DD Form 2992 Medical Recommendation for Flying or Special Operational Duty

DD Form 2992 - also known as the "Medical Recommendation For Flying Or Special Operational Duty" - is a United States Military form issued by the Department of Defense.

The form - often incorrectly referred to as the DA form 2992 - was last revised on January 1, 2015. Download an up-to-date fillable PDF version of the DD 2992 below or request a copy through the chain of command.

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MEDICAL RECOMMENDATION FOR FLYING OR SPECIAL OPERATIONAL DUTY
(Read Privacy Act Statement and Instructions on back before completing form.)
1. TO:
2. FROM:
3. DATE
(YYYYMMDD)
7. DATE OF BIRTH
4. MEMBER NAME
5. IDENTIFICATION NUMBER
6. GRADE
(Last, First, Middle Initial)
(YYYYMMDD)
10. FLIGHT PHYSICAL DATE
8. ORGANIZATION
9. TYPE OF DUTY
(YYYYMMDD)
(If applicable)
UP: THE ABOVE INDIVIDUAL HAS BEEN FOUND QUALIFIED BY MEDICAL AUTHORITY.
11.
a. X one:
CLEARED AFTER
:
Temporary medical disqualification
Waiver recommended (Not USAF)
Aircraft mishap
(X)
Reporting to new duty station
Waiver granted
Other
(See remarks)
CLEARED AFTER FLIGHT DUTY MEDICAL EXAMINATION
b. EFFECTIVE DATE
c. EXPIRATION DATE
(YYYYMMDD)
(YYYYMMDD)
DOWN: THE ABOVE INDIVIDUAL HAS BEEN FOUND DISQUALIFIED BY MEDICAL AUTHORITY.
12.
a. X one:
TEMPORARY DISQUALIFICATION DUE TO
:
Illness or Injury
Aircraft mishap
Other
(X)
(See remarks)
MAY PARTICIPATE IN
:
Simulator duties
Ground based flight line duties
Other
(X)
(See remarks)
PERMANENT DISQUALIFICATION
b. EFFECTIVE DATE
c. ESTIMATED DURATION OF GROUNDING
(YYYYMMDD)
13. REMARKS/LIMITATIONS
VISION CORRECTION DEVICES REQUIRED IN THE PERFORMANCE OF FLIGHT DUTIES.
MUST CARRY EXTRA SPECTACLES.
14. (X one):
FLIGHT SURGEON
OTHER
(Countersignature required for Air Force and Navy upslip)
d. DATE SIGNED
a. TYPED NAME
b. GRADE
c. PROVIDER SIGNATURE
(Last, First, Middle Initial)
(YYYYMMDD)
h. DATE SIGNED
e. TYPED NAME
f. GRADE
g. FLIGHT SURGEON COUNTERSIGNATURE
(Last, First, Middle Initial)
(YYYYMMDD)
15. MEMBER CERTIFICATION
c. DATE SIGNED
a. I certify that I understand the above recommendations and that I:
b. AIRCREW MEMBER SIGNATURE
(YYYYMMDD)
MAY
MAY NOT
perform flight duties.
16. ACTION TAKEN BY COMMANDER
APPROVE
DISAPPROVE
(Not required for Air Force and Navy)
d. DATE SIGNED
a. TYPED NAME
b. TITLE
c. SIGNATURE
(Last, First, Middle Initial)
(YYYYMMDD)
DD FORM 2992, JAN 2015
REPLACES DA FORM 4186, AF FORM 1042, AND NAVMED FORMS 6410/1 AND 6410/2,
Adobe Designer 9.0
WHICH ARE OBSOLETE.
MEDICAL RECOMMENDATION FOR FLYING OR SPECIAL OPERATIONAL DUTY
(Read Privacy Act Statement and Instructions on back before completing form.)
1. TO:
2. FROM:
3. DATE
(YYYYMMDD)
7. DATE OF BIRTH
4. MEMBER NAME
5. IDENTIFICATION NUMBER
6. GRADE
(Last, First, Middle Initial)
(YYYYMMDD)
10. FLIGHT PHYSICAL DATE
8. ORGANIZATION
9. TYPE OF DUTY
(YYYYMMDD)
(If applicable)
UP: THE ABOVE INDIVIDUAL HAS BEEN FOUND QUALIFIED BY MEDICAL AUTHORITY.
11.
a. X one:
CLEARED AFTER
:
Temporary medical disqualification
Waiver recommended (Not USAF)
Aircraft mishap
(X)
Reporting to new duty station
Waiver granted
Other
(See remarks)
CLEARED AFTER FLIGHT DUTY MEDICAL EXAMINATION
b. EFFECTIVE DATE
c. EXPIRATION DATE
(YYYYMMDD)
(YYYYMMDD)
DOWN: THE ABOVE INDIVIDUAL HAS BEEN FOUND DISQUALIFIED BY MEDICAL AUTHORITY.
12.
a. X one:
TEMPORARY DISQUALIFICATION DUE TO
:
Illness or Injury
Aircraft mishap
Other
(X)
(See remarks)
MAY PARTICIPATE IN
:
Simulator duties
Ground based flight line duties
Other
(X)
(See remarks)
PERMANENT DISQUALIFICATION
b. EFFECTIVE DATE
c. ESTIMATED DURATION OF GROUNDING
(YYYYMMDD)
13. REMARKS/LIMITATIONS
VISION CORRECTION DEVICES REQUIRED IN THE PERFORMANCE OF FLIGHT DUTIES.
MUST CARRY EXTRA SPECTACLES.
14. (X one):
FLIGHT SURGEON
OTHER
(Countersignature required for Air Force and Navy upslip)
d. DATE SIGNED
a. TYPED NAME
b. GRADE
c. PROVIDER SIGNATURE
(Last, First, Middle Initial)
(YYYYMMDD)
h. DATE SIGNED
e. TYPED NAME
f. GRADE
g. FLIGHT SURGEON COUNTERSIGNATURE
(Last, First, Middle Initial)
(YYYYMMDD)
15. MEMBER CERTIFICATION
c. DATE SIGNED
a. I certify that I understand the above recommendations and that I:
b. AIRCREW MEMBER SIGNATURE
(YYYYMMDD)
MAY
MAY NOT
perform flight duties.
16. ACTION TAKEN BY COMMANDER
APPROVE
DISAPPROVE
(Not required for Air Force and Navy)
d. DATE SIGNED
a. TYPED NAME
b. TITLE
c. SIGNATURE
(Last, First, Middle Initial)
(YYYYMMDD)
DD FORM 2992, JAN 2015
REPLACES DA FORM 4186, AF FORM 1042, AND NAVMED FORMS 6410/1 AND 6410/2,
Adobe Designer 9.0
WHICH ARE OBSOLETE.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 3031, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 8013, Secretary of the Air Force; 14 U.S.C.
92, Secretary, General Powers; AR 40-501 Standards of Medical Fitness, AFI 48-123 Medical Examinations and Standards, OPNAVINST 3710
NATOPS General Flight and Operating Instruction, and COMDTINST M6410.3A, Coast Guard Aviation Medicine Manual.
PRINCIPAL PURPOSE(S): This form is used to inform the commander about medical fitness to perform flying or special operational duty. It is also
used to populate the service specific flight records management system used by the Army, Air Force and Navy.
ROUTINE USE(S):
Law Enforcement Routine Use: If a system of records maintained by a Component to carry out its functions indicates a violation or potential
violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute or by regulation, rule, or order issued pursuant
thereto, the relevant records in the system of records may be referred, as a routine use, to the agency concerned, whether Federal, State, local, or
foreign, charged with the responsibility of investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule,
regulation or order pursuant thereto.
Congressional Inquiries Disclosure Routine Use: Disclosure from a system of records maintained by a Component may be made to a congressional
office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual.
Disclosure to the Department of Justice for Litigation Routine Use: A record from a system of records maintained by a Component may be disclosed
as a routine use to any component of the Department of Justice for the purpose of representing the Department of Defense or the U.S. Coast Guard,
or any officer, employee or member of these entities in pending or potential litigation to which the record is pertinent.
Disclosure of Information to the National Archives and Records Administration Routine Use: A record from a system of records maintained by a
Component may be disclosed as a routine use to the National Archives and Records Administration for the purpose of records management
inspections conducted under authority of 44 U.S.C. 2904 and 2906.
Data Breach Remediation Purposes Routine Use: A record from a system of records maintained by a Component may be disclosed to appropriate
agencies, entities, or persons when (1) the Component suspects or has confirmed that the security or confidentiality of the information in the system
of records has been compromised; (2) the Component has determined that as a result of the suspected or confirmed compromise there is a risk of
harm to economic or property interests, identity theft or fraud, or harm to the security or integrity of this system or other systems or programs
(whether maintained by the Component or another agency or entity) that rely upon the compromised information; and (3) the disclosure made to
such agencies, entities, and persons is reasonably necessary to assist in connection with the Components efforts to respond to the suspected or
confirmed compromise and prevent, minimize, or remedy such harm.
DISCLOSURE: Voluntary. Failure to provide information or sign may delay determination of medical fitness to perform flying or special operational
duty.
INSTRUCTIONS
Blocks 1-8: These may be completed by the clinic staff or the service member.
Block 5: Identification Number
a. Air Force, Army and Navy – Use DoD ID number.
b. Coast Guard – Use Employee ID number.
Block 9: Place the Flying Class category and the duty performed using the references below.
Army – See AR 40-501, Chapter 6.
Air Force – See AFI 48-123, Chapter 6.
Navy – See NAVMED P-117, Chapter 15, Article 15-63.
Coast Guard – See Coast Guard Aviation Medicine Manual, Chapter 1.
Block 10 – Date flight physical was completed.
Block 11 (a-c) – This section is used for qualification. Mark the appropriate boxes.
Block 12 (a-c) – This section is used for disqualification. Mark the appropriate boxes.
Block 13 – Make remarks as appropriate and do not include any protected health information in this section.
Blocks 14 – 16 are self-explanatory except as detailed below.
Block 14 – Other credentialed providers who are not flight surgeons require a countersignature by a flight surgeon. Army
aeromedical physician assistants and aviation medicine nurse practitioners do not require a countersignature for Army personnel
only.
Block 15 – Selecting "MAY NOT" does not prohibit simulator duties or ground based flight line duties if these boxes are marked in
block 12.
DD FORM 2992 (BACK), JAN 2015

Download DD Form 2992 Medical Recommendation for Flying or Special Operational Duty

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