL ADDRESS (.mil or .gov)
j . DATE (YYYYMMDD )
Page 1 of 2
DA FORM 7574-1, MAR 2008
PREVIOUS EDITION IS OBSOLETE.
APD LC v1.01ES

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How to Fill Out DA Form 7574-1?

An overview of the form and filing guidelines can be found in the Department of the Army Pamphlet 135–381, Incapacitation of Reserve Component Soldiers Processing Procedures, released in May 2008. DA Form 7574-1 instructions are as follows:

  • The DA 7574-1 relates to the medical documentation pertaining to the treatment received by the soldier and should be completed when requesting incapacitation payments. The document contains two sections in total.
  • Section I - Soldier Identification - is mostly self-explanatory. All boxes are completed by the soldier making the claim and require their personal identifying data. This information includes their name, SSN, rank, MI, duty MOS or AOC.

This part should also identify the service member’s civilian occupation with a copy of the job description attached to the completed form.

  • Section II - Incapacitation/Fitness for Duty Verification - consists of two parts. A soldier’s incapacitation to perform military duties must be verified by U.S. Government or military physician. Incapacitation for a civilian job can be verified by any licensed physician.

All lines in Box 10 are completed by an attending government physician. Authorized personnel includes licensed government or military physicians, Reserve commissioned officers employed as licensed physicians by the Department of Veteran Affairs and non-military physicians employed by military services (DVA, TRICARE, MMSO).

The required information includes the diagnosis and prognosis, the date of the next follow-up appointment along with the physician's personal data and their signature.

DA 7574-1 Related Forms

  1. DA Form 7574, Incapacitation Pay Monthly Claim Form, used to determine the eligibility of the soldier to receive incapacitation pay.
  2. DA Form 7574-2, Soldier's Acknowledgement of Incapacitation Pay Counselling, by which the soldier testifies that they were properly informed on incapacitation pay claims.

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