DA Form 4107 "Operation Request and Worksheet"

What Is DA Form 4107?

This is a military form that was released by the U.S. Department of the Army (DA) on March 1, 1982. The form, often mistakenly referred to as the DD Form 4107, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

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OPERATION REQUEST AND WORKSHEET
For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General
SECTION A - REQUEST FOR SURGERY
1. PATIENT'S NAME (Last, First, MI) (Print)
RELI-
6. SSN (with Family Member
2. STATUS
3. AGE
4.
5. REGISTER NO
GION
Prefix)
8. NURSING UNIT (from -
7. PREOPERATIVE DIAGNOSIS
to)
9. OPERATION PROPOSED
10. REQUESTING SERVICE
11. DATE OF SURGERY
12. TIME OR CASE NO
13. SCHEDULE PRIORITY (check one)
14. BLOOD REQUIRED
15. SEPTIC
(Unit)
EMERGENCY
SEMI-EMERGENCY
ROUNTINE
cc
16. SURGEON
17. ASSISTANT(S)
18. POSITION OF PNT
19. PREP REQUIRED
20. NURSING STAFF
21. ANESTHETIST(S)
22. ANESTHESIA
23. SPECIAL INSTRUCTIONS AND REMARKS
24. REQUESTING OFFICER (Printed Name and Signature)
SECTION B - OPERATION WORKSHEET
25. OPERATING
26. TIME OR CASE NO
27. SEPTIC
28. FLUIDS (other than blood)
29. BLOOD ADMINISTERED
ROOM NO
33. ANESTHESIA
30. SURGEON
31. ASSISTANT(S)
32. ANESTHETIST(S)
TIME (Began and
Ended)
AGENT
TECHNIQUE
39. SPECIAL PROCEDURES
34.
37. AIRWAY
INDUCTION
(Anesthesia)
ANESTHETIC
AGENT
TECHNIQUE
35.
38. RELAXANTS
PRIMARY
INTUBATION
OTHER
ANESTHETIC
AGENT
TECHNIQUE
36.
SECONDARY
ANESTHETIC
40. NURSING TIME (Began
41. SCRUBBED PERSON(S)
42. CIRCULATING PERSON(S)
and Ended)
43. OPERATION DATE
44. OPERATION TIME
45. DRAINS
46. SPONGE COUNT
47. LABORATORY SPECIMEN
(Began and Ended)
48. OPERATIVE DIAGNOSIS
49. OPERATIONS(S) PERFORMED
EPISODES OF SURGERY
50. COMPLICATIONS (Continue on reverse, if more space is required)
51. DICTATOR'S NAME, SERVICE & PHONE EXT
RECORDED IN REGISTER
(Initials)
DA FORM 4107, MAR 1982
EDITION OF 1 JUN 73 MAY BE USED.
APD LC v1.02ES
OPERATION REQUEST AND WORKSHEET
For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General
SECTION A - REQUEST FOR SURGERY
1. PATIENT'S NAME (Last, First, MI) (Print)
RELI-
6. SSN (with Family Member
2. STATUS
3. AGE
4.
5. REGISTER NO
GION
Prefix)
8. NURSING UNIT (from -
7. PREOPERATIVE DIAGNOSIS
to)
9. OPERATION PROPOSED
10. REQUESTING SERVICE
11. DATE OF SURGERY
12. TIME OR CASE NO
13. SCHEDULE PRIORITY (check one)
14. BLOOD REQUIRED
15. SEPTIC
(Unit)
EMERGENCY
SEMI-EMERGENCY
ROUNTINE
cc
16. SURGEON
17. ASSISTANT(S)
18. POSITION OF PNT
19. PREP REQUIRED
20. NURSING STAFF
21. ANESTHETIST(S)
22. ANESTHESIA
23. SPECIAL INSTRUCTIONS AND REMARKS
24. REQUESTING OFFICER (Printed Name and Signature)
SECTION B - OPERATION WORKSHEET
25. OPERATING
26. TIME OR CASE NO
27. SEPTIC
28. FLUIDS (other than blood)
29. BLOOD ADMINISTERED
ROOM NO
33. ANESTHESIA
30. SURGEON
31. ASSISTANT(S)
32. ANESTHETIST(S)
TIME (Began and
Ended)
AGENT
TECHNIQUE
39. SPECIAL PROCEDURES
34.
37. AIRWAY
INDUCTION
(Anesthesia)
ANESTHETIC
AGENT
TECHNIQUE
35.
38. RELAXANTS
PRIMARY
INTUBATION
OTHER
ANESTHETIC
AGENT
TECHNIQUE
36.
SECONDARY
ANESTHETIC
40. NURSING TIME (Began
41. SCRUBBED PERSON(S)
42. CIRCULATING PERSON(S)
and Ended)
43. OPERATION DATE
44. OPERATION TIME
45. DRAINS
46. SPONGE COUNT
47. LABORATORY SPECIMEN
(Began and Ended)
48. OPERATIVE DIAGNOSIS
49. OPERATIONS(S) PERFORMED
EPISODES OF SURGERY
50. COMPLICATIONS (Continue on reverse, if more space is required)
51. DICTATOR'S NAME, SERVICE & PHONE EXT
RECORDED IN REGISTER
(Initials)
DA FORM 4107, MAR 1982
EDITION OF 1 JUN 73 MAY BE USED.
APD LC v1.02ES