Member Forms / DD FORM 2978
← Member FormsPrivacy Act Statement & Instructions
This form must be completed electronically. Handwritten forms will not be accepted. CUI when filled — Controlled by DHA · CUI Category: PRVCY, HLTH · Distribution/Dissemination Control: FEDCON.
Authority: 10 U.S.C. 1074f; 10 U.S.C. 1074m; 10 U.S.C. 1074n; DoDI 6490.03, Deployment Health; DoDI 6490.12; and E.O. 9397 (SSN), as amended.
Purpose: Information is being collected from you in order to identify any mental health concerns and, if necessary, refer you for additional assessment and/or care.
Disclosure: Voluntary. Care will not be denied if you decline to provide the requested information, but you may not receive the required care and may experience 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. This assessment applies to all required mental health assessments including those required in-theater or at the time of separation.
Section I. Demographics
Identification. Provide the information exactly as it appears in your official records.
10. Deployment & Contact Information
Please answer all questions based on your deployment.
Current contact information
Point of contact who can always reach you
1. Major Life Stressors
1.a. Over the PAST MONTH, which major life stressors, if any, have you experienced that are a cause of significant concern or make it difficult for you to do your work, take care of things at home, or get along with other people? Mark all that apply.
2. Mental Health Care (Past Year)
In the PAST YEAR, did you receive care for any mental health condition or concern such as, but not limited to, post-traumatic stress disorder (PTSD), depression, anxiety disorder, alcohol abuse, or substance abuse?
3. Current Medications
What prescription or over-the-counter medications (including herbals/supplements) for sleep, pain, combat stress, or a mental health problem are you CURRENTLY taking?
4. Alcohol Use (AUDIT-C)
Answer each item about your alcohol use.
5. Traumatic Experience (PCL-C)
Have you ever had any experience that was so frightening, horrible, or upsetting that, in the PAST MONTH you:
NOTE: If three or more items on 5a. through 5e. are marked yes, continue to answer items 5f. through 5w. For each item below, check how much you have been bothered by that problem in the PAST MONTH. (Scale: Not at all · A little bit · Moderately · Quite a bit · Extremely)
6. Depression (PHQ-8)
Over the LAST 2 WEEKS, how often have you been bothered by the following problems? (Scale: Not at all · Few or several days · More than half the days · Nearly every day)
NOTE: If 6a. or 6b. are marked “More than half the days” or “Nearly every day,” continue to answer items 6c. through 6i.
7–10. Assistance & Referral Requests
Indicate whether you would like assistance or an appointment.
Section II. Mental Health Assessment (MHA) Provider Information
Health Care Provider Only — Provider Review, Interview, Assessment, and Recommendations.
Provider Review & Assessment (Blocks 1–8)
Deployer reports most recent deployment was to ______ and has deployed ______ times before in the past five years.
2. Address concerns as reported in Deployer questions 2 and 3.
3. Alcohol use as reported in Deployer question 4. Based on the AUDIT-C score and assessment of alcohol use, follow the Alcohol Use Intervention Matrix guidance. (If score between 0-4 (men) or 0-3 (women) nothing required, go to block 4).
4. PTSD screening as reported in Deployer question 5.
5. Depression screening as reported in Deployer question 6.
6. Suicide risk evaluation
7. Violence/harm risk evaluation
Assessment & Referral (Blocks 9–13)
After review of Deployer's responses and interview with the Deployer, the assessment and need for further evaluation is indicated in blocks 9 through 12.
9. Summary of provider's identified concerns needing referral (Mark all that apply)
10. Recommended referral(s) (Mark all that apply even if Deployer does not desire) — indicate timeframe: Within 24 hours / Within 7 days / Within 30 days
12. Address requests as reported on Deployer questions 7 through 10. (Not answered / Yes response / Comments)
13. Supplemental services recommended / information provided
Certification
I hereby certify that the Mental Health Assessment process has been completed.
Certification: I hereby certify that the Mental Health Assessment process has been completed.