DD Form 3111 Adult Immunization Screening Guide – DD Form 3111 is the official Department of Defense (DoD) document used across Military Health System facilities to screen adult patients before routine immunizations. Managed by the Defense Health Agency (DHA), the current edition is dated March 10, 2025. This standardized checklist helps healthcare providers identify potential contraindications or precautions so vaccines can be administered safely.
For service members, DoD civilians, retirees, and eligible family members in the United States, completing this form is a standard part of vaccination visits at military treatment facilities, troop medical clinics, and immunization clinics.
What Is DD Form 3111?
DD Form 3111, titled “Routine Immunization Screening Form: Adult,” is a two-page controlled form (CUI when filled in) prescribed for use within the DoD. Its sole purpose is to determine whether an adult patient can safely receive a routine immunization.
The form is issued under the authority of 10 U.S.C. 1071-1085 and related DoD and Army regulations governing medical care and immunizations. It is maintained by the Defense Health Agency and available through the official Washington Headquarters Services Executive Services Directorate forms library.
Official download link (latest edition): https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd3111.pdf
Who Uses DD Form 3111?
The form is primarily used by:
- Military treatment facility immunization clinics
- Troop medical clinics and battalion aid stations
- DoD civilian employee health programs
- TRICARE-authorized providers operating under DoD immunization protocols
It applies to adults (generally ages 19 and older) receiving routinely recommended vaccines such as influenza, COVID-19, Tdap, hepatitis A/B, MMR, varicella, pneumococcal, shingles (RZV), and others listed on the current CDC Adult Immunization Schedule.
Purpose of the Screening Form
According to the form itself, the purpose is “To determine whether you can safely receive a routine immunization.” Screening occurs before every vaccine dose—even if the patient has received the same vaccine previously—because a person’s health status or vaccine recommendations can change.
This practice aligns with CDC and Advisory Committee on Immunization Practices (ACIP) General Best Practice Guidelines for Immunization, which require standardized screening for contraindications and precautions prior to vaccine administration.
Key Sections of DD Form 3111
The form contains:
- Patient identification fields (name and date of birth in YYYYMMDD format)
- A 12-question Screening Checklist for Contraindications to Vaccines for Adults
- Space to list current medications
- Questions about the patient’s personal immunization record
- Signature blocks for the person completing the form and the reviewing healthcare professional
- Detailed guidance notes for healthcare professionals on page 2 explaining each screening question
A special note appears at the top: if cholera vaccine is being considered, a separate cholera-specific screening form must be completed instead.
The Screening Checklist Questions
Patients answer Yes, No, or Don’t Know to the following questions:
- Are you sick today?
- Have you ever had a serious reaction after receiving a vaccination?
- Do you have allergies to medication, food, a vaccine component, or latex?
- Have you had a seizure or a brain or other nervous system problem?
- Have you had a health problem involving heart, lung (e.g., asthma), kidney, or metabolic disease (e.g., diabetes), anemia, or other blood disorder?
- Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?
- In the past 3 months, have you taken medications that weaken your immune system (steroids, anticancer drugs, biologics for autoimmune disease) or had radiation treatments?
- In the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
- Have you had (or are you a candidate for) your spleen removed, or do you have sickle cell anemia?
- Have you ever passed out (had vasovagal syncope) during or after a previous immunization or blood draw?
- Have you received any vaccinations in the past 4 weeks?
- Are you pregnant or is there a chance you could become pregnant during the next month?
Answering “Yes” or “Don’t Know” does not automatically prevent vaccination. It simply prompts the healthcare provider to ask additional clarifying questions and apply current ACIP guidance.
How Healthcare Professionals Use the Form?
Page 2 of DD Form 3111 provides clinical explanations for each question, referencing CDC ACIP recommendations, the CDC Pink Book, and other authoritative sources. Providers use these notes to decide whether a true contraindication exists, whether a precaution warrants delay, or whether the benefit of vaccination outweighs any risk.
Common temporary precautions (for example, moderate or severe acute illness) usually result in postponing vaccination until the patient improves. Permanent contraindications (such as a history of anaphylaxis to a vaccine component) generally mean that specific vaccine should not be given.
How to Complete and Submit DD Form 3111?
- Download the official PDF from the Executive Services Directorate website.
- Open the file in Adobe Acrobat Reader for full functionality.
- Fill in patient name and date of birth.
- Answer every screening question honestly.
- List current medications.
- Indicate whether you brought your immunization record.
- Sign and date the form (or have a parent/guardian sign if applicable for certain adult dependents).
- Present the completed form to the immunization clinic staff for review.
The reviewing clinician signs and dates the form after evaluating the responses. The completed form becomes part of the patient’s permanent medical record in the Military Health System.
Privacy and Disclosure Information
Information collected on DD Form 3111 is protected under the Privacy Act of 1974 and HIPAA rules as implemented by DoD. Disclosure is voluntary; however, failure to provide the information may delay assessment of contraindications. Routine uses include sharing with other federal agencies (HHS, VA), state and local health departments, and authorized private entities when necessary for public health or force health protection.
The applicable System of Records Notice is EDHA 07, Military Health Information System.
Where to Get Help or Additional Information?
For clinical questions about immunizations, DoD beneficiaries and providers can contact the DHA Immunization Healthcare Support Center 24/7 at 1-877-438-8222 (Option 1).
Official form page: https://www.esd.whs.mil/Directives/forms/dd3000_3499/DD3111/
CDC Adult Immunization Schedule and contraindications guidance: https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-notes.html
Immunize.org Screening Checklist for Contraindications to Vaccines for Adults (widely used companion resource aligned with ACIP): https://www.immunize.org/clinical/topic/screening-checklists/
Download the Latest Official DD Form 3111
Always use the most current edition published by Washington Headquarters Services. Previous editions are obsolete.
Direct PDF download:
Download DD Form 3111 (PDF)
Save the file to your computer and open it with Adobe Acrobat Reader to ensure proper display and fillable fields.
Conclusion
DD Form 3111 is an essential patient-safety tool that supports the Military Health System’s commitment to evidence-based, high-quality immunization care. By systematically screening for contraindications and precautions before every adult vaccination, the form helps protect both individual patients and force readiness. Service members and beneficiaries should keep a personal immunization record and bring it to every medical appointment. For the most accurate and up-to-date version of the form, always download it from the official DoD forms website.