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Commissioned Personnel Official Forms
  • Appointment/Application
  • Assignment Incentive Pay
  • Assimilation
  • Awards
  • Billets
  • COSTEP
  • Leave
  • Medical
  • Payroll
  • Payroll - Special Pays
  • Performance
  • Personnel Actions
  • Promotions
  • Separation/Retirement
  • Shipment of Household Goods
  • Training
  • Travel
  • Uniform Allowance


    • PHSCC Administrative Forms

    Links to Frequently Requested Non-PHS Government Forms
  • ID Cards/Deers Enrollment
  • Outside Activities
  • Payroll
  • Travel
  • Travel Incident to Health Care
  • VA Education Benefits


    • Other Than Commissioned Personnel Specific Forms
    		 

    Commissioned Personnel Official Forms
    These documents (unless otherwise noted) are saved in Adobe PDF format and require version 4.05 or greater of the reader which may be found at: www.adobe.com

    Appointment/Application    		 Return to top
    Click here to begin the prescreen commissioning process.
     PHS-5141-1 Appointment Affidavit Reserve Corps 10/2006

     PHS-6134

    		 Statement of Uniformed Service Other Than U.S. Public Health Service Commissioned Corps 07/2002

    Assignment Incentive Pay    		 Return to top
     PHS-7080 Request for Designation of a Critical Public Health Assignment Billet Qualifying for AIP 09/2008
     PHS-7065 AIP Contract Request 09/2008

    Assimilation    		 Return to top
     PHS-7034 Fillable Application for Assimilation into the Regular Corps 10/2008
     PHS-7034 Fillable WORD document Application for Assimilation into the Regular Corps 04/2006

    Awards    		 Return to top
     PHS-6342-1 Unit Honor Award Nomination Record 01/2007
     PHS-6342-2 Individual Honor Award Nomination Record 01/2007

    Billets    		 Return to top
     PHS-4392 Fillable Billet Description (PDF) 10/2008
     PHS-4392 Fillable Billet Description (Word Document) 04/2006
     PHS-7046 Fillable Flag Grade Billet Assessment (Note: Use Adobe Acrobat Reader 6.0 or higher to complete this fillable form). 10/2008
     PHS-7046 Fillable Flag Grade Billet Assessment (Word Document) 03/2006

    COSTEP    		 Return to top
     PHS-4772 JRCOSTEP Status Report 07/2005
     PHS-4772 Fillable PDF - JRCOSTEP Status Report 10/2008
     PHS-4772 Fillable WORD document - JRCOSTEP Status Report 07/2005
     PHS-4469-1 JRCOSTEP Evaluation Questionnaire 07/2005
     PHS-4469-1 Fillable PDF -  JRCOSTEP Evaluation Questionnaire 10/2008
     PHS-4469-1 Fillable WORD document -  JRCOSTEP Evaluation Questionnaire 07/2005
     PHS-6279 JRCOSTEP Statement of Duties 07/2005
     PHS-6279 Fillable PDF -   JRCOSTEP Statement of Duties 10/2008
     PHS-6279 Fillable WORD document - JRCOSTEP Statement of Duties 07/2005
     PHS-6373 Extramural Training Agreement - Fillable PDF 10/2008
     PHS-6373 Extramural Training Agreement - Fillable MS Word Document 03/2007

    Leave    		 Return to top
     PHS-1345 Request and Authority for Leave of Absence 09/2005
     PHS-1345 Fillable PDF - Request and Authority for Leave of Absence 10/2008
     PHS-1345 Fillable WORD document - Request and Authority for Leave of Absence     09/2005

    Medical    		 Return to top

     DD-2807-1

    		 Applicants to JRCOSTEP - Instructions for Completion of DD Form 2807-1 09/2004

     DD-2807-1

    		 Report of Medical History -Privacy Act Statement 10/2004

     DD-2808

    		 Report of Medical Examination -Privacy Act Statement 10/2004

     DD-2808/DD-2807-1

    		 General Instructions for Completion of DD-2808 and DD-2807-1 for Periodic, Assimilation, Retirement/Separation, Long Term Training, Limited Tour Removal, and Other Physicals. 08/2005
     PHS-6355 Report of Dental Examination of Applicants to the CC of the PHS. Also used for Active-Duty officers' 5-year periodic physical examination. 01/2005
     PHS-6355 Fillable Report of Dental Examination of Applicants to the CC of the PHS. Also used for Active-Duty officers' 5-year periodic physical examination. 01/2005
     PHS-6380 Request for Uniformed Services Medical Records 01/2005
     PHS-6380 Fillable Request for Uniformed Services Medical Records 01/2005
     PHS-6379 Supplemental Medical History Record Required of Applicants 01/2005
     PHS-6379 Fillable Supplemental Medical History Record Required of Applicants 01/2005
     PHS-7044 Physical Readiness Standards Report 08/2004
     PHS-7044 Fillable Physical Readiness Standards Report 08/2004

    Payroll    		 Return to top
     PHS-488 Claim for Temporary Lodging Allowance 09/2005
     PHS-488       Fillable PDF - Claim for Temporary Lodging Allowance  09/2005
     PHS-488  Fillable WORD document - Claim for Temporary Lodging Allowance 09/2005
     PHS-1637-1 PHS Commissioned Officer's Request for Dependency Determination (Spouse and/or Child) 08/2005
     PHS-1637-1 Fillable PHS Commissioned Officer's Request for Dependency Determination (Spouse and/or Child) 08/2005
     PHS-1637-1 Fillable WORD document -  PHS Commissioned Officer's Request for Dependency Determination (Spouse and/or Child) 08/2005
     PHS-1637-2 Parent's/Parent-in-Law's Statement 04/2005
     PHS-1637-3 Parent's Dependency Affidavit 09/1981
     PHS-1637-4 Child's Dependency Statement 09/1990
     PHS-2874 Notice of Arrival 04/2005
     PHS-2874 Fillable Notice of Arrival 04/2005
     PHS-2977 Quarters Allowance Certificate 05/1990
     PHS-5150 Survivor Benefit Plan Election Certificate 07/2007
    PHS-6059 Request for Overseas Station Allowance 04/2005
     PHS-6173 Application for Allotment of Pay (NON-GI BILL: use PHS-7039 below for GI BIll) 04/2005
     PHS-6231 Certification for Intermittent Tours of Duty 09/2002
     PHS-6273 Fillable Montgomery GI Bill Election and Statement of Understanding (Print COVER MEMO ) 04/2007
     PHS-6353 PHS Commissioned Officer State Tax Withholding Allowance Certificate 04/2005
     PHS-6353-1 Request for Voluntary State Income Tax Withholding from Retired Pay 04/2005
     PHS-6363 Request to Establish/Change Mailing Address 12/2004
     PHS-6363 Fillable Request to Establish/Change Mailing Address 12/2004
     PHS-6367 Active-Duty Certification (Short Tours of Less Than 30 Days) 04/2005
     PHS-7036 Reimbursement Request for Adoption Expense 04/1998

     PHS-7039/    DD2366-1

    		 Application for Allotment of Pay (for Additional Mont GI Bill Benefits)  Also print the COVER MEMO! 11/2007

    Payroll - Special Pays    		 Return to top
     PHS-7033 Accession Bonus - Special Pay Contract 02/2006
     PHS-7033      Fillable Accession Bonus - Special Pay Contract 02/2006
     PHS-7040 Optometrist Retention Special Pay 08/2004
     PHS-7043 CSRB - Critical Skills Retention Bonus Agreement. CSRB Information Sheet 11/2003
     PHS-6289 DSP - Dental Special Pay Contract Request 11/2008
     PHS-7015 ESCCP - Engineering and Scientific Career Continuation Pay Contract Request 09/2001
     PHS-6300-1 MSP - Medical Special Pay Contract Request
    Medical Officer Special Pay Information Sheet.   Includes 2004 rates and contract form.    		 04/1998
     PHS-7049 Incentive Special Pay (ISP) - Nurse Anesthetist Agreement 02/2006
     PHS-7049 Fillable Incentive Special Pay (ISP) – Nurse Anesthetist Agreement  02/2006

    Performance    		 Return to top
     PHS-838 GENERIC Commissioned Officers' Effectiveness Report 06/2000
     Attachment 1 COER Attachment 1, Section 1, Officer Section -- pdf format that may be completed electronically --- will NOT save information if you do not own full Adobe Acrobat product. 05/2000
     Attachment 2 COER Attachment 2, Section 1, Rater Section -- pdf format that may be completed electronically --- will NOT save information if you do not own full Adobe Acrobat product. 05/2000
    PHS-6385 Status Report for Officers on Probation NO LONGER USED! QUESTIONS ARE CONTAINED ON THE COER FORM IF THEY ARE NEEDED. 03/1998

    Personnel Actions    		 Return to top
     PHS-1662 Request for Personnel Action 10/2004
     PHS-1662 FillableRequest for Personnel Action 10/2008

    Promotions    		 Return to top
    OS Officer Statement - 2010 PY 2010
     ROS Reviewing Official Statement - 2010 PY 2010
     PHS-7052 Fillable  Associate Recruiter Activity Report 12/2006
     PHS-7052 Fillable WORD document Associate Recruiter Activity Report 12/2006

    Separation/Retirement    		 Return to top
     PHS-1373 Separation of Commissioned Officer 09/2005
     Memo Home of Selection Upon Retirement Memo 08/2003

    Shipment of Household Goods    		 Return to top
     PHS-4013-1 Application for Shipment of Household Goods 02/1999

    Training    		 Return to top
     Training Purposes and Objectives
     Request for Basic Training Contract
     PHS-1122-1 Application for Training for PHS Commissioned Personnel (Privacy Act) - Also See PHS-1122-1 Supplement Form   03/2007
     PHS -1881-1 Basic Training Contract - Fillable PDF 03/2007
     PHS -1881-1 Basic Training Contract - Fillable MS WORD Document 03/2007
     PHS-1881-2 Order Pursuant to Basic Training Contract - Fillable PDF 03/2007
     PHS-1881-2 Order Pursuant to Basic Training Contract - Fillable MS WORD Document 03/2007
     PHS-6373 Extramural Training Agreement - Fillable PDF 03/2007
     PHS-6373 Extramural Training Agreement - Fillable MS Word Document 03/2007
     PHS-6374 Intramural Training Agreement - Fillable PDF 03/2007
     PHS-6374 Intramural Training Agreement - Fillable MS Word Document 03/2007
     PHS-7062 Extramural Training Agreement (Scholarships, Grants, Fellowships) 07/2007
     PHS-7064 Training Agreement for Officers Assigned as Students to School of Medicine, USUHS. Please also print COVER LETTER 05/2008

    Travel    		 Return to top
     PHS-2988 Voucher for Reimbursement for Travel (Dependents of PHS Commissioned Officers) 09/1992
     PHS-7045 Fillable PHS-7045 Temporary Lodging Expense (TLE) Computation Worksheet - NEW 03/2009

    Uniform Allowance    		 Return to top
     Memo Request for Uniform Allowance NA

    PHSCC Administrative Forms
    Online Access to PHSCC Systems Return to top
     Combined CC & CCP User Registration Form
     Direct Access User Registration Form

    Links to Frequently Requested Non-PHS Government Forms

    ID Cards/Deers Enrollment    		 Return to top
     DD-1172 Application for Uniformed Services Identification Card/DEERS Enrollment. 
    Cover memo that you must also print and review.
    NOTE:  You have the option of filling this form out online using Acrobat Reader, but you must print the form after filling it out.  You will not be able to save your work.  You also have the option of printing a hard copy and filling it out using the traditional method.    		 07/2002

    Outside Activities    		 Return to top
     HHS-520

    Request for Approval of Outside Activities (Fillable PDF)

    		 01/2006
      HHS-520 Request for Approval of Outside Activities (MS Word Document) 01/2006
     HHS-521 Annual Report On Outside Activities (Fillable PDF) 01/2006
     HHS-521 Annual Report On Outside Activities (MS Word Document) 01/2006

    Payroll    		 Return to top
     W-4 Employee's Withholding Allowance Certificate
     DD-2058 State of Legal Residence Certificate 02/1977
    SGLV-8286 Servicemen's Group Life Insurance Election and Certificate 09/2005
    SGLV-8286A Family Coverage Election 08/2001
     SF-1199A Direct Deposit Sign-Up Form 06/1987
     TSP-U-1 Thrift Savings Plan Election Form
    TSP Information  (editions prior to 01/2006 are obsolete)    		 05/2007
     TSP-U-1-C Thrift Savings Plan Catch-Up Contribution Election 07/2004
    SB-2362 E 

    Authorization for Purchase and Request for Change.  
    United States Series EE Savings Bonds (or) United States Series I (Inflation-Indexed) Savings Bonds.

    		 07/2005

    Travel    		 Return to top
     SF-1012

    Travel Voucher

    		 10/1977
     SF-1038

    Advance of Funds Application and Account

    		 10/1977

    Travel Incident to Health Care    		 Return to top
     SF-1080

    Voucher for Transfers Between Appropriations And/Or Funds

    		 04/1982

    VA Education Benefits    		 Return to top
    VA Form 22-1990

    Application for VA Education Benefits NOTE: IMPORTANT INSTRUCTIONS FROM OCCO

    		06/2006

    Other Than Commissioned Personnel Specific Forms
    U. S. Government Electronic Library of GSA, Standard and Optional Forms:  General Services Administration maintains an extensive library of electronic forms for use.
    Office of Personnel Management Electronic Forms.
    Program Support Center Electronic Forms.

    Commissioned Corps Management Information System
    1101 Wootton Parkway, Plaza Level, Suite 100 | Rockville, MD 20857

    Department of Health and Human ServicesU.S. Public Health Service HHS Home Disclaimers Office of Public Health and Science
    Accessibility USA.gov Office of the Surgeon General
    Privacy Notice The White House USPHS.gov
    Freedom of Information Act
    Rules of Behavior for Use of PSC ESS Systems

    Last updated: 05 January 2010