DA Form 7595-4-4 "Initiate Treatment for Anaphylactic Shock"

What Is DA Form 7595-4-4?

This is a military form that was released by the U.S. Department of the Army (DA) on May 1, 2014. The form, often mistakenly referred to as the DD Form 7595-4-4, 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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Download DA Form 7595-4-4 "Initiate Treatment for Anaphylactic Shock"

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INITIATE TREATMENT FOR ANAPHYLACTIC SHOCK
For use of this form see TC 8-800; the proponent agency is TRADOC.
IV
TABLE:
REFERENCE:
STP 8-68W13-SM-TG, Task: 081-833-0003, Initiate Treatment for Anaphylactic Shock
PRIVACY ACT STATEMENT
10 U.S.C.
3013 Secretary of the Army; AR 350-1, Army Training Leadership and
AUTHORITY:
Development.
PRINCIPAL PURPOSE:
To ensure that accomplishment of training is properly credited to the correct individual for NREMT
certification IAW AR 40-68, AR 220-1 and AR 350-1.
Used by Unit personnel to monitor training. The DOD "Blanket Routine uses" set forth at the beginning of
ROUTINE USES:
the Army's compilation of system of records notices may apply to this system.
DISCLOSURE:
Voluntary. Failure to provide your name may result in a loss of credit for accomplishing the training or error
in processing applicable favorable personnel actions. For Official Use Only.
1. Soldier (Last Name, First Name, MI)
2. Date (YYYYMMDD)
SCENARIO:
You are a Soldier Medic performing sick call examinations. Your next patient is carried in by another NCO. He was stung by a bee and now is having
difficulty breathing. Initiate treatment for anaphylactic shock on this patient.
GRADING SHEET
TASK
COMPLETED
1ST
2ND
3RD
3. Performance Measures
P
F
P
F
P
F
a. Opened the airway, if necessary.
b. Administered high concentration oxygen, if available.
c. Administered one 0.3mg epinephrine auto-injector. Administered a second dose in 5 to 10 minutes
as needed.
d. Performed an emergency medical treatment history and physical examination of the patient.
e. Checked the patient's vital signs every 3 to 5 minutes until patient was stable.
f. Recorded the treatment given on DD Form 1380 [Tactical Combat Casualty Care (TCCC) Card].
g. Evacuated the patient. Continued to monitor the patient while en route to further care.
4. Demonstrated Proficiency
Yes
No
5. Start Time
6. Stop Time
7. Initial Evaluator
8. Start Time
9. Stop Time
10. Retest Evaluator
12. Stop Time
13. Final Evaluator
11. Start Time
14. Evaluator's Comments
This form was prepared by U.S. Government employees for use in the 68W MOS. Although it contains, in part, copyrighted material from National
Registry of Emergency Medical Technicians, Inc. (NREMT), skill sheets ©2011, this form has neither been prepared nor approved by NREMT.
Use is restricted to guidelines contained in the Preface to TC 8-800.
APD LC v1.00
DA FORM 7595-4-4, MAY 2014
INITIATE TREATMENT FOR ANAPHYLACTIC SHOCK
For use of this form see TC 8-800; the proponent agency is TRADOC.
IV
TABLE:
REFERENCE:
STP 8-68W13-SM-TG, Task: 081-833-0003, Initiate Treatment for Anaphylactic Shock
PRIVACY ACT STATEMENT
10 U.S.C.
3013 Secretary of the Army; AR 350-1, Army Training Leadership and
AUTHORITY:
Development.
PRINCIPAL PURPOSE:
To ensure that accomplishment of training is properly credited to the correct individual for NREMT
certification IAW AR 40-68, AR 220-1 and AR 350-1.
Used by Unit personnel to monitor training. The DOD "Blanket Routine uses" set forth at the beginning of
ROUTINE USES:
the Army's compilation of system of records notices may apply to this system.
DISCLOSURE:
Voluntary. Failure to provide your name may result in a loss of credit for accomplishing the training or error
in processing applicable favorable personnel actions. For Official Use Only.
1. Soldier (Last Name, First Name, MI)
2. Date (YYYYMMDD)
SCENARIO:
You are a Soldier Medic performing sick call examinations. Your next patient is carried in by another NCO. He was stung by a bee and now is having
difficulty breathing. Initiate treatment for anaphylactic shock on this patient.
GRADING SHEET
TASK
COMPLETED
1ST
2ND
3RD
3. Performance Measures
P
F
P
F
P
F
a. Opened the airway, if necessary.
b. Administered high concentration oxygen, if available.
c. Administered one 0.3mg epinephrine auto-injector. Administered a second dose in 5 to 10 minutes
as needed.
d. Performed an emergency medical treatment history and physical examination of the patient.
e. Checked the patient's vital signs every 3 to 5 minutes until patient was stable.
f. Recorded the treatment given on DD Form 1380 [Tactical Combat Casualty Care (TCCC) Card].
g. Evacuated the patient. Continued to monitor the patient while en route to further care.
4. Demonstrated Proficiency
Yes
No
5. Start Time
6. Stop Time
7. Initial Evaluator
8. Start Time
9. Stop Time
10. Retest Evaluator
12. Stop Time
13. Final Evaluator
11. Start Time
14. Evaluator's Comments
This form was prepared by U.S. Government employees for use in the 68W MOS. Although it contains, in part, copyrighted material from National
Registry of Emergency Medical Technicians, Inc. (NREMT), skill sheets ©2011, this form has neither been prepared nor approved by NREMT.
Use is restricted to guidelines contained in the Preface to TC 8-800.
APD LC v1.00
DA FORM 7595-4-4, MAY 2014