To submit this form, ensure all required fields are accurately filled out. You can email the form to the designated email address, fax it to the provided fax number, or use the online submission form if available. Alternatively, you can send it to the physical address specified. Review all details before submission to avoid any delays in processing.

The form is typically updated and revalidated periodically by the Department of Defense. Ensure to check for any updates or changes in form requirements.

The purpose of this form is to record an assessment of an individual's dental health, as required by the Department of Defense. It helps to determine fitness for prolonged duty without ready access to dental care and potential deployment outside the United States and its territories. This form is used to ensure that Active Duty, Reserve, Guard, and Civilian members of the United States Armed Forces maintain good oral health and are free from dental emergencies that could affect their ability to perform their duties effectively. The form must be completed by a licensed dentist who will assess the service member's dental health and provide necessary information to guide medical care and possible referrals. Ensuring the accuracy and completeness of this form is crucial for maintaining the dental readiness and overall health of military personnel.

• 1. SERVICE MEMBER'S NAME: Requires the full name (Last, First, Middle Initial) of the service member.
• 2. SOCIAL SECURITY NUMBER: Requires the social security number of the service member.
• 3. BRANCH OF SERVICE: Indicate the branch of the service to which the member belongs.
• 4. UNIT OF ASSIGNMENT: Specify the unit of assignment for the service member.
• 5. UNIT ADDRESS: Provide the full address of the unit of assignment.
• 6. EXAMINATION RESULTS: Dentist's assessment of the service member's dental health, categorized into four blocks based on the condition and expected dental treatment needs.
• 7. DENTIST'S NAME: Full name of the dentist conducting the examination.
• 8. DENTIST'S ADDRESS: Complete address of the dentist, including street, city, state, and ZIP code.
• 9. DENTIST'S TELEPHONE NUMBER: Contact telephone number of the dentist, including area code.
• 10. DENTIST'S SIGNATURE/STATE LICENSE NUMBER: Dentist's signature and state license number verifying the accuracy of the examination results.
• 11. DATE OF EXAMINATION: The date on which the dental examination was conducted, in YYYYMMDD format.

Failure to submit this form may result in delays in assessing dental health needs and determining fitness for duty or deployment. It is important to submit the form to avoid potential consequences.

• Delay in Dental Health Assessment: Failure to submit may lead to delays in obtaining a dental health assessment for military service.
• Deployment Readiness: Incomplete submission could affect deployment readiness and fitness for duty.

• 1. Active Duty Assessment: To evaluate the dental health of Active Duty members for worldwide duty.
• 2. Reserve Assessment: Used by Reserve members to determine fitness for prolonged duty.
• 3. Guard Assessment: For Guard members to ensure dental readiness for deployment.
• 4. Civilian Assessment: Required by Civilian members to document their dental health status.
• 5. Dental Examination Record: Dentists use this form to record examination results and provide additional comments.