Member Forms / NAVMED 6110/4

NAVMED 6110/4 (12/2023)

Physical Fitness Assessment Medical Clearance/Waiver

Navy — Physical Readiness Program (OPNAVINST 6110.1 series) medical clearance / waiver

Your service

Patient identification

Use this space for mechanical imprint. Fields are blank in this demonstration environment (notional data only).

Patient's name (Last, First, Middle Initial)

Sex

DODID/EDIPI

Status

Rank/Grade

Records maintained at

Date of birth

Section 1 — Completed by Member

Command and referral information.

A. Command

B. UIC/RUIC

C. CFL/POC

D. CFL Telephone No.

E. Reason for Referral — Positive PARFQ Screening

E. Reason for Referral — Injury/Illness

Section 2 — Completed by Treating Provider OR AMDR

PRT waiver recommendation, cardio event modification clearance, and physical training clearance.

A. PRT Waiver Recommended — Push-Ups

A. PRT Waiver Recommended — Forearm Plank

A. PRT Waiver Recommended — 1.5 mile run/walk

B. Cardio Event Modification Clearance. Cardio Waiver is NOT REQUIRED if member is cleared for at least one modification unless command is not authorizing alternate cardio event(s).

Cleared to participate	PRT activity	Comments
	Treadmill
	Rower
	Stationary Bike
	Swim

C. Physical Training Clearance. Indicate if member is cleared to participate in the following physical training activities. If 'No', comment is required and light duty chit should be provided.

Cleared to participate	Physical training	Comments
	Command Physical Training / Fitness Enhancement Program
	Individual Physical Training

D. AMDR/Treating Provider Name

E. AMDR/Treating Provider Signature

F. Date

Section 3 — Completed by Treating Physician and AMDR/AMDR Supervising Physician

Body Composition Assessment (BCA) waiver recommendation.

A. BCA Waiver Recommended (Requires two physician signatures) — Waiver

First Physician Signature (AMDR/Treating Physician)

Second Physician Signature (AMDR/AMDR Supervisor)

B. Reason IAW OPNAVINST 6110.1 (series)

Inability to obtain BCA measurement Medical Treatment/Therapy

Section 4 — Final Waiver Recommendation, Completed by AMDR only

Final waiver determination and expiration.

A. Member Cleared for full PFA

B. PRT Waiver Recommended

If yes, please specify the PRT event(s)

Push-Ups Forearm Plank 1.5 mile run/walk (Cardio Event)

C. BCA Waiver Recommended

D. Is this a second consecutive waiver for the same medical condition?

Yes No Not applicable

E. Waiver Expiration Date

F. AMDR Name

G. AMDR Signature

H. Date

Section 5 — CO Endorsement Required Prior to Input into PRIMS

Commanding Officer / OIC endorsement of waiver status and approvals.

A. Waiver Status

Number of Waivers in last 4 years

Meets MEB Requirements

CFL Signature

Date

B. PRT Waiver Approved

C. BCA Waiver Approved

D. Member CO/OIC Signature

E. Date

CO/OIC endorsement: I endorse the waiver status recorded above prior to input into PRIMS.