A REPLY TO ATTENTION OF:

DEPARTMENT OF THE ARMY UNITED STATES ARMY ENGINEER SCHOOL

US ARMY MANEUVER SUPPORT CENTER OF EXCELLENCE DIRECTORATE OF TRAINING AND LEADER DEVELOPMENT

14000 MSCOE LOOP, BUILDING 3200, SUITE 336 FORT LEONARD WOOD, MISSOURI 65473-8300

ATSE-DT 22 July 2019

MEMORANDUM FOR Prospective Engineer Diver Applicants

SUBJECT: Becoming an Army Engineer Diver MOS 12D

1. The Army is looking for highly motivated soldiers as volunteers to become Engineer Divers,MOS 12D. This job is both physically and mentally demanding, but can be a very rewardingcareer for those who accept and meet the challenge.

Note: As of 07 May 2016, there are restrictions for some individuals attempting to re-class to MOS 12D. Refer to the latest MILPER Message for Update to Reclassification IN/OUT Calls for more information. Contact the undersigned (ref. encl. 1) for more details.

2. Our Dive Program offers:

a. Overseas and CONUS assignmentsb. Monetary incentive (Dive pay)c. Basic and Advanced training in underwater construction, repair, reconnaissance,demolition, salvage and hyperbaric treatment.d. The opportunity to work with highly motivated and dedicated individuals in units withextremely high levels of esprit de corps.

3. Prospective applicants must apply.

a. Formally apply for reclassification or reenlistment for MOS 12D by completing a DAForm 4187 (Personnel Action), DA Form 5030 (Engineer Diver Training Application) andin some instances, a reenlistment contract.

b. Be in the rank of PVT, PFC, or SPC/CPL. SPC and CPL must be in a NON- PROMOTABLE status when reporting for initial MOS 12D training and duty. Please notethat all Soldiers in the ranks of SPC and CPL will remain in a NON-PROMOTABLE statusuntil evaluation by their leadership at their first diving duty assignment. NOTE: Soldierswill be disenrolled from the Diver Phase 1 and 2 courses if they arrive in an E-4(promotable) status.

c. Soldiers must meet the 24 months service-remaining requirements IAW AR 614-200,Ch. 4 upon graduation from the Diver Phase 2 course.

d. If on a current term of enlistment in which an enlistment bonus (EB) or selectivereenlistment bonus (SRB) has been received, Soldier should be advised that the bonusMAY be prorated and he/she MAY be responsible to pay the unearned portion back to thegovernment. Contact your career counselor to discuss your situation.

e. Have attained a minimum score of 107 in aptitude area General Technical (GT) ora minimum score of 106 in aptitude area Skilled Technical (ST) and attained a minimum score of 98 in aptitude area General Mechanical (GM).

f. Have attained a minimum score of 180 (60 points in each event) or higher on the APFT. (Keep in mind these are the minimum standards. It is highly recommended that Diver candidates score a minimum of 270 or above on the APFT with at least 90 points in each event).

g. Have successfully completed the Diver Physical Fitness Test (DPFT) according to standards outlined in MILPERSMAN 1220-410, dated 06 January 2013. See Dive Physical SOP for conduct of Dive Physical.

h. Have undergone a Diving Medical Examination as prescribed in AR 40-501 within9 months of attending Phase I.

i. Have a physical profile of 111111 (PULHES) and meet the height and weight standards prescribed in AR 600-9.

j. Understand that Soldier must successfully complete a 3 week Diver Phase I course conducted at Ft. Leonard Wood, Missouri prior to attending Phase II at the Naval Diving and Salvage Training Center at Panama City, Florida.

4. Enclosed is an easy to follow process to ensure your packet gets the attention it deserves.

5. Good luck and HOOYAH! DEEP SEA!

6. POC for this memorandum is the Army Diver Phase I Reclassification Manager at (573)563-7192 or DSN 676-7192.

8 ENCLS 1. Dive Candidate Application Process2. Requests for Waiver Info3. Medical Screening Requirementsand Checksheet4. DD Form 2807-15. DD Form 28086. DA 4187 Example7. Waiver Example

///original signed/// LOGAN M. FORBING SSG, USA Phase I Reclassification Manager

Encl. 1 DIVE CANDIDATE APPLICATION PROCESS

1. Contact the 12D Reclassification Manager SSG Forbing. He will guide and advise you through the process. Use this memorandum as a checklist to make sure you don’t miss anything.

a. Work with your Career Counselor/Retention NCO throughout this process.

2. Contact your installation medical facility and schedule a physical examination.

3. Review Enclosure 3 - Dive Physical SOP.

4. Provide the medical provider with the DD forms 2808-1 and 2807 from:

(https://www.public.navy.mil/netc/centers/ceneoddive/ndstc/Default.aspx).

NOTE: DO NOT USE THE DD 2808 or 2807 FROM APD.

5. Tell them you need a “Dive Physical” for your application to become an Engineer Diver.

6. Make several copies of the completed DD Form 2808, DD Form 2807-1 (Report of Medical History), and Medical Screening form. This will prevent having to complete another physical exam if the originals become lost.

7. Complete a Personnel Action, DA Form 4187, indicating that you want to reclassify (if greater than one year left in service) as an Engineer Diver, MOS 12D.

8. If the Soldier has less than one year left in service before ETS, he or she must reenlist for MOS 12D. NOTE: For Soldiers in a critical shortage MOS, this is your only way out of your MOS.(Do not re-up; option 1 (reg. Army) if you are in a critical MOS. This will lock you back into your old MOS. You must only re-up under option 3 (retraining) for MOS 12D. To qualify for this you must be a first term Soldier and meet all other prerequisites outlined for entry into 12D, Engineer Diver MOS (ref. DA 5030, Part III and IV). Make sure you are using your Retention NCO as regulations change.

9. Complete the Engineer Diver Training Application, DA Form 5030

(https://armypubs.army.mil)

10. Complete Waiver Request(s) if applicable. See Enclosure 2.

11. Provide a current ERB.

12. Provide your most recent APFT Score card, DA Form 705; within 6 months.

13. Provide separate copies of labs report, vaccine report, and radiology report from chest x-ray.

14. Scan and e-mail the application packet to logan.m.forbing.mil@mail.mil.

Ensure that all scanned documents are clear and legible. If you can’t read it, we can’t read it.

Do not submit your packet directly from a digital sender. Send it to yourself then submit it to the above.

14. While waiting for approval of your packet, begin increasing the intensity of your physical fitness level. It is imperative that you report to the Diver Phase I Course in the best physical condition of your life.

15. If approved, you will receive a signed memorandum from the 12D Reclassification Manager

stating that you are a qualified candidate for dive training. Take this memorandum to your

Retention NCO for processing.

NOTES:

For purposes of assignment orders, 12D training is a PCS move to Panama City, FL, with Phase I training conducted in Fort Leonard Wood, MO. Phase 1 is done as a “TDY en Route” through Missouri to final PCS in Florida upon successful completion of PhaseI. If your orders do not bring you to Fort Leonard Wood prior to arrival in Panama City, contact your retention NCO and also the 12D Reclassification Manager at 573-563-7192 immediately to correct the issue.

Ensure you are consulting your chain of command. See ALARACT 114-2017 regardingmandatory promotions. One of the biggest problems for re-class candidates is promotions.You need to make sure your timeline isn’t going to be an issue. You cannot arrive to yourduty assignment after dive school in a SPC (P) status. Dive school Phase I is 3 weeks, PhasesII and III are 6 months. Use these numbers for planning purposes.

Read the packet thoroughly and come up with questions for the re-classification manager.

Encl. 2 REQUEST FOR WAIVERS AND MOU

1. The following guidelines outline requests for waivers if prospective candidates do not meet certain criteriaor prerequisites. Waiver requests are approved on a case by case basis and based on MOS strength. Awaiver request is a request for an exception to the current policy. A waiver may be necessary if thecandidate does not meet requirements outline in Part III of DA Form 5030 or Para. 5.11of AR 40-501.Waiver requests must be submitted with the original application. Call the 12D Training DevelopmentOffice at 573-563-7192 or DSN 676-7192 before submitting to ensure that specific conditions may bewaivered. An example may be found in enclosure 12.

2. Age (DA Form 5030, part III, item 8.b): Currently processing age waivers.

3. Current term of enlistment for which an enlistment or selective reenlistment bonus has been received(DA Form 5030, part III, item 8.e): Submission of a waiver is not necessary for this prerequisite;however, Soldiers falling into this category must contact their Retention NCO to determine responsibilityfor repayment of bonuses.

4. Medical issues (DA Form 5030, part III, item 9.g): We are currently not processing waivers formedical issues which are considered disqualifying conditions.

NOTE: We need Soldiers for this MOS. Due to the extreme environmental conditions and risks associated with this MOS and the expense of training, we must recruit only qualified and able personnel.

Encl. 3 – DIVE PHYSICAL SOP

Dive Physical SOP

Purpose: This guide will provide clear, step by step instructions for completing the dive physical portion of your application.

Overview: The physical is made of 3 parts; the attached labs, 2807, and 2808. Each section must have all relevant portions completed. Failure to do so will result in your physical being kicked back and will cause significant processing delays.

1- Schedule/attain Labs and attached documents: Before beginning your examination, ensure you complete all of the following labs. Keep documentation of each lab completed. Note: once you complete your first lab you only have 90 days to have the 2808 signed by a physician!

a. Lateral chest x-ray b. EKG – Signed by a Provider or Nurse c. Hearing d. Vision e. PPD/Tuberculosis test f. Complete blood count g. Urinalysis dipstick h. Fasting blood glucose i. G6PD- any time prior to dive training j. Sickle cell- any time prior to dive training k. Hep A- 2 doses l. Hep B- 2 doses m. Hep C screening n. Complete and up to date immunization record o. IMR printout- All green with G6PD, sickle cell, blood type, and DNA

documented

2- Complete Medical history form (2807):

Note: 2807 and 2808 must be signed within 30 days of each other. It is recommended that they are completed simultaneously.

a. Obtain from the following website: https://www.public.navy.mil/netc/centers/ceneoddive/ndstc/Default.aspx

b. Under the “Training Resources” tab select “DD 2807” and print out blank form. c. Fill out the form in its entirety, making sure to document any allergy or

medication information in blocks 9 and 10.

Encl. 3 – DIVE PHYSICAL SOP

d. Any questions answered “Yes” must have a full explanation in block 29 and be reviewed by a physician in block 30.

3- Complete Medical examination form (2808):

Note: Hearing, vision, and dental exams must be completed and signed off on the 2808 prior to physician exam date.

a. Obtain from the following website: https://www.public.navy.mil/netc/centers/ceneoddive/ndstc/Default.aspx

b. Under the “Training Resources” tab select “DD 2808 Dive and Special OPS Assist” and print out blank form.

c. Have your examining physician use the printed form so no necessary tests are missed.

d. Ensure all portions of block 44 are filled out as directed. e. Ensure all portions of block 73 are filled out including findings and lab dates. f. Leave block 84a blank. It is not signed by the physician unless they are an

undersea/diving medical officer.

Review: Go over required lab documentation and medical forms to verify all fields are appropriately filled out. Once completed, include all associated medical documentation in your application packet.

References:

Army regulation 40-501- Standards of medical fitness. Chapter 5 paragraphs 11 and 12.

US Navy NAVMED P-117 Article 15-102: Diving duty.

https://www.public.navy.mil/netc/centers/ceneoddive/ndstc/Default.aspx

Encl. 4 - MEDICAL SCREENING REQUIREMENTS

ENSURE THAT THE DOCTOR CONDUCTING YOUR PHYSICAL GETS THIS INFORMATION!

In order to facilitate faster processing of medical requests, please format all forms according to the examples in this packet. Any disease or condition that causes chronic or recurrent disability shall be disqualifying at the discretion of the cognizant medical officer. Detailed medical fitness standards for MOS 12D can be found in AR 40-501, Chapter 5-11 Medical fitness standards for initial selection for other marine diving training (MOS 00B). Particular attention shall be directed to the following items:

(1) Weight – IAW AR 600-9

(2) Vision – All divers shall correct to 20/20 (100 percent B.V.E.) and documented on DD 2808.Combat swimmers shall have uncorrected vision no lower than 77 percent B.V.E; nor shallhave uncorrected vision in either eye less than 20/70. All other divers shall haveuncorrected vision no lower than 49 percent B.V.E.; nor shall have uncorrected visionin either eye less than 20/200.

(3) Color Vision – Diving candidates must pass the Pseudo Isochromatic Plate (P.I.P) Test,unless the applicant is able to identify vivid red and vivid green as projected by theOphthalmological Projector or the SVT, and have results documented on DD 2808. TheFarnsworth Lantern Test is no longer required.

(4) Dental – A dental officer shall conduct a complete dental exam. If a dental officer is notavailable, a medical officer shall conduct the exam. Acute infectious diseases of the soft tissueof the oral cavity are disqualifying until remedial treatment is completed. Advanced oraldiseases and generally unserviceable teeth shall be cause for rejection. Applicants withmoderate malocclusion, or extensive restorations and replacements by bridges or dentures, maybe accepted, if such do not interfere with effective use of self-contained underwater breathingapparatus. If student meets this criteria and does not require any dental work (i.e. fillings, etc.,then document on DD 2808 type of exam and dental class. (Note: Must indicate Type ofExam (annual, physical, etc.), and must read “Acceptable” (class 1 or 2 only) to beconsidered).

(5) Ears, Nose, and Throat – The following conditions are disqualifying: acute disease, chronicserous otitis or otitis media, perforation of the tympanic membrane, any nasal or pharyngealrespiratory obstruction, chronic sinusitis if not readily controlled, speech impediments due toorganic defects, or inability to equalize pressure due to any cause.

(6) Pulmonary – Congenial and acquired defects, which may restrict pulmonary function, causeair-trapping, or affect the ventilation-perfusion balance shall disqualify for both initial trainingand continuation. In general, chronic obstructive or restrictive pulmonary disease of any typeshall be disqualifying.

(7) Hematology – Any significant anemia or history of hemolytic disease must be evaluated.When due to a variant hemoglobin state, it shall be disqualifying. All applicants for divingduty shall have a sickle cell test in their health record. The minimum requirement for such testis the dithionite solubility test, for which a hemoglobin electrophoresis may be substituted.Sickle trait is disqualifying in applicants.

(8) Skin – Acute or chronic diseases that are exacerbated by the hyperbaric environment aredisqualifying.

(9) Neurological – Organic brain disease seizure disorders of any sort, and head injuries withsequelae shall be disqualifying.

(10) Musculoskeletal – Saturation divers shall have triennial long bone roentgenogram surveyswith diving medical examinations.

(11) Psychiatric – The special nature of diving duties requires a careful appraisal of theindividual’s emotional and temperamental fitness. Personality disorders, neuroses, immaturity,instability, asocial traits, and stammering or stuttering shall be disqualifying.

(12) Ability to equalize Pressure – All candidates shall be subjected in a recompression chamberto a pressure of 50 pounds per square inch (22.50 kg) to determine their ability to withstand theeffects of pressure. This test should not be performed in the presence of a respiratory infectionthat may temporarily hinder the ability to equalize or ventilate. (For Army this test should beattempted prior to attending Diver Phase I Course. However, inability to perform thistest due to inadequate facility will not be disqualifying).

Documentation of the following items on DD Form 2808 (Report of Medical Examination) is important during execution of the medical examination. Failure to document these items correctly may lead to delayed processing of the application packet.

(1) Dental Class (block 43)

(2) Comment on TM’s and Valsalva SAT (block 44 or 72b)

(3) Complete Neurological Exam in detail (block 44, Cranial Nerves, Strength, Sensation, DeepTendon Reflexes, Motor Sensory, Mental Status)

(4) Complete list of scars and/or tattoos (block 44)

(5) Urinalysis (Block 45, within 30 days of physical)

(6) Complete Blood Count (CBC) with differential (H/H block 47, WBC/PLT block 73 withdate of lab, within 30 days of physical)

(7) Blood type recorded (block 48)

(8) HIV (block 49, results and date, within one year of training)

(9) G6PD (block 52b, any time prior to physical)

(10) Sickle Cell (block 52c, any time prior to physical)

(11) Blood Pressure lower than 140/90 (block 58)

(12) Vision (block 61)

(13) Audiogram (block 71, no results greater than 55db, within one year of training)

(14) Electrocardiogram (block 73, date and impression, within one year of training)

(15) Chest X-ray (block 73, Date, Exam#, Location, Impression, within one year of training)

(16) Fasting Lipid Panel (block 73, within 30 days of physical)

(17) Fasting Glucose (FBS) Panel (block 73, within 30 days of physical)

(18) PPD (block 73, date read and reaction, within one year of training)

(19) Two Doses of both Hepatitis A and Hepatitis B documented (block 73, YES/NO/IMMUNE)

(20) Immunizations up to date (block 73, YES/NO, initials of screener)

(21) Hepatitis C Screening (block 73, result with date of draw, within one year of training)

Encl. 4 – DD Form 2807-1 Report of Medical History

Please ensure that section 6 of DD 2807-1 is filled out according to the example.

Have the medical officer review AHLTA records and initial on page 3 if candidate is fit for dive duty

Encl. 5- DD Form 2808 Report of Medical Examination

Please print and use the following form for your medical examination

5. TELEPHONE NUMBER

Nor-

mal

Ab-

normNE

Pap Smear Results: Pap Smear Date:

b/l Babinski nml / abn

(abn = upward deflect)

37. MST (mark/scars/tattoos):

Mild

Moderate

Severe

Acceptable

29. Vascular system (Varicosities, etc.)

39. Neurologic

Class

Normal Arch

Pes Cavus

Pes Planus

37. Identifying body marks, scars, tattoos

(Please explain. Use dental form if completed by

dentist. If dental examination not done by dental

officer, explain in Item 44.)Not Acceptable

43. DENTAL DEFECTS AND DISEASE

Comments:

33. Upper Extremities

34. Lower Extremities (Except feet)

35. Feet (See Item 35 continued)

36. Spine, other musculoskeletal

Symptomatic

42. Endocrine 35. FEET (Continued) (Check each category)

40. Psychiatric (Specify any personality deviation)

41. Pelvic (Females only)

38. Skin, lymphatics

22. Drums (Perforation)

27. Heart (Thrust, size, rhythm, sounds)

32. External genitalia (Genitourinary)

30. Anus and rectum (Hemorrhoids, Fistulae) (Prostate if indicated)

31. Abdomen and viscera (Include hernia)

23. Eyes - General (Visual acuity and refraction under items 61 - 63)

24. Ophthalmoscopic

25. Pupils (Equality and reaction)

26. Ocular motility (Associated parallel movements, nystagmus)

28. Lungs and chest (Include breasts)

19. Sinuses

20. Mouth and throat

21. Ears - General (Int. and ext. canals/Auditory acuity under item 71) 39. Neuro Exam In detail:

Coast Guard Active Duty

Commission

Army Enlistment

Air Force NFD

DIVE

Retirement

Academy/ROTC

OTHER

Reserve

National Guard

Navy

15.a. SERVICE b. COMPONENT c. PURPOSE OF EXAMINATION

SO

SUB

MENTAL STATUS EXAM: nml / abn

CN II-XII intact and symmetric b/l: Yes No

(Include ZIP Code)

STRENGTH U/L extremity 5/5 symmetric throughout: Yes No

SENSATION ALL DERMATOMES intact and symmetric: Yes No

REPORT OF MEDICAL EXAMINATION

1. DATE OF EXAMINATION

(YYYYMMDD)

2. SOCIAL SECURITY NUMBER

Not Hispanic/Latino

Black or African

American

21. Eyes and Field of View OU: nml / abn

Medical Board

CLINICAL EVALUATION (Check each item in appropriate column. Enter "NE" if not evaluated.)

17. Head, face, neck, and scalp

18. Nose

6. GRADE 7. DATE OF BIRTH

14.A. RATING OR SPECIALTY (Aviators Only) b. TOTAL FLYING TIME

N/A

Asian

b. ETHNIC CATEGORY

44. NOTES: (Describe every abnormality in detail. Enter pertinent item number before

each comment. Continue in Item 73 and use additional sheets if necessary.)

N/A

Separation

RetentionMarine Corps

11. TOTAL YEARS GOV'T SERVICE

b. CIVILIANa. MILITARY

12. AGENCY (Non-Service Members Only)

N/A

(YYYYMMDD)

White

Hispanic/Latino

c. LAST SIX MONTHS

N/A

16. NAME OF EXAMINING LOCATION, AND ADDRESS

13. ORGANIZATION UNIT AND UIC/CODE

Native Hawaiian or

Other Pacific Islander

AUTHORITY: 10 USC 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397.

PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for

applicants and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the

Armed Forces.

ROUTINE USE(S): None.

DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the

individual's application to enter the Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual

being placed in a non-deployable status.

PRIVACY ACT STATEMENT

(SUFFIX)

4. HOME ADDRESS (Street, Apartment Number, City, State, ZIP code)3. LAST NAME - FIRST NAME - MIDDLE NAME

8. AGE 9. SEX

Female

Male

COORDINATION:

American Indian or

Alaska Native

10.a. RACIAL CATEGORY (X one or more)

22. TM's Mobile/intact bilaterally: Yes No

25. PERRL and ACCOMMODATION: Yes No

GAIT nml/abn F-2-N nml/abn RAM nml/abn

RHOMBERG: nml / abn H-S nml/abn

REFLEXES:

Bicep + /4 + /4

Brachioradialis + /4 + /4

Tricep + /4 + /4

Patellar + /4 + /4

Achelles + /4 + /4

41. Date of last well woman exam:

Name of Provider:

Asymptomatic

DD FORM 2808, OCT 2005DoD exception to SF 88 approved by ICMR, August 3, 2000.

PREVIOUS EDITION OBSOLETE.Page 1 of 3 Pages

Microsoft Office Excel 2003

HIV SPECIMEN LABEL DRUG TEST SPECIMEN ID LABEL

55. MIN WGT - MAX WGT MAX BF%

59. RED/GREEN (Army Only)

By S. CX by

By S. CX by

/ 14

*SO Only, as clinically indicated

DATE

WBC: Date:

HGB: Impression:

HCT:

DATE

LIPIDS (Parachute or age >40)

HDL:

LDL:

TRIG: DATE

HIV:

HCV:

Tuberculosis Screen/Test:

PPD: mm OR DATE

NAVMED 6224/8 - mininmal risk

DATE

UA (circle) dispstick / micro

Spec Grav:

pH:

Gluc:

Prot:

Ket:

Blood:

**SEE BLOCK 73***

47. H/Ha. Albumin *BLK 73*

b. Sugar *BLK 73*

CBC

Blood type: O- O+ A- A+ B- B+ AB- AB+

Must Use Block 66

*Any Cardiac Dysrhythmia ("history of" or current) other than 1st degree heart block or

sinus bradicardia, must be cleared by cardiology with hard copy report filed in record.

EKG (12 LEAD)

CXR PA/LAT *CXR is Indicated for:

Date Calibrated (YYYYMMDD)

71b. AUDIOMETER Unit Serial Number

Date Calibrated (YYYYMMDD)

73. NOTES (Continued) AND SIGNIFICANT INTERVAL HISTORY (Use additional sheets if necessary.)

Exam #: OR 3. As Clinically indicated. (If not clinically indicated,

2/3 Hep B vaccinations OR appropriate titers: Yes / No / Immune (titer in record)

2 Hep A vaccinations OR appropriate titers: Yes / No / Immune (titer in record)

DATE

All required immunizations reviewed and completed: Yes / No

input the results of the most recent radiograph results)Impression:

Date: 1. Candidates. OR 2. Upon new program entry.

PLT:

*If abnormal, document repeat lab in 7

days. Abnormal x2 requires clinical eval.

SAT UNSATLeftLeft

UNSAT

Right 72b. VALSALVA **SEE BLOCK 44**Right

6000 SATHZ 500 1000 2000 40003000

*Only do if concern for speech impediment

HZ 500 1000 2000 3000 4000 6000

O.S.

72a. READING ALOUD TEST

***SEE BLOCK 44*** O.D.

71a. AUDIOMETER

Uncorrected

Unit Serial Number

Corrected

68. FIELD OF VISION 69. NIGHT VISION (Test used and score) 70. INTRAOCULAR TENSION *Only if Age >40

PIP

65. ACCOMMODATION 66. COLOR VISION (Test used and result)

Right *BLK 44 Left *BLK 44 PASS / FAIL

Prism div. Prism div.

CT

NPR PDES° EX° R.H. L.H.

Cor. to 20/Left 20/ Cor. to 20/

*BLK 62 Required if

uncorrected >20/20 Left 20/

Cor. to 20/

61. DISTANT VISION 62. REFRACTION BY AUTOREFRACTION OR MANIFEST 63. NEAR VISION

Right 20/ Cor. to 20/

SYS. SYS.

DIAS. DIAS. DIAS.

58. BLOOD PRESSURE * >140/90 needs clinical eval. 60. OTHER VISION TEST *As clinically indicated

a. 1ST b. 2ND c. 3RD

SYS.

**SEE BLOCK 73***

48. BLOOD TYPE

***SEE BLOCK 73***

MEASUREMENTS AND OTHER FINDINGS

53.HEIGHT 54. WEIGHT 56. TEMPERATURE 57. PULSE

45. URINALYSIS

52. OTHER ***SEE BLOCK 73***

Not Required

46. URINE HCG

LAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX)

Not Required51. ALCOHOL Not Required

LABORATORY FINDINGS *** SEE BOX 73 ***

c. ***SEE BLOCK 73*** ***SEE BLOCK 73***

TESTS RESULTS

a. PAP SMEAR

Right 20/

49. HIV ***SEE BLOCK 73***

50. DRUGS Not Required

Not Required***SEE BLOCK 44***

Not Required

b. ***SEE BLOCK 73*** ***SEE BLOCK 73***

Periodic Health Assessment Current OR <1 year of service: YES / NO / <1 YR

G6PD entrance screen: POS / NEG

Sickle entrance screen: NML / ABNL

67. DEPTH PERCEPTION (Test used and score) AFVT *SO Only

Stool Guiac (Parachute):

SOCIAL SECURITY NUMBER

64. HETEROPHORIA (Specify distance) *Test only as clinically indicated for when the visual axis is asymetric on examination (i.e. one eye deviates)

*ALL Special Operator (SO) exams are considered to cover parachuting (aka "JUMP"), with no need for additional labs. If

not an SO exam, the addition of parachute special duty needs FASTING LIPID, RPR, AND STOOL GUIAC to meet AR-501

required labs.

PSA (male age >40):

RPR (Parachute):

GLUC:

CHOL:

*Postive testing (due to vaccine/active/latent TB infection) requires full clinical

investigation, documentation, and comment in block 77.

*UA with microscopy for SO/Parachute

*UA Dipstick for DIVE

DD FORM 2808, OCT 2005DoD exception to SF 88 approved by ICMR, August 3, 2000.

PREVIOUS EDITION OBSOLETE.Page 2 of 3 Pages

Microsoft Office Excel 2003

77. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers.) (Use additional sheets if necessary.)

86. WAIVER GRANTED (If yes, date and by whom)

OTHERDIVE SOIS QUALIFIED FOR SERVICE b. DATE (YYYYMMDD)

80. MEDICAL INSPECTION DATE HT WT %BF PHYSICIAN'S SIGNATURE

a. SIGNATURE

82.a. TYPE OR PRINTED NAME OF PHYSICIAN OR EXAMINER

81.a. TYPE OR PRINTED NAME OF PHYSICIAN OR EXAMINER

MAX WT

IS NOT QUALIFIED FOR SERVICE

a. SIGNATURE OF EXAMINEE

SUB

Leave Blank

Leave Blank

Leave Blank

RBJ DATE

Leave Blank

E

(YYYYMMDD)

HCG

85. This examination has been administratively reviewed for completeness and accuracy.

b. SIGNATURE *DATE

b. SIGNATURE *DATE

b. SIGNATURE *DATE

YES ATTACHED SHEETS

87. NUMBER OF

b. GRADE c. DATE (YYYYMMDD)

84.a. TYPE OR PRINTED NAME OF REVIEWING OFFICER *MUST BE A UMO

83.a. TYPE OR PRINTED NAME OF DENTIST OR PHYSICIAN

NO

QUAL DISQ

INITIALST

79. MEPS WORKLOAD (For MEPS use only) *BLOCK 79. IS NOT REQUIRED

DATE (YYYYMMDD)DATE (YYYYMMDD) INITIAL WKID

78. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify) (Use additional sheets if necessary.)

WKID ST

FEMALE DIVERS: Member was counseled on fetal hazards of diving while pregnant per BUMEDINST 6200.15 series: “Medical and scientific evidence demonstrate that the hyperbaric environment may be hazardous to a

fetus, potentially resulting in developmental anomalies or fetal death. These untoward fetal events may occur despite the absence of discernible maternal effects. Safe diving profiles that protect the fetus have not been

developed. Factors related to the normal maternal-fetal circulation place the fetus at increased risk of injury, even if exposed to routine, “low risk” dive profiles performed by the mother. Therefore, pregnant divers should

not dive or be occupationally exposed to a hyperbaric environment”.

Leave BlankLeave Blank

Leave BlankLeave Blank

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SERIAL

WAIVER RECEIVED

SERVICE DATE (YYYYMMDD)

Leave Blank

ITEM

NO.MEDICAL CONDITION/DIAGNOSIS ICD CODE

QUALI-

FIED

DIS-

QUALI-

FIED

EXAMINER

INITIALS

PROFILE

76. SIGNIFICANT OR DISQUALIFYING DEFECTS

P U L H S X

b. PHYSICAL PROFILE *BLOCK 74 b. IS NOT REQUIRED

74a. EXAMINEE/APPLICANT (Check one) *Check all that apply

PROFILER INITIALS DATE (YYYYMMDD)

75. I have been advised of my disqualifying condition.

NFD

SOCIAL SECURITY NUMBERLAST NAME - FIRST NAME - MIDDLE NAME (SUFFIX)

b. SIGNATURE *DATE

DD FORM 2808, OCT 2005DoD exception to SF 88 approved by ICMR, August 3, 2000.

PREVIOUS EDITION OBSOLETE.Page 3 of 3 Pages

Microsoft Office Excel 2003

1. DATE OF EXAMINATION (YYYYMMDD)

'ZOl'T0G 1.0

2. SOCIAL SECURITY NUMBER REPORT OF MEDICAL EXAMINATION

o=-oo -OOOD

PRIVACY ACT STATEMENT AUTHORITY: 10 use 504,505,507,532,978, 1201, 1202, and4346; and E.O. 9397. PRINCIPAL PURPOSE(S): To obtaln medical data for determination of medical fitness for enlistment, induction, appointment and retention for

�pplicants and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces. ROUTINE USE(S): None. DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status.

3. LAST NAME. FIRST NAME. MIDDLE NAME (SUFFIX)

4. HOME ADDRESS (Slreet Apartment Number, City, State, ZIP code) 5. TELEPHONE NUMBER

6, GRADE 7. OATEOFBIRTH (YYYYMMDD)

1'l'l7f'l22J 8. AGE

L\

9, SEX h Female � Male

10.a. RAC!AL CATEGORY (X one or more)

R"'�"'"'°"'"'" r:;rtllaCJ<orAtacao ""'""�"" Af0011ean

Maan Whole QNatwe Hawa1<an o,

Othor Pactlic l5lruider

b, ETHNIC CATEGORY IH1sp,inJo/Latino x1Nol Hlapa111cJLa1"10

11, TOTAL YEARS GOV'T SERVICE 12. AGENCY (Non-Se,vice Members Only)

a. MILITARY lb. CIVILIAN '"

14.A. RATING OR SPECIAL TY (A via/ors Only) b. TOTAL FL YING TIME NIA N/A

13. ORGANIZATION UNIT AND UJC/CODE +•

52 "! Exi:-ple, CO. c. LAST SIX MONTHS

�/A

WDPO:Z::'-1

15.a. SERVICE b. COMPONENT c. PURPOSE OF EXAMINATION � □ - � � 2 Am,y Coast Guard X Active Duty Enlistment Medical Board Navy ......,_ Reserve - Commission - Retirement

DIVE so SUB

,rn

16. NAME OF EXAMINJNG LOCATION, ANO ADORESS (Include ZIP Code)

- Marine Corps -National Guard - Retention - Academy/ROTC -- Air Force -

- Separation - OTHER 1--

(rJo.,,e,. 0-�d "'"""'" of relevrd- '"'J,rcJ f:o.c , I,_,_,)

CLINICAL EVALUATION (Check each item in appropriate column. Enter "NE" if not eva/ualed.)

';;,ec;;;;--;;;;;;--;=,c-;;;;;-;;;;;;------------------i:,:;, f'

""CI•••'•

I 44. NOTES: (Describe every' abnonnatity in detail. Enter pertinent ilem number before

1, =

each comment. Continue in Item 73 and use additional sheets if necessaw) 17. Head, face, neck, and scalp -g f,c,c_7N

C,soo

cc-------�------------------t-ct- 21 EycsandFieldofViewOU �abn 19. Sinuses 22 TM'� Mobilc/mlacl bilaterally: -� No 20. Mouth and throat 25. PERRL and ACCOMMODATION-� No 21. Ears· General (Jnl. and ext canals/Auditory acuity under item 71) 39. Neuro E�am In detail: 22. Drums (Perforation) MENTAL STATUS E.,\'.AM: MMSE �bn A&Ox3:® No 23. Eyes - General (Visual acuity and refraction under items 61 - 63) x;; , CN ll•Xll inrnct and symmetric b/1: � No

',"4","0°

,"oe-,",=-,",",,";",---�-------------------tX�+-" STRENG Tl l UI!. extremlly 5/5 symmetric throughout: � No 5. Pupils (Equiilily and reaction) )I SENSAT!ON ALL DP.RMI\ TOMES intact and symmelric.@ No

26. Ocular motillty (Associated parallel movements, nystagmus) , COORDINATION: GAIT@abn F-2-N@"abn RAl-.-�bn 27. Heart (Thrust, size, rhythm, sounds) , RIIOMBERG@)abn H-SE!)bn 28. Lungs and chest (Include breasts) X REFLEXES; r-'i. t,a,c_<v<,=�",c,.c,c,c,,c,===-'r<,c,c,,c,c,c.;11c,=,.=,c.�"1;----------------+x=I-., Bicep T l:14 \... _)~ z.i4 30, Anus and rectum (Hetl'J()rr/Joids, F1s/ulae) (Pros/ate if indicated) Bmchioradialis + 2-14 ..._ __ .::,,=:-�•+ 214 31. Abdomen and viscera (Include hemia) Tricep f }<....14 + 'Z.J4 32. External genltalla (Genitourinary) x Patellar + Z. /4 ""'-; 2,'4 33. Upper Extremities Achelles + Z.t4 I + ,Z 14 4. Lower Extremities (Except feet) � b.'l Babin�ki g abn

35. Feet (See Item 35 confillued)

36. Spine, other musculoskeletal X 37. lden!ifying body marks, scars, 1alloos 38. Skin, lymphatics 39. Neumlogic

(ob11 "l"""<l donoco) , 37. MST (mark/scars/tattoos)· /Jone 41 Dale of last well woman exam NIA

Name of Provider: Comments:

o. Psychiatric (Specify anypersonalilydeviation) I Y he=�=======-------++-·1. Pelvic (Females only)

Pap Smear Results: Pap Smear Date·

42. Endocrine " 35. FEET (Continued)

""=======--«=======cc±';i,c;�'"+= 43. DENTAL DEFECTS ANO DISEASE (Please explain. Use dental fonn if complefecl by X Nonnal Arch

M �-,,c-, Acceptable Class [D dentist. If dental examination not done by dental r avu

Not Acceptable officer, explain m Item 44.)

- Pes Planus

DD FORM 2808, OCT 2005 DoD excop1Jon 10 SF 88 approved by ICMR, August 3, 2000.

PREVIOUS EDITION OBSOLETE.

(Check each category')

r- MJld El

Asymptomatic - Moderate Symptomatic �

Page 1 of3 Pages M,crosofl Ofr«:e =1 2003

LAST NAME - FIRST NAME - MIDDLE NAME {SUFFIX) s� :+h., Joh.,-,_ A

SOCIAL SECURITY NUMBER CCY.J-00 -0000

LABORATORY FINDINGS ·••SEEBOX73*"' 45, URINALYSIS a. Albuml11 •BLK 73• j46. URINE HCG 47. H/H 48, BLOOD TYPE

'""SEE BLOCK 73-• b. Sugar "BLK 73' I Not Required �sEE BLOCK 73" .. ''SEE BLOCK 73''* TESTS RESULTS HIV SPECIMEN LABEL DRUG TEST SPECIMEN !D LABEL 49. HIV ···see BLOCK 73•--50. DRUGS Not Required 51, ALCOHOL Not Required 52. OTHER ···see BLOCK 73-• Not Required Nat Required

a. PAP SMEAR •••SEE BLOCK 44•-b. -see BLOCK 73"*' ···see BLOCK 73••· c. •-see BLOCK 73"* ""SEE BLOCK 73 ...

MEASUREMENTS AND OTHER FINDINGS 53.HEIGHT

/ 2 s !54. WEIGHT 55. MIN WGT- MAX WGT MAX BF% 56. TEMPERATURE o ]57. PULSE

E() bp '" 72_•1 Not Reauired "J'2."1 F

58. BLOOD PRESSURE • >140/90 needs dinical eval. 59. RED/GREEN (Army Only) 60. OTHER VISION TEST "As clinlcallyindicated a. 1ST b. 2ND c. 3RD SYS. I /2.0 SYS. ! SYS. I Must Use Block 66 DIAS. go DIAS. I DIAS. I 81. DISTANT VISION 62. REFRACTION BY AUTOREFRACTtON OR MANIFEST 63. NEAR VISION Righl201 1-;,o 1Cor.to20/I ,, s. ex •m,K6?Re.i,�«!,f Right 20/ l (_O 10:lr. to 201 I ,,, Lett 20/ l'JO 1Cor.to20/I ,, s ex WJCO=<Eed �W/211 Left20/ I 2..0 ICor. to 20/ I '"' 64. HETEROPHORJA (Specify distance) *Test only as clinically indicated for when the visue/ axis is asymeln'o on examine/ion (i.e. one eye deviates) es· e,• R.H. L.H. Prism div. Prism div NeR "

e,

65. ACCOMMODATION Righi •BLK 44 \Left •BLK44

166. COLOR VISION (Tosi�

result) PIP ('-/! 14 PASS FAIL

167. DEPTH PERCEPTION ('Test used and score) AFVT Uncorrected !corrected

·soon1r

68. FIELD OF VISION 69. NIGHTVlSlON (Test used and score) 70. lNTRAOCULAR TENSION *Only if Age >40 .. *SEE BLOCK 44*'*

71a. AUDIOMETER Unit Serial Number 7'-11.. '12. Date Calibrated (YYYYMMDD) -Z.019'0404

"' ""' ,ooo 2000 ,COO 4000 Right () -s 0 0 lo "' s 0 � � 0

eooo "' s

l•so Oo�."' cllntcall\ ,ndacated O.D. n lo.s n 71b. AUDIOMETER Unit Serial Number Dale Calibrated (YYYYMMDD)

HZ eoo 1000 2000 Right "'

3000 '"" sooo

72a. REAPING ALOUD TEST •only do if concern for speech impediment

]$AT nuNSAT 72b. VALSALVA ••sEE BLOCK 44••

SAT huNSAT 73. NOTES (Continued) AND SIGNIFICANT INTERVAL HISTORY (Use additional sheets ifneca.ssa,y) CBC DATE WBC� I Wfl0513 HGB· ,1 •Jfah"om,a/ d,1<t,mcnu,p,a1k,b m C HCT; '- ,

3,

,lay, Ab,,,1,nu,hJrc,F<1resdm,c"/e,�/

l'LT: S DATE

LIPIDS (ParJlcimtc or age "'�OJ I 2s:w1os1� CHOL ,,;o MDL: 3.2. LDL: z.o TRIG: 12D DAn; GLUC: ,, ' 2.,d\C(OS.13, HIV: tJCG Z..Ofl0'-12.7 HCV: .vEG 2,ot r1,1s1-i,

Tuberculosis Scrcenffcst: PPD; [filmm OR DATE 1'AVMED 622'118 - mininmal risk I ?Ol"l0Sl3

I

I

I

EKG (12LEAD) "Any Cardw,· o,•.1rh,·ihm,a r'lmtorJ, I!/" v, ,wmnl) other 1hon /st dew-ee hcurt block or Dale: '2.dl'JC'lS,.( 3, \,1nu, bradt«tt·d;a, ,;

,,,,, be deun-d hy ,-ord,u!" ,,·u,th hard"'"' re/'{,,-/ Med /111-u,ird

Impression: Nor,nl EKG

CXR PA/LAT 'CXI/ t. lru/rmtedfm" Date. '2.0t'lOS.13 ,. C,md1da1e, OR ], UP"""''"' program entry. faam #: G;o4--,4i o, 3. h C/m1ca/ly md1m1ed. (/fm,t clm1<·r1/l,·md1ca/ed, Impression: mpr,t the '""'I/.! uj /he ntrl,<I recem mdmgraph ,.,,,,11-')

JJor,-,,-,.J Cl,,,-+

Blood type: 0- �A- A- 8 - B• AB- AB• G6PD entrance screen:

�� Sklde en Ira nee sc�n: I A NL Periodic Health Assessment Current OR <l year of service: ®' NO, <I YR 213 Hep B va,:ciuations OR appropriNte titers:@ I No I !m1nune (liter in record)

'f'os/1''<! 1ew11g (due /0 ,,,ccinc ac/mJ /ale/!/ 11! "!frC/tr,n) rl'q,m·e-'fa/1 drmcal 2 Hep A Yaccinations OR appropriate titers: §' No / llnnrnne (titer in record) 1m•e.wgmion. df1c11111e11ta1wn, <111d cmmnem m block ?7,

DATE l!A (cirdellllisnstick y microl Z..OJ"/0S.f3 I Spec Grav: /.O�L\ pH: 4,2 •11.1 '""' 1111c10.«:1Jpyjar SO /'arudwt� Gluc: • ES •11,1 IJ,p.wckfor IJJJ 'E

Prot: t--Jt=G Ket· t,.Jf'G Blood ,J(;(-,

DD FORM 2808, OCT 2005

All rt:quircd immuniiations reviewed and completed: 0!:J No DATE

PSA (male age >40):

I IRPR (Para,hutc). Stool Guiac (Parachute)·

'Al.I. Special Opera/or �','0) exam,, ar� comidereJ w ,m-er paradw/i,ag (ak,, "JUJff'"), n·'1h 1w ,aeedforaddttuma//abs. ff Ital w, SO exam, 1/m a,Mma11 <>/ paroclmte special dury, i,eed< fiA,\77NG /,/l'lfl. Rl'JI, ANIJ .\"/00/. GU/AC w meet A/ / -50! req111red/ah>.

DoD excepton to SF 88 apprnved by ICMR. August 3, 2000 PREVIOUS EDITION OBSOLETE.

Page 2 of 3 Pages Microsoft Office Excel 2003

Circle the appropriate copy designatorCopy 2 Copy 3

Encl. 7-DA 4187 EXAMPLE

Y REPLY TO ATTENTION OF

Encl. 8- WAIVER EXAMPLE

DEPARTMENT OF THE ARMY YOUR UNIT AND BATTALION

YOUR DIVISION YOUR POST, STATE & ZIP CODE

OFFICE SYMBOL DATE

MEMORANDUM FOR: Engineer Personnel Development Office, Fort Leonard Wood, MO 65473

SUBJECT: Request age waiver to reclassify into MOS 12D, Engineer Diver.

1. Reference: DA FORM 5030 Engineer Dive Training Application.

2. Request age waiver for the following Soldier:

SPC John Doe W. XXX-XX-1234

3. A prerequisites for the MOS 12D is to be no more than 35 years old. SM is 38 years old andrequests an age waiver.

4. Point of Contact for this request is SPC John Doe W. at (your number) or atjohn.w.doe@us.army.mil.

JOHN W. DOE SPC, USA Duty Position/MOS