Form DHA 780 DHA 780 DHA 780

PROFESSIONAL QUALIFICATIONS
MEDICAL/PEER REVIEWERS

OMB No. 0720-0005
OMB approval expires

The public reporting burden for this collection of information is estimated to average 20 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, Washington Headquarters
Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0720-0005). 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 ADDRESS. RETURN COMPLETED FORM TO:
Keystone Peer Review Organization, Inc., 777 East Park Drive, P.O. Box 8310, Harrisburg, PA 17105-8310
1. PHYSICIAN/REVIEWER'S NAME

2. YEAR OF BIRTH

3. ADDRESS

4. MEDICAL INFORMATION
a. STATE

b. YEAR OF DEGREE c. SCHOOL

d. YEAR OF LICENSE

e. AMERICAN SPECIALTY BOARDS

D R A F T
f. SPECIALTIES

g. TYPE OF PRACTICE

h. NATIONAL SCIENTIFIC MEDICAL SOCIETIES

DHA FORM 780, 20160323 DRAFT

REPLACES CHAMPUS FORM 780, WHICH IS OBSOLETE.

Adobe Designer 11

5. PROFESSIONAL APPOINTMENTS
a. STATE

b. SCHOOL

c. TITLE AND CURRENT STATUS

d. OTHER INFORMATION

D R A F T
6. SOURCES OF INFORMATION (Professional Listing)
a. NAME OF DIRECTORY

b. YEAR

c. EDITION

e. OTHER SOURCES

DHA FORM 780 (BACK), 20160323 DRAFT

d. PAGE