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Phs-7044-1 FORM PHS-7044-1

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Country of origin: US
File type: PDF

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
U.S. Public Health Service Commissioned Corps
Division of Commissioned Corps Personnel and Readiness
VERIFIED WEIGHT REPORT
Instructions: If possible, officers should be evaluated by an active-duty commissioned officer from the United States Public Health
Service or one of the other Uniformed Services. When unavailable, officers can be evaluated by an active-duty commissioned officer
remotely (via live or recorded video) or by a federal employee non-officer adult in person. Officers may also be evaluated by their
healthcare provider. The person evaluating the officer is referred to as the testing official. Enter whole numbers for height and body
weight (round down for values 0.4 and lower and round up for values 0.5 or higher). Once complete, officer uploads the form to
eDOC-U.
Section A
1. Date Tested (mm/dd/yy)
2. Officer's Name (Print Last, First, Middle Initial)
3. Rank/Grade
4. PHS Serno
5. Height (in feet and inches no shoes)
(feet) (inches)
6. Weight
(in pounds, light clothing)
7. BMI
(kg/m
2
)
BMI = [body weight in lbs. x 703] ÷ [height in inches]
2
If BMI Greater Than 27.5, Complete Section B, Otherwise Leave Blank
Section B
Officers must use method described at
https://dcp.psc.gov/ccmis/weightstandards_m.aspx
to obtain measurements recorded below.
8. Waist (at narrowest)
(in)
9. Hip (at widest)
(in)
10. Neck (at narrowest)
(in)
11. Gender
Female
Male
12. Body Fat
%
Signatures
Testing Official (Print Last, First, Middle Initial)
PHS Serno (Corps Officers Only)
Testing Official's Signature
Testing Official's Email Address
Officer's Signature
Officer's Email Address
NOTE: I understand that the falsification or other nondisclosure of material medical information may result in the immediate close out of
my application or my separation from active duty without benefits at any time during my career. The determination of material non-
disclosure (a form of misconduct) is made by the Director, Division of Commissioned Corps Personnel and Readiness, and this
decision is final, in accordance with CCPM 23.8 INSTR 6 “Disability Retirement” and CCPM Pamphlet No. 47 “Disability Evaluation
Manual for the Commissioned Corps of the U.S. Public Health Service”.
PHS-7044-1 (09/18)
PSC Publishing Services (30) 443-6740
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Phs-7044-1 FORM PHS-7044-1

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Completed 28 February 2020

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