DA Form 5027-R Medcase Program Requirement (Lra)

DA Form 5027-R - also known as the "Medcase Program Requirement (lra)" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 5027-R - was last revised on July 1, 1997. Download an up-to-date fillable PDF version of the DA 5027-R below or request a copy through the chain of command.

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1. DATE (YYYYMMDD)
MEDCASE PROGRAM REQUIREMENT
For use of this form, see SB 8-75 MEDCASE; the proponent agency is the OTSG
2. ACTIVITY (Name and Address)
3. FROM (Div, Dept or Svc)
4. ASSET CONTROL NUMBER
5. TDA-UIC
6. HAND RECEIPT CODE
7. BUDGET LINE ITEM CODE
8. REQUIREMENT SUBMISSION
9. POINT OF CONTACT
10. PHONE NUMBER
st
NEW (1
Submission)
RE-SUBMISSION
11. STANDARD ITEM DESCRIPTION OR GENERIC NOMENCLATURE (See SB 8-75 MEDCASE)
12. EXTENDED/SYSTEM DESCRIPTION
13. QUANTITY
14. UNIT PRICE
15. JUSTIFICATION
15a. HOW IS THE FUNCTION NOW BEING ACCOMPLISHED?
15b. WHY IS THIS EQUIPMENT REQUIRED? (Workload data, new technology, cost reduction, maintenance costs, equipment down time or
nonavailability, obsolescence of current methods, etc.)
15c. IMPACT IF EQUIPMENT IS NOT PROVIDED
16. ARE PERSONNEL ASSIGNED AND TRAINED TO OPERATE EQUIPMENT? (If No, explain)
YES
NO
17. SPECIAL EQUIPMENT CATEGORY
FOR NEW OR RENOVATED FACILITY (BLIC NF)
CLINICAL INVESTIGATION PROGRAM (BLIC CF)
FOR NEW OR RENOVATED FACILITY (BLIC MB)
POLLUTION CONTROL PROGRAM (BLIC PC)
DRUG ABUSE/CONTROL PROGRAM (BLIC DA)
REPLACE, MODERNIZE, OR ACQUIRE EQUIPMENT FOR EXISTING FACILITY (BLIC UR)
REPLACEMENT NORMAL
REPLACEMENT ACCELERATED
NEW MISSION
MODERNIZATION
OTHER
UPGRADE
EXCESS
LEASE
18. ITEM BEING REPLACED?
19. NSN/MCN
20. MMCN
21. SERIAL NUMBER
YES
NO
22. MODEL NUMBER
23. LOCATION
24. DISPOSITION
RETAIN AS BACK-UP
TURN IN AS EXCESS
TRADE-IN
25. I CERTIFY THE INFORMATION ON THIS PAGE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
25a. TYPED NAME AND TITLE OF REQUESTOR
25b. SIGNATURE
26. THIS EQUIPMENT IS NECESSARY FOR THE ACCOMPLISHMENT OF THIS ACTIVITY'S MISSION.
26a. TYPED NAME AND TITLE OF CHIEF OF DIV/DEPT/SVC
26b. SIGNATURE
APD LC v1.03ES
DA FORM 5027-R, JUL 1997
DA FORM 5027-R (TEST), NOV 81 IS OBSOLETE
1. DATE (YYYYMMDD)
MEDCASE PROGRAM REQUIREMENT
For use of this form, see SB 8-75 MEDCASE; the proponent agency is the OTSG
2. ACTIVITY (Name and Address)
3. FROM (Div, Dept or Svc)
4. ASSET CONTROL NUMBER
5. TDA-UIC
6. HAND RECEIPT CODE
7. BUDGET LINE ITEM CODE
8. REQUIREMENT SUBMISSION
9. POINT OF CONTACT
10. PHONE NUMBER
st
NEW (1
Submission)
RE-SUBMISSION
11. STANDARD ITEM DESCRIPTION OR GENERIC NOMENCLATURE (See SB 8-75 MEDCASE)
12. EXTENDED/SYSTEM DESCRIPTION
13. QUANTITY
14. UNIT PRICE
15. JUSTIFICATION
15a. HOW IS THE FUNCTION NOW BEING ACCOMPLISHED?
15b. WHY IS THIS EQUIPMENT REQUIRED? (Workload data, new technology, cost reduction, maintenance costs, equipment down time or
nonavailability, obsolescence of current methods, etc.)
15c. IMPACT IF EQUIPMENT IS NOT PROVIDED
16. ARE PERSONNEL ASSIGNED AND TRAINED TO OPERATE EQUIPMENT? (If No, explain)
YES
NO
17. SPECIAL EQUIPMENT CATEGORY
FOR NEW OR RENOVATED FACILITY (BLIC NF)
CLINICAL INVESTIGATION PROGRAM (BLIC CF)
FOR NEW OR RENOVATED FACILITY (BLIC MB)
POLLUTION CONTROL PROGRAM (BLIC PC)
DRUG ABUSE/CONTROL PROGRAM (BLIC DA)
REPLACE, MODERNIZE, OR ACQUIRE EQUIPMENT FOR EXISTING FACILITY (BLIC UR)
REPLACEMENT NORMAL
REPLACEMENT ACCELERATED
NEW MISSION
MODERNIZATION
OTHER
UPGRADE
EXCESS
LEASE
18. ITEM BEING REPLACED?
19. NSN/MCN
20. MMCN
21. SERIAL NUMBER
YES
NO
22. MODEL NUMBER
23. LOCATION
24. DISPOSITION
RETAIN AS BACK-UP
TURN IN AS EXCESS
TRADE-IN
25. I CERTIFY THE INFORMATION ON THIS PAGE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
25a. TYPED NAME AND TITLE OF REQUESTOR
25b. SIGNATURE
26. THIS EQUIPMENT IS NECESSARY FOR THE ACCOMPLISHMENT OF THIS ACTIVITY'S MISSION.
26a. TYPED NAME AND TITLE OF CHIEF OF DIV/DEPT/SVC
26b. SIGNATURE
APD LC v1.03ES
DA FORM 5027-R, JUL 1997
DA FORM 5027-R (TEST), NOV 81 IS OBSOLETE

Download DA Form 5027-R Medcase Program Requirement (Lra)

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