DD Form 2369 DoD Medical Examination Review Board (DoDMERB) Cyclopleg

DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
CYCLOPLEGIC REFRACTION

OMB No. 0704-0396
OMB approval expires
Sep 30, 2006

(Please read Privacy Act Statement before completing this form.)

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0396). Respondents should be aware that notwithstanding any other provision of
law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO DODMERB/DR, 8034 EDGERTON
DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.
PRIVACY ACT STATEMENT
AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397.
PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States
Service Academy, Reserve Officer Training Corps (ROTC) Scholarship Program, or the Uniformed Services University of the Health
Sciences (USUHS).
ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applications to their
Academies.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your
candidacy. Use of the Social Security Number (SSN) is used for positive identification of records.
1. NAME OF APPLICANT (Last, First, Middle Initial)

2. SSN OF APPLICANT

3. DATE OF EXAMINATION
(YYYYMMDD)

4. ADDRESS OF FACILITY (City, State, ZIP Code)

5. TELEPHONE NUMBER OF
FACILITY (Include Area Code)

6. CONTACT LENS DATA (X all that apply)

7. FAMILY EYE HISTORY (X all members

of your immediate family who wear glasses
or contact lenses.)

a. I DO NOT WEAR CONTACT LENSES.
b. SOFT CONTACT LENSES WERE REMOVED

DAYS PRIOR TO THE ABOVE EXAMINATION.

FATHER

c. HARD CONTACT LENSES WERE REMOVED

DAYS PRIOR TO THE ABOVE EXAMINATION.

MOTHER

d. SIGNATURE OF APPLICANT

BROTHER
SISTER
NONE OF MY FAMILY

8. VISION EVALUATION BEFORE INSTALLATION OF DROPS (Before cycloplegic)
a. DISTANT VISION

b. CURRENT RX

OD 20/

CORR TO 20/

OD SPHERE

CYL

AXIS

OS 20/

CORR TO 20/

OS SPHERE

CYL

AXIS

9. MEDICATION USED FOR CYCLOPLEGIC

c. NEAR VISION
OD 20/

CORR TO 20/

OS 20/

CORR TO 20/

10. VISION EVALUATION AFTER CYCLOPLEGIA OBTAINED (NOTE: Correct to 20/20 absolute. Record number of letters missed on 20/20, i.e. 20/20-2,
20/20-3, etc. If unable to correct to 20/20, record best correctable vision. Do NOT over correct; correct ONLY to 20/20.)
a. DISTANT VISION CORRECTED TO

b. CYCLO RX

OD 20/

CORR TO 20/

OD SPHERE

CYL

AXIS

OS 20/

CORR TO 20/

OS SPHERE

CYL

AXIS

11. REMARKS (Examiner should list any diagnosis which interferes with visual function which was noted on this examination.)

12. TYPED OR PRINTED NAME OF EXAMINER

DD FORM 2369, MAR 2004

13. SIGNATURE OF EXAMINER

PREVIOUS EDITION IS OBSOLETE.

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