VETERINARY HEALTH RECORD
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136; DoD DIrective 5136.01; Army Regulation 40-905, SECNAVINST 6401-1B; AFI 48-131.
PRINCIPAL PURPOSE(S): To establish and maintain health records of animals and to locate animal owners for follow-up notification of care or
treatment received.
ROUTINE USE(S): The information may be used to aid in preventive health and communicable disease control programs, report medical conditions
required by law to Federal, state, and local agencies. The DoD Blanket Routine Uses found at:
http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html may also apply.
DISCLOSURE: Voluntary. However, if you fail to provide the requested information, the animal will not be provided veterinary care.
1. SPONSOR DATA
a. NAME (Last, First, Middle Initial)
b. GRADE OR RANK
c. HOME ADDRESS (Street, City, State, Zip Code)
d. PERSONAL TELEPHONE NO. (Include Area Code)
e. DUTY STATUS (X one)
f. RESIDENCE (X one)
ACTIVE
RETIRED
ON POST
OFF POST
g. ORGANIZATION
h. DUTY PHONE (Include Area Code)
2. ANIMAL DATA
a. NAME
b. SPECIES
c. BREED
d. COLOR
e. DATE OF BIRTH f. SEX
g. MICROCHIP #
3. IMMUNIZATION DATA
b. VACCINE
d. LOT
b. VACCINE
d. LOT
a. DATE
a. DATE
c. MANUFACTURER
c. MANUFACTURER
TYPE
NUMBER
TYPE
NUMBER
DD FORM 2343, AUG 2013
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X
VETERINARY HEALTH RECORD
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136; DoD DIrective 5136.01; Army Regulation 40-905, SECNAVINST 6401-1B; AFI 48-131.
PRINCIPAL PURPOSE(S): To establish and maintain health records of animals and to locate animal owners for follow-up notification of care or
treatment received.
ROUTINE USE(S): The information may be used to aid in preventive health and communicable disease control programs, report medical conditions
required by law to Federal, state, and local agencies. The DoD Blanket Routine Uses found at:
http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html may also apply.
DISCLOSURE: Voluntary. However, if you fail to provide the requested information, the animal will not be provided veterinary care.
1. SPONSOR DATA
a. NAME (Last, First, Middle Initial)
b. GRADE OR RANK
c. HOME ADDRESS (Street, City, State, Zip Code)
d. PERSONAL TELEPHONE NO. (Include Area Code)
e. DUTY STATUS (X one)
f. RESIDENCE (X one)
ACTIVE
RETIRED
ON POST
OFF POST
g. ORGANIZATION
h. DUTY PHONE (Include Area Code)
2. ANIMAL DATA
a. NAME
b. SPECIES
c. BREED
d. COLOR
e. DATE OF BIRTH f. SEX
g. MICROCHIP #
3. IMMUNIZATION DATA
b. VACCINE
d. LOT
b. VACCINE
d. LOT
a. DATE
a. DATE
c. MANUFACTURER
c. MANUFACTURER
TYPE
NUMBER
TYPE
NUMBER
DD FORM 2343, AUG 2013
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X
4. LABORATORY PROCEDURES
a. DATE
b. LABORATORY TEST - RESULT - REMARKS
a. DATE
b. LABORATORY TEST - RESULT - REMARKS
5. MASTER PROBLEM LIST
c. DATE
d. DATE
a. PROBLEM NO.
b. DESCRIPTION
ENTERED
RESOLVED
DD FORM 2343 (BACK), AUG 2013
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