SUPPLEMENTAL HEALTH SCREENING …

1. Last Name - First Name - Middle Name (Suffix)2. Social Security Number3. Date of BirthSUPPLEMENTAL HEALTH SCREENING QUESTIONNAIRE(For use of this form, see usmepcom Reg 40-1)PRIVACY ACT STATEMENTA uthority:Principal purpose:Routine uses:Disclosure: usmepcom FORM 40-1-15-E, OCT 20098. SCREENING Questions Part 1 - Place a mark (X) in the column that corresponds to your answer to each of the following questions. (Any "YES" answer must be fully explained on page 2 of this form). Note: An answer is required for every SCREENING Questions Part 2 - Place a mark (X) in the box that corresponds to your answer to each of the following questions. Write thescore that corresponds to your answer in the score Were youeverdepressed or down, most of the day, nearly every day for 2 weeks?NOYEST itle 10, United States Code (USC), Sections 504, 505, 507, 532, 978, 1201, 1202, and 4346; Executive Orders 9397 and 13478 (SSN)To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and members of the ArmedForces.

1. Last Name - First Name - Middle Name (Suffix) 2. Social Security Number 3. Date of Birth SUPPLEMENTAL HEALTH SCREENING QUESTIONNAIRE (For use of this form, see USMEPCOM Reg 40-1)

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