Beruflich Dokumente
Kultur Dokumente
This statement serves to inform you of the purpose for collecting the personal information requested by this form and how it may be used.
AUTHORITY: 10 U.S.C. 1074f, Medical Tracking System for Members Deployed Overseas; 10 U.S.C. 1074m, Mental Health Assessments for Members of the Armed
Forces Deployed in Support of a Contingency Operation; DoDI 6490.03, Deployment Health; DoDI 6490.12, Mental Health Assessments for Service
Members Deployed in Connection with a Contingency Operation; and E.O. 9397 (SSN), as amended..
PURPOSE: Your information will be collected in order to identify any mental health concerns and, if necessary, refer you for additional assessment and/or care.
ROUTINE USES: Use and disclosure of you records outside of DoD may occur in accordance with the DoD Blanket Routine Uses published at:
http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html and as permitted by the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)).
Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160
and 164), as implemented within DoD. Permitted uses and discloses of PHI include, but are not limited to, treatment, payment, and healthcare
operations.
DISCLOSURE: Voluntary. Care will not be denied if you decline to provide the requested information, but you may not receive the care you deserve and may face
administrative delays.
INSTRUCTIONS: You are encouraged to answer all questions. You must at least complete the first portion on who you are and when and where you deployed. If you do
not understand a question, please discuss the question with a health care provider.
DEMOGRAPHICS
Last Name __________________________ First Name ______________________ Middle Initial ____
S A M P L E
Social Security Number ______________________
Current contact information: Point of contact who can always reach you:
Phone: ______________________________ Name: ________________________________
Cell: ________________________________ Phone: _______________________________
DSN: _______________________________ Email: ________________________________
Email: _______________________________ Address: ______________________________
Address: _____________________________ ______________________________
_____________________________ ______________________________
_____________________________
Primary location of last deployment: _______________ Date departed theater (dd/mmm/yyyy) _____________
1. a. Over the PAST MONTH, what major life stressors have None or
you experienced that are a cause of significant concern Please list and explain: ___________________________
or make it difficult for you to do your work, take care of
things at home, or get along with other people (for example, ______________________________________________
serious conflicts with others, relationship problems,
or a legal, disciplinary or financial problem)? ______________________________________________
2. In the PAST YEAR did you receive care for any mental health condition or concern such as, but not limited Yes No
to post traumatic stress disorder (PTSD), depression, anxiety disorder, alcohol abuse or substance abuse?
If yes, please explain: ___________________________________________________________________________________________
S A M P L E
c. How often do you have six or more drinks on one occasion?
Never Less than monthly Monthly Weekly Daily or almost daily
5. Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH, you:
a. Have had nightmares about it or thought about it when you did not want to? Yes No
b. Tried hard not to think about it or went out of your way to avoid situations that remind you of it? Yes No
c. Were constantly on guard, watchful or easily startled? Yes No
d. Felt numb or detached from others, activities, or your surroundings? Yes No
NOTE: If two or more items on 5a. through 5d. are marked yes, continue to answer items 5e through 5v.
Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each question
carefully and check the box for how much you have been bothered by that problem in the LAST MONTH. Please answer all items.
Not at all A little bit Moderately Quite a bit Extremely
5e. Repeated, disturbing memories, thoughts, or images of a stressful
experience from the past?
5f. Repeated, disturbing dreams of a stressful experience from the
past?
5g. Suddenly acting or feeling as if a stressful experience were
happening again (as if you were reliving it)?
5h. Feeling very upset when something reminded you of a stressful
experience from the past?
5i. Having physical reactions (e.g., heart pounding, trouble breathing, or
sweating) when something reminded you of a stressful experience
from the past?
5j. Avoid thinking about or talking about a stressful experience from the
past or avoid having feelings related to it?
5k. Avoid activities or situations because they remind you of a stressful
experience from the past?
5l. Trouble remembering important parts of a stressful experience from
the past?
5m. Loss of interest in things that you used to enjoy?
5n. Feeling distant or cut off from other people?
5o. Feeling emotionally numb or being unable to have loving feelings for
those close to you?
5p. Feeling as if your future will somehow be cut short?
5q. Trouble falling or staying asleep?
5r. Feeling irritable or having angry outbursts?
5s. Having difficulty concentrating?
5t. Being super alert or watchful, on guard?
5u. Feeling jumpy or easily startled?
Not difficult at all Somewhat difficult Very difficult Extremely difficult
5v. How difficult have these problems (5e through 5u.)
made it for you to do your work, take care of things at
home, or get along with other people?
DD FORM 2978, FEB 2014 Page 2 of 7 Pages
This form must be completed electronically. Handwritten forms will not be accepted.
Deployers SSN (Last 4 digits): ________________________
6. Over the LAST 2 WEEKS, how often have you been bothered by the following problems?
Not at all Few or several days More than half the days Nearly every day
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
NOTE: If 6a. or 6b. are marked More than half the days or Nearly every day, continue to answer items 6c.
through 6i.
Over the LAST 2 WEEKS, how often have you been bothered by any Few or several More than half
Not at all Nearly every day
of the following problems? days the days
6c. Trouble falling/staying asleep, sleep too much.
6d. Feeling tired or having little energy.
6e. Poor appetite or overeating.
6f. Feeling bad about yourself or that you are a failure or have
let yourself or your family down.
6g. Trouble concentrating on things, such as reading the
newspaper or watching television.
6h. Moving or speaking so slowly that other people could have
noticed. Or the opposite being so fidgety that you have
been moving around a lot more than usual.
Somewhat Extremely
Not difficult at all Very difficult
difficult difficult
6i. How difficult have these problems (6a.-6h.) made it for you
to do your work, take care of things at home, or get along with
other people?
7. Would you like to schedule an appointment with a health care provider to discuss any health concern(s)? Yes No
8.
9. S A M P L E
Are you interested in receiving information or assistance for a stress, emotional or alcohol concern?
10. Would you like to schedule a visit with a chaplain or a community support counselor?
Yes
Yes
Yes
No
No
No
Health Care Provider Only Provider Review, Interview, Assessment, and Recommendations:
Deployer reports most recent deployment was to ____________________________________ and has deployed _____________ times
before in the past five years.
a. Did deployer mark they have a concern or a Yes Deployers concern: _________________________
difficulty with a major life stressor? No (go to block 2)
Not answered by deployer
b. If yes, ask additional questions to determine level of problem: _________________________________________________________
c. Consider need for referral. Referral indicated? Yes (complete blocks 9 and 10)
No Already under care
Already has referral
No significant impairment
Other reason (explain) _________________________
Medications
S A M P L E
a. Deployers AUDIT-C screening score was ______. (If score between Not answered by deployer
0-4 (men) or 0-3 (women) nothing required, go to block 4).
Number of drinks per week: _____________ Maximum number of drinks per occasion: _____________
Based on the AUDIT-C score and assessment of alcohol use, follow the guidance below:
* BRIEF counseling: Bring attention to elevated level of drinking; Recommend limiting use or abstaining; Inform about the effects of alcohol
on health; Explore and help/support in choosing a drinking goal; Follow-up referral for specialty treatment, if indicated.
S A M P L E
AND
Somewhat Difficult
provide PTSD education*
Assess need for further
Very Difficult Consider referral for further evaluation Refer for further evaluation
evaluation
to AND AND
AND
Extremely Difficult provide PTSD education* provide PTSD education*
provide PTSD education*
* PTSD Education = Reassurance/supportive counseling, provide literature on PTSD, encourage self-management activities, and counsel
deployer to seek help for worsening symptoms.
c. Referral indicated? Yes (complete blocks 9 and 10)
No Already under care
Already has referral
No significant impairment
Other reason (explain): _________________________
S A M P L E
actually hurting yourself?
d. Ask Have you thought about how you might actually hurt yourself?
b. Does member pose a current risk to others? Yes (complete blocks 9 and 10)
No (briefly state reason): __________________________
8. Deployer issues with this assessment (mark as appropriate): 10. Recommended referral(s)
Within Within Within
Deployer declined to complete form < Mark all that apply even if
24 hours 7 days 30 days
Deployer declined to complete interview/assessment
deployer does not desire>
a. Primary Care, Family Practice,
Internal Medicine
Assessment and Referral: After review of deployers responses b. Behavioral Health in Primary Care
and interview with the deployer, the assessment and need for
further evaluation is indicated in blocks 9 through 12. c. Mental Health Specialty Care
d. Dental
S A M P L E
d. Mental health symptoms
Podiatry
e. Alcohol use
Other, list
f. PTSD symptoms
f. Case Manager / Care Manager
g. Depression symptoms
g. Substance Abuse Program
h. Environment/work exposure
h. Other, list:
i. Risk of self-harm
j. Risk of violence
11. Comments:
k. Other, list: ______________________________________________________
______________________________________________________
______________________________________________________
Title: MD or DO PA Nurse Practitioner Adv Practice Nurse IDMT IDC IDHS MH Provider