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Sick Call Record Form

Identity and Assignment

Last Name

First Name

M.I.

DoD ID (10 Digits)

Age

Gender

Male Female

Rank

MOS

Battalion

Company/Unit

Complaint Details

Complaint Type

Injury Illness

Date of Onset (When did it start?)

Symptoms (Select All That Apply)

Fever Stomach/GI Issues Cold/Flu Symptoms Body/Joint Pain Skin Issues (Rash, Blisters) Severe Headache Other

Injury Details

Pain Severity

Type of Injury (Select All That Apply)

Bone or Muscle Hurt Burn or Deep Cut Hit to the Head/Neck Twist or Strain Another Type of Injury

Body Part Affected (Select All That Apply)

Head or Neck Chest Area Stomach Area Back Left Arm/Hand Right Arm/Hand Left Leg/Foot Right Leg/Foot

Mechanism of Injury (How did it happen?)

Ruck Details

Exercise/Activity Description

Terrain

Ruck Weight

Ruck Start Time (HH:MM)

Ruck Distance (Miles)

Wearing IOTV/ACH or carrying a weapon?

Pre/Post Activity Checklist (PT/H2F)

Specific H2F Exercise

Warmup Performed?

Stretching Performed?

Cooldown Performed?

Contact Info

Phone Number

Enter exactly 10 digits (no +, no hyphens). Example: 9121234567

By checking this box, I consent to receive text messages about my sick call request and status updates from Sickcall.xyz. Message and data rates may apply. Text STOP to cancel.

(I agree to receive notification alerts for form updates.)

Final Submission

I digitally sign and verify the accuracy of this data.

Prototype & Security Notice

This is a non-official, prototype-only form for demonstration purposes.

Not DOW Endorsed: This application is not approved or utilized by the U.S. Army or Department of War.

Data Security: Though encrypted, data is not stored on DOW-approved/compliant servers (e.g., IL-4/IL-5). Do not enter PII or sensitive/classified information.

Prototype & Security Notice

Please read carefully before proceeding

Prototype Application

This is a non-official, prototype-only form designed for demonstration and testing purposes.

Not DOW Endorsed

This application is not approved or utilized by the U.S. Army or Department of War.

Data Security Warning

Though data is encrypted, it is not stored on DOW-approved/compliant servers (e.g., IL-4/IL-5). This system is for demonstration only.

⚠️ Do not enter PII or sensitive/classified information.