Medical assignment screening service member name




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MEDICAL ASSIGNMENT SCREENING





SERVICE MEMBER NAME


GRADE / RATE


SSN



PURPOSE: Completed by a military physician, nurse practitioner, physician assistant, or independent duty corpsman after a service member is returned to medically unrestricted duty after a period of limited duty (LIMDU) or a finding of “fit for continued Naval service” by the Physical Evaluation Board (PEB). The assignment screening determines if a service member is “worldwide assignable” or “assignment limited” due to ongoing medical conditions. The military treatment facility (MTF) assignment screening coordinator will forward the completed original form to the service member’s parent command, place a copy in the member’s MTF medical record and LIMDU or PEB file, and retain a copy for audit. The parent command will coordinate with the Navy Personnel Command, who will use this information to manage assignments or to make administrative determinations regarding the service member. Refer to BUMEDINST 1300.2A for implementing guidance.

Yes

No

ITEM








  1. Are there any chronic or recurrent medical conditions that might materially increase the probability that the service member

would not successfully complete an operational or overseas assignment? Note: Access to specific medication alone should not

be considered a limitation but the underlying condition should be directly addressed. (If ‘YES’, explain in block 3.)









2. Are there any pending consults or tests that may impact assignment suitability? (If ‘YES,’ explain in block 3.)

3. Explain any ‘YES’ answers from above. Include the reason/diagnosis for any medical evaluation boards, ICD-9 code(s), PEB findings (if applicable), limiting conditions and prognosis/timeline for improvement, and any other pertinent information.


IS THE MEMBER WORLDWIDE ASSIGNABLE WITHOUT LIMITATIONS FOR DUTIES CONSISTENT WITH RATE/RANK/DESIGNATOR?




YES - Worldwide Assignable Without Limitations




NO - Assignment Limited (explain below)

The member has the following limitations: (include all limitations such as specific activities to be avoided, required access to specialty care, and other pertinent issues for consideration in the assignment of next duty station)



____________________________________ _____________

Military Medical Screener (Signature) Date

___ _________________________________________________

Printed Name, Rank or Grade


_______________________________ _____________________

MTF or Duty Station


_________________________________ ___________________

Telephone Number (include area/country code)


______________________________ ______________________

DSN Number


______________________________ ______________________

Telefax Number (include area/country code)


_______________________________ ____________________

E-mail Address



_________________________________________ _____________

Parent Command POC (Signature) Date

________________________________________________________

Printed Name, Rank or Grade
________________________________________________________

Command or Duty Station


________________________________________________________

Telephone Number (include area/country code)


________________________________________________________

DSN Number


________________________________________________________

Telefax Number (include area/country code)


________________________________________________________

E-mail Address




NAVMED 1300/3 (xx-05)



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