DOD INSTRUCTION 6040

1 DOD INSTRUCTION THE SEPARATION HISTORY AND PHYSICAL EXAMINATION (SHPE) FOR THE DOD SEPARATION HEALTH ASSESSMENT (SHA) PROGRAM Originating Component: Office of the Under Secretary of Defense for Personnel and Readiness Effective: April 14, 2016 Releasability: Cleared for public release. Available on the DoD Issuances Website at Incorporates and cancels: Directive-type Memorandum 14-006, Separation History and Physical Examination (SHPE), July 7, 2014 Approved by: Robert Work, Deputy Secretary of Defense Purpose: In accordance with the authority in Chapter 58 of Title 10, United States Code ( ): This issuance establishes policy and assigns responsibilities for completion of a SHPE as the principal component of the DoD-Department of Veterans Affairs (VA) SHA Program in compliance with Section 1145(a) of Title 10, and the 2013-2015 Joint Executive Committee Joint Strategic Plan.

2 The SHPE and SHA Program facilitate the transfer of care from the DoD to the VA and support the evaluation of disability claims. DoDI , April 14, 2016 TABLE OF CONTENTS 2 TABLE OF CONTENTS SECTION 1: GENERAL ISSUANCE INFORMATION .. 3 Applicability.. 3 Policy.. 3 Information Collections.. 3 SECTION 2: RESPONSIBILITIES .. 5 Assistant Secretary of Defense for Health Affairs (ASD(HA)) .. 5 Director, Defense Health Agency (DHA).. 5 Secretaries of the Military Departments and Commandant of the USCG.. 6 SECTION 3: SHPE GUIDANCE AND PROCEDURES .. 7 General Procedural Guidance.. 7 DoD Administered SHPE Documentation Standards.. 8 VA Administered Exams.. 10 Timing of SHPE.. 11 Coordination with Transition Assistance Program .. 11 Information Collection Requirements .. 12 GLOSSARY .. 13 Acronyms.

3 13 Definitions.. 13 REFERENCES .. 15 TABLE Table 1: Summary of SHPE Qualification Categories .. 7 DoDI , April 14, 2016 SECTION 1: GENERAL ISSUANCE INFORMATION 3 SECTION 1: GENERAL ISSUANCE INFORMATION APPLICABILITY. This issuance applies to OSD, the Military Departments (including the Coast Guard at all times, including when it is a Service in the Department of Homeland Security by agreement with that Department), the Office of the Chairman of the Joint Chiefs of Staff and the Joint Staff, the Combatant Commands, the Office of the Inspector General of the Department of Defense, the Defense Agencies, the DoD Field Activities, and all other organizational entities within the DoD. POLICY. It is DoD policy that: a. All Service members completing a period of active duty as detailed in Section 3 must complete a SHPE according to the timelines described there.

4 B. The SHPE may be waived only in cases where the Service member is not under control of the Secretary of a Military Department or the Commandant of the United States Coast Guard (USCG), such as unauthorized absences or civilian incarceration. c. Documentation of the SHPE must be entered into each member s Service Treatment Record (STR) before final separation from military service. d. For Service members who are filing disability claims with the VA, the separation exam performed by the VA may be used to meet the SHPE requirements if it can be performed and documented according to the procedures detailed in Section 3. e. Service members suspected of having a medical condition that precludes continued military service will be referred to the disability evaluation system (DES), the integrated DES (IDES) subject to the criteria described in DoDI , or the equivalent USCG process.

5 Service members not referred to these processes and otherwise qualifying for a SHPE are presumed to be fit for continued active duty, separation, or retirement. f. The SHPE must be completed in addition to other deployment health activities that may be required in accordance with DoDI g. Service members who have otherwise met Career Readiness Standards in compliance with DoDI will not be retained past their separation or retirement date to complete SHPEs unless an authorized commander approves retaining the Service member. INFORMATION COLLECTIONS. a. The DoD (DD) Form 2807-1 Report of Medical History, referred to in Paragraph has been assigned Office of Management and Budget control number 0704-0413 in accordance with the procedures in Volume 2 of DoD Manual The expiration date of this control number is listed at DoDI , April 14, 2016 SECTION 1: GENERAL ISSUANCE INFORMATION 4 b.

6 DD Form 2808 Report of Medical Examination, referred to in Paragraphs , , , and , does not require licensing with a report control symbol in accordance with Paragraph (13) of Volume 1 of DoD Manual c. The SHPE participation quarterly report, described in Paragraph , has been assigned report control number DD-HA(Q)2549 in accordance with the procedures of Volume 1 of DoD Manual The expiration date of this information collection is listed in the DoD Information Collections system at DoDI , April 14, 2016 SECTION 2: RESPONSIBILITIES 5 SECTION 2: RESPONSIBILITIES ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS (ASD(HA)) Under the authority, direction, and control of the Under Secretary of Defense for Personnel and Readiness (USD(P&R)), the ASD(HA): a. Establishes and updates as needed a memorandum of agreement (MOA) with the VA specifying: (1) Timely sharing of the STR, consistent with applicable authorities for disclosure of protected health information, as summarized in the guidance in the July 7, 2014 USD(P&R) Memorandum.

7 (2) Documentation standards of the SHPE, including a list of all relevant diagnoses. b. Ensures that data from the VA and from the DoD electronic medical record systems is made available to the Military Services to support reporting requirements. c. Develops and updates other DoD policies as may be needed to execute the SHPE, in coordination with the Services. d. Provides guidance for collection, analysis, and use of the aggregate data from the SHPE to inform and improve health and safety programs for the benefit of all Service members in coordination with the Services. DIRECTOR, DEFENSE HEALTH AGENCY (DHA). Under the authority, direction, and control of the USD(P&R) through the ASD(HA), the Director, DHA: a. Develops procedural guidance in coordination with the Military Departments to ensure that the STR is complete, in accordance with DoDI , DoDI , the March 14, 2014 DoD/VA Memorandum of Understanding for Sharing Personal Information, and applicable DoD/VA agreements.

8 B. Ensures that STR documentation entered into centrally managed medical record systems, including the SHPE report, is shared with the VA through an interface between the DoD s record archive system and the VA s record archive system in accordance with the 2014 DoD/VA Memorandum of Understanding, and subsequent applicable DoD/VA agreements. c. Develops and distributes procedures to implement this issuance in coordination with the Services. d. Ensures that the DHA coding authority updates the SHPE s diagnosis code standard as necessary in coordination with DHA s Coding Compliance Work Group. DoDI , April 14, 2016 SECTION 2: RESPONSIBILITIES 6 SECRETARIES OF THE MILITARY DEPARTMENTS AND COMMANDANT OF THE USCG. The Secretaries of the Military Departments and the Commandant of the USCG: a. Establish procedures necessary to carry out the requirements of this issuance, to include waiver review and designation of a waiver approval authority.

9 B. Provide information and guidance to the Service members and unit commanders on the SHPE process. c. Ensure separating Service members have completed a separation exam when required, within the timeline detailed in Section 3, either by completing a SHPE within a military treatment facility (MTF) or by DoD-contracted health care services, or by receiving notification and report of a VA performed exam intended to serve as a separation exam in support of a VA claim, in accordance with the December 3, 2013 MOA between the VA and DoD. Members may complete both DoD and VA performed exams if the VA exam results are not available within the timelines detailed in Section 3. d. Ensure all required SHPE forms and test results are included in the STR when the SHPE is conducted by the DoD, or that a statement by a DoD official is included that acknowledges review of the VA exam report when the VA provides notification and the report of a VA performed exam intended to meet the requirement.

10 E. Ensure documentation standards are met for SHPEs performed under their authority, including a list of all relevant diagnoses. DoDI , April 14, 2016 SECTION 3: SHPE GUIDANCE AND PROCEDURES 7 SECTION 3: SHPE GUIDANCE AND PROCEDURES GENERAL PROCEDURAL GUIDANCE. a. The SHPE qualification categories and requirements are summarized in Table 1. Table 1: Summary of SHPE Qualification Categories Service Member SHPE Required Notes Active Component or Active Guard and Reserve Yes The SHPE must be completed prior to separation from active duty. Not Filing Claim: Complete the SHPE at an MTF or by DoD-contracted services. Filing Claim: No later than 90 days prior to date of separation from active duty, complete the separation exam with the VA when possible. Service members who separate from overseas locations should refer to the Services for SHPE location and timing.