DD Form 503 Health Assessment Certificate for Segregation

DD Form 503 or the "Health Assessment Certificate For Segregation" is a Department of Defense-issued form used by and within the United States Army.

The form - often mistakenly referred to as the DA form 503 - was last revised on March 1, 2013. Download an up-to-date fillable PDF version of the DD 503 down below or find it on the Department of Defense documentation website.

ADVERTISEMENT
HEALTH ASSESSMENT CERTIFICATE FOR SEGREGATION
(Annotate all medical information on SF 600 and maintain in the prisoner medical records.)
1. CORRECTIONAL FACILITY/INSTALLATION
2. DATE (YYYYMMDD)
3. TIME
4. PRISONER NAME (Last, First, Middle)
5. REGISTRATION NUMBER
6. SEGREGATION AUTHORIZED BY
a. PRINTED NAME (Last, First)
b. SIGNATURE
c. PURPOSE (X one)
ADMINISTRATIVE SEGREGATION (AS)/
DISCIPLINARY SEGREGATION (DS)/
On the below date and time, I have examined the above named prisoner for serious physical and mental injuries and illness requiring further immediate
medical attention, and find no medical reason(s) that prohibit(s) segregated housing as required at this time.
7. REMARKS
8. HEALTH CARE STAFF
a. PRINTED NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE (YYYYMMDD)
d. TIME
This form is maintained in the Prisoner's Correctional Treatment File with other segregation documents.
DD FORM 503, MAR 2013
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X
HEALTH ASSESSMENT CERTIFICATE FOR SEGREGATION
(Annotate all medical information on SF 600 and maintain in the prisoner medical records.)
1. CORRECTIONAL FACILITY/INSTALLATION
2. DATE (YYYYMMDD)
3. TIME
4. PRISONER NAME (Last, First, Middle)
5. REGISTRATION NUMBER
6. SEGREGATION AUTHORIZED BY
a. PRINTED NAME (Last, First)
b. SIGNATURE
c. PURPOSE (X one)
ADMINISTRATIVE SEGREGATION (AS)/
DISCIPLINARY SEGREGATION (DS)/
On the below date and time, I have examined the above named prisoner for serious physical and mental injuries and illness requiring further immediate
medical attention, and find no medical reason(s) that prohibit(s) segregated housing as required at this time.
7. REMARKS
8. HEALTH CARE STAFF
a. PRINTED NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE (YYYYMMDD)
d. TIME
This form is maintained in the Prisoner's Correctional Treatment File with other segregation documents.
DD FORM 503, MAR 2013
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X

Download DD Form 503 Health Assessment Certificate for Segregation

569 times
Rate
4.3(4.3 / 5) 126 votes
ADVERTISEMENT