To submit this form, ensure all questions are answered, and the form is signed by the appropriate healthcare provider. Bring the completed form to the check-in at your high-risk training site. For further information, contact your training site's administrative office. It is essential to submit the form promptly to avoid delays or disqualification from training.

This form is valid for 45 days after the healthcare provider signs it. Ensure to submit the form before its expiration.

The purpose of the High Risk Student Medical Screening Form (NETCINST 1500.13E) is to determine the medical suitability of individuals participating in high-risk training programs. This form consists of a series of health-related questions that must be answered accurately to ensure the safety of the trainee and others during the training. By completing and submitting this form, trainees provide essential information that allows healthcare providers and training site authorities to assess their readiness for high-risk activities. The form requires input from a medical professional, such as a Doctor, Physician Assistant, Nurse Practitioner, or Hospital Corpsman, ensuring that all health conditions are thoroughly evaluated. This proactive approach helps mitigate potential risks and ensures that only medically cleared individuals participate in high-risk training programs. Ultimately, the form plays a critical role in maintaining the safety and well-being of all trainees involved in rigorous training activities.

• 1. Trainee Name: This field requires the full name of the trainee.
• 2. Rank/Rate: This field requires the trainee's rank or rate.
• 3. Screen Date: The date on which the screening is conducted.
• 4. Course Name: The name of the course the trainee is enrolled in.
• 5. Parent Command: The command to which the trainee belongs.
• 6. Course CDP or CIN: The course's CDP or CIN number.
• 7. Medical Questions: A series of health-related questions to determine the trainee's medical suitability.
• 8. Trainee Remarks: Additional remarks or explanations provided by the trainee.
• 9. Healthcare Provider Information: Details about the healthcare provider, including their name, phone number, and signature.
• 10. Approval Section: Indicates whether the trainee is qualified or not qualified by the training site authority.

Failure to submit this form may preclude participation in high-risk training. It is crucial to complete and submit the form to ensure safety.

• Disqualification: You may be disqualified from participating in high-risk training.
• Health Risks: Unsubmitted health information may pose risks to your well-being and others.
• Training Delays: Failure to submit the form may cause delays in your training schedule.

• 1. High-Risk Training Enrollment: Submit the form when enrolling in high-risk training programs.
• 2. Medical Assessment: Use the form to provide essential health information for assessment.
• 3. Training Site Check-In: Submit the form during check-in at the training site.