DA Form 2173, Statement of Medical Examination and Duty Status , is a form used during Line of Duty Investigations (LDI) in cases when a Soldier contracts an injury, illness, or disease during Active Duty service, Inactive (IDT) and Active Duty (AD) training or traveling to and from IDT or AD.
The latest version of the form was released by the U.S. Department of the Army (DA) on June 1, 2021 . An up-to-date fillable DA Form 2173 is available for download and digital filing down below or can be found on the Army Publishing Directorate (APD) website.
DA Form 2173 must be completed by the authorized personnel no later than 7 days after receiving notice of said injury, illness, or disease unless the injury was not a direct result of Active Duty or IDT. The form expires either in 60 days after the incident (in case of an informal LDI) or in 90 days (in case of a formal LDI). The statement must be submitted within an adequate period of time for all allowances to come into effect within 30 days after reported injury, illness, or disease. The completed DA 2173 must undergo a detailed review and be approved by superiors for the continuation of incapacitation benefits.
Regulation AR 600-8-4 contains a detailed overview and instructions for the statement of medical examination and duty status. Detailed instructions are provided below.
DA Form 2173 and - if applicable - DD Form 261, Report of Investigation Line of Duty and Misconduct Status, are prepared during the LDI.
Five copies of the DA 2173 must be provided for active-duty personnel. The form may only be verified by an MTF commander, an attending physician, or a patient administrator. All personal data must be reviewed and checked. Changes made in pen and ink are allowed. The form must be returned to the unit commander or the MTF commander in case other corrections are needed. An investigation officer can be appointed in case any further investigation is required.
The first lines on the form require basic information about the Soldier and their case. This includes their full name, SSN, grade, organization, station, the date and place of the accident, and the to and from addresses for forwarding the form.
Section I is completed by an attending physician or a hospital patient administrator:
Section II is completed by a Unit commander or adviser:
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