Admission and Coding Information
ADMISSION AND CODING INFORMATION
For use of this form, see AR 40-400; the proponent agency is OTSG
19. TRAUMA
10. LENGTH OF SERVICE 12. SOCIAL SECURITY NUMBER
18. MOS
1. REPORTING MTF
3. REGISTER NUMBER
2. MTF LOCATION
NAME (Last, First, Middle Initial)
5. SEX4. PAY GRADE
6. DATE OF BIRTH (Y Y Y Y M M D D)
9. ETHNIC8. RACE7. AGE AT ADMISSION
RELIGION
1
2 3
4
5 6 7
8
9 10
11
12
13 14 15
16 17 18
19 20 21 22 23 24 25 26 27 28 29 30 31
32 33 34
ETS 11. FMP
35 36 37 38 39 40 41 42 43 44 45
ORGANIZATION (Active Duty Only)
13. MARITAL STATUS
46
HOUR OF
ADMISSION
BRANCH / CORPS
14. FLYING STATUS
47 48 49
15. BENEFICIARY CATEGORY
50 51 52 53 54 55 56 57 58 59 60 61
16. ZIP CODE OF RESIDENCE
17. UNIT LOCATION (State or
62 63 64 65 66 67 68 69 70 71
PREV. ADMISSION
YEAR
NO
20. SOURCE OF ADMISSION/ AUTHORITY FOR
72
WARD
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION
73 74
22. MTF TRANSFERRED TO
75 76 77 78 79 80
23. DATE OF DISPOSITION (Y Y Y Y M M D D)
81 82 83 84 85 86
24.
89 90
25. MTF TRANSFERRED FROM
93 94 95 96 97 98
26. DATE THIS ADMISSION (Y Y Y Y M M D D)
99 100 101 102 103 104
27. LOCATION OF OCCURRENCE
107 108
28. MTF OF INITIAL ADMISSION
109 110 111 112 113 114
29. DATE INITIAL ADMISSION (Y Y Y Y M M D D)
115 116 117 118 119 120
91 92
FOR LOCAL USE
ADMITTING OFFICER (Signature, as required)
SIGNATURE OF ADMITTING CLERK
APD LC v1.02ES
DA FORM 2985, MAR 2000
EDITION OF MAR 89 IS OBSOLETE
Country Code)
ADMISSION
CLINIC SVC - ADMITTING
(Battle Casualty Only)
A
(State or
Country
Code.)
BACK-
GROUND
87 88
105 106
121 122
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