DA Form 2984 "Very Seriously Ill/Seriously Ill/Special Category Patient Report"

What Is DA Form 2984?

This is a military form that was released by the U.S. Department of the Army (DA) on April 1, 2009. The form, often mistakenly referred to as the DD Form 2984 "Component Privacy and Civil Liberties Report (42 U.s.c. 2000ee-1)", 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.

Form Details:

  • A 1-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;

Download an up-to-date fillable DA Form 2984 down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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Download DA Form 2984 "Very Seriously Ill/Seriously Ill/Special Category Patient Report"

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VERY SERIOUSLY ILL/SERIOUSLY ILL/SPECIAL CATEGORY PATIENT REPORT
For use of this form, see AR 40-400; the proponent agency is OTSG.
PERSON TO BE NOTIFIED
TO:
PATIENT ADMINISTRATOR
5. RELATIONSHIP
ADMINISTRATIVE OFFICER OF THE DAY
1. DATE
2. HOUR
6. NAME AND ADDRESS
3. RELIGION OF PATIENT
4. WARD
ACTION TAKEN BY MEDICAL OFFICER
7. BRIEF DIAGNOSIS (Use lay terminology)
8. STATUS OF PATIENT
PLACED ON ROSTER
PROGNOSIS: RECOVERY IS -
a.
VERY SERIOUSLY ILL
NOT EXPECTED
QUESTIONABLE
b.
SERIOUSLY ILL
QUESTIONABLE
EXPECTED
NON SERIOUSLY ILL
EXPECTED LENGTH OF HOSPITALIZATION
DAYS
c.
d.
SPECIAL CATEGORY (Specify)
CHANGE OF STATUS
RECOVERED
DIED
g.
i.
SI TO VSI
e.
h.
j.
ADDITIONAL SPECIAL CATEGORY
TRANSFERRED
VSI TO SI
f.
(Specify in remarks)
9. REMARKS
10. TYPED OR PRINTED NAME OF MEDICAL OFFICER
11. SIGNATURE
ACTION TAKEN BY PATIENT ADMINISTRATOR OR ADMINISTRATIVE OFFICER OF THE DAY
METHOD OF NOTIFICATION (Initial one)
ACTION
DATE
HOUR
TELEPHONE
TELEGRAM
LETTER
IN PERSON
12. REPORT RECEIVED
13. PERSON (Same as Item 6)
14. INFORMATION OFFICE
15. RED CROSS
16. CHAPLAIN
17. UNIT COMMANDER
18. OTHER (Specify)
9. REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first,
20. TYPED OR PRINTED NAME OF PATIENT ADMINISTRATOR OR
ADMINISTRATIVE OFFICER OF THE DAY
middle; grade; family member prefix)
21. SIGNATURE
DA FORM 2984, APR 2009
PREVIOUS EDITION IS OBSOLETE
APD LC v1.00ES
VERY SERIOUSLY ILL/SERIOUSLY ILL/SPECIAL CATEGORY PATIENT REPORT
For use of this form, see AR 40-400; the proponent agency is OTSG.
PERSON TO BE NOTIFIED
TO:
PATIENT ADMINISTRATOR
5. RELATIONSHIP
ADMINISTRATIVE OFFICER OF THE DAY
1. DATE
2. HOUR
6. NAME AND ADDRESS
3. RELIGION OF PATIENT
4. WARD
ACTION TAKEN BY MEDICAL OFFICER
7. BRIEF DIAGNOSIS (Use lay terminology)
8. STATUS OF PATIENT
PLACED ON ROSTER
PROGNOSIS: RECOVERY IS -
a.
VERY SERIOUSLY ILL
NOT EXPECTED
QUESTIONABLE
b.
SERIOUSLY ILL
QUESTIONABLE
EXPECTED
NON SERIOUSLY ILL
EXPECTED LENGTH OF HOSPITALIZATION
DAYS
c.
d.
SPECIAL CATEGORY (Specify)
CHANGE OF STATUS
RECOVERED
DIED
g.
i.
SI TO VSI
e.
h.
j.
ADDITIONAL SPECIAL CATEGORY
TRANSFERRED
VSI TO SI
f.
(Specify in remarks)
9. REMARKS
10. TYPED OR PRINTED NAME OF MEDICAL OFFICER
11. SIGNATURE
ACTION TAKEN BY PATIENT ADMINISTRATOR OR ADMINISTRATIVE OFFICER OF THE DAY
METHOD OF NOTIFICATION (Initial one)
ACTION
DATE
HOUR
TELEPHONE
TELEGRAM
LETTER
IN PERSON
12. REPORT RECEIVED
13. PERSON (Same as Item 6)
14. INFORMATION OFFICE
15. RED CROSS
16. CHAPLAIN
17. UNIT COMMANDER
18. OTHER (Specify)
9. REMARKS
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first,
20. TYPED OR PRINTED NAME OF PATIENT ADMINISTRATOR OR
ADMINISTRATIVE OFFICER OF THE DAY
middle; grade; family member prefix)
21. SIGNATURE
DA FORM 2984, APR 2009
PREVIOUS EDITION IS OBSOLETE
APD LC v1.00ES