FM 8-42
APPENDIX E
COMBAT HEALTH SUPPORT ASSESSMENT CHECKLIST
E-1.
General
a. This appendix provides a tool for use in assessing the health care delivery system and the
medical needs of a HN or US-backed group. This checklist is intended only as a guide and may be modified
for use as the situation dictates.
b. This checklist is arranged by category of information. The more detailed the information
obtained, the better this checklist will aid the CHS planner in correctly identifying the medical threat,
assessing the medical requirements, and developing the requisite programs for alleviating the identified
deficiencies. Additional information in the form of brochures, magazine or newspaper articles, or
advertisements of medical facilities, health service education programs, and medical equipment or supplies
available will also assist in the planning effort.
c. The mission reconnaissance checklist presented in Appendix M is more limited in scope and is
intended for the assessment of a specific village, town, or district.
d.
E-2.
Predeployment medical assessments may be available through supporting CA units.
Sample Medical Assessment Checklist
COUNTRY ___________________________________________ DATES VISITED _____________________ TO ________________
I.
GENERAL INFORMATION
Name of Location ______________________________________________________________________________________________
Map Grid Coordinates _________________________________________________________________________________________
Topography (such as mountains or desert) ______________________________________________________________________
Climate (such as tropic or arctic) ________________________________________________________________________________
Temperature Ranges:
Summer __________ to __________
Winter
__________ to __________
Significant Seasonal Variants (such as monsoon season) _________________________________________________________
Availability of Water
Source
Quality
Quantity
Contaminants
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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FM 8-42
Epidemiology
Disease
Occurrence
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Leading Cause of Death
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Status of Sanitation Impacting on the Overall Health
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Insects, Plants, and Animals of Medical Importance
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Religious, Social, and/or Political Factors of Medical Importance
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
II.
CIVILIAN HEALTH SERVICES
Organization and Administration (to include public and private)
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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FM 8-42
Public Health Laws
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Accessibility to Care (to include both physical, social, and financial barriers)
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Comments on Overall Quality of Civilian Health Care
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Significant Individuals
Name
Title
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
III.
MILITARY MEDICAL SERVICES
Force Strength
Active ______________________ Reserve _______________________
Organization and Administration
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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FM 8-42
Policies and Programs
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Physical Fitness Standards
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Medical Logistics and blood Management
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Medical Evacuation and Regulating
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Hospitalization
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Preventive Medicine
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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FM 8-42
Dental
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Veterinary
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Pharmacy, Laboratory, and X-ray
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Combat Stress/Neuropsychiatric
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Nursing
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Paraprofessionals
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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FM 8-42
Military Medical Training and Education Programs
Course/School
Location
Type of Training
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Comments on the Overall Quality of Military Care
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Significant Individuals
Name
Title
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
IV.
MEDICAL MATERIEL
Production Capability
Product
Quantity
Demand
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Stockpiles
Product
Quantity
Demand
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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FM 8-42
Products Obtained from Outside Sources
Product
Quantity
Demand
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Equipment Repair Capability
Type of Equipment
Source of Repair
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
V.
MEDICAL RESEARCH AND DEVELOPMENT
Institutes
Name
Location
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Significant Individuals
Name
Title
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
VI.
CIVILIAN MEDICAL TRAINING
Course/School
Location
Type of Training
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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FM 8-42
Other Comments
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
E-8
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NAME
LOCATION
COMMENTS
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
VII. HOSPITAL DATA
Please rate capabilities
1 (minimal) through 5 (excellent)
FM 8-42
E-9