In September 2003, we reported that the Army and Air Force did not comply with DOD’s force health protection and surveillance requirements for many servicemembers deploying in support of OEF in Central Asia and OJG in Kosovo at the installations we visited. Specifically, our review disclosed problems with the Army and Air Force’s implementation of DOD’s force health protection and surveillance requirements in the following areas: Deployment health assessments. Significant percentages of Army and Air Force servicemembers were missing one or both of their pre- and post-deployment health assessments and, when health assessments were conducted, as many as 45 percent of them were not done within the required time frames. Immunizations and other pre-deployment requirements. Based on the documentation we reviewed, as many as 46 percent of servicemembers in our samples were missing one of the pre-deployment immunizations required, and as many as 40 percent were missing a current tuberculosis screening at the time of their deployment. Up to 29 percent of the servicemembers in our samples had blood samples in the repository older than the required limit of 1 year at the time of deployment. Completeness of medical records and centralized data collection. Servicemembers’ permanent medical records at the Army and Air Force installations we visited did not always include documentation of the completed health assessments that we found at AMSA and at the U.S. Special Operations Command. In one sample, 100 percent of the pre-deployment health assessments were not documented in the servicemember medical records that we reviewed. Furthermore, our review disclosed that the AMSA database was lacking documentation of many health assessments and immunizations that we found in the servicemembers’ medical records at the installations visited. We also wrote in our 2003 report that DOD did not have oversight of departmentwide efforts to comply with health surveillance requirements. There was no effective quality assurance program at the Office of the Assistant Secretary of Defense for Health Affairs or at the Offices of the Surgeons’ General of the Army or Air Force that helped ensure compliance with force health protection and surveillance policies. We believed that the lack of such a system was a major cause of the high rate of noncompliance we found at the installations we visited, and thus recommended that the department establish an effective quality assurance program to ensure that the military services comply with the force health protection and surveillance requirements for all servicemembers. The department concurred with our recommendation. “(a) SYSTEM REQUIRED—The Secretary of Defense shall establish a system to assess the medical condition of members of the armed forces (including members of the reserve components) who are deployed outside the United States or its territories or possessions as part of a contingency operation (including a humanitarian operation, peacekeeping operation, or similar operation) or combat operation. “(b) ELEMENTS OF SYSTEM—The system described in subsection (a) shall include the use of predeployment medical examinations and postdeployment medical examinations (including an assessment of mental health and the drawing of blood samples) to accurately record the medical condition of members before their deployment and any changes in their medical condition during the course of their deployment. The postdeployment examination shall be conducted when the member is redeployed or otherwise leaves an area in which the system is in operation (or as soon as possible thereafter). “(c) RECORDKEEPING—The results of all medical examinations conducted under the system, records of all health care services (including immunizations) received by members described in subsection (a) in anticipation of their deployment or during the course of their deployment, and records of events occurring in the deployment area that may affect the health of such members shall be retained and maintained in a centralized location to improve future access to the records. “(d) QUALITY ASSURANCE—The Secretary of Defense shall establish a quality assurance program to evaluate the success of the system in ensuring that members described in subsection (a) receive predeployment medical examinations and postdeployment medical examinations and that the recordkeeping requirements with respect to the system are met.” As set forth above, these provisions require the use of pre-deployment and post-deployment medical examinations to accurately record the medical condition of servicemembers before deployment and any changes during their deployment. In a June 30, 2003, correspondence with GAO, the Assistant Secretary of Defense for Health Affairs stated that “it would be logistically impossible to conduct a complete physical examination on all personnel immediately prior to deployment and still deploy them in a timely manner.” Therefore, DOD required both pre- and post-deployment health assessments for servicemembers who deploy for 30 or more continuous days to a land-based location outside the United States without a permanent U.S. military treatment facility. Both assessments use a questionnaire designed to help military healthcare providers in identifying health problems and providing needed medical care. The pre-deployment health assessment is generally administered at the home station before deployment, and the post-deployment health assessment is completed either in theater before redeployment to the servicemember’s home unit or shortly upon redeployment. As a component of medical examinations, the statute quoted above also requires that blood samples be drawn before and after a servicemember’s deployment. DOD Instruction 6490.3, August 7, 1997, requires that a pre-deployment blood sample be obtained within 12 months of the servicemember’s deployment. However, it requires the blood samples be drawn upon return from deployment only when directed by the Assistant Secretary of Defense for Health Affairs. According to DOD, the implementation of this requirement was based on its judgment that the Human Immunodeficiency Virus serum sampling taken independent of deployment actions is sufficient to meet both pre- and post-deployment health needs, except that more timely post-deployment sampling may be directed when based on a recognized health threat or exposure. Prior to April 2003, DOD did not require a post-deployment blood sample for servicemembers supporting the OEF and OJG deployments. In April 2003, DOD revised its health surveillance policy for blood samples and post-deployment health assessments. Effective May 22, 2003, the services were required to draw a blood sample from each redeploying servicemember no later than 30 days after arrival at a demobilization site or home station. According to DOD, this requirement for post-deployment blood samples was established in response to an assessment of health threats and national interests associated with current deployments. The department also revised its policy guidance for enhanced post-deployment health assessments to gather more information from deployed servicemembers about events that occurred during a deployment. More specifically, the revised policy requires that a trained health care provider conduct a face-to-face health assessment with each returning servicemember to ascertain (1) the individual’s responses to the health assessment questions on the post-deployment health assessment form; (2) the presence of any mental health or psychosocial issues commonly associated with deployments; (3) any special medications taken during the deployment; and (4) concerns about possible environmental or occupational exposures. The overall record of the military services in meeting force health protection and surveillance system requirements for OIF was mixed and varied by service, by installation visited, and by specific policy requirement; however, our data shows much better compliance with these requirements in the Army and Air Force installations we reviewed compared to the installations in our earlier review of OEF/OJG. Of the installations reviewed for this report, the Marine Corps generally had lower levels of compliance than the other services. None of the services fully complied with all of the force health protection and surveillance system requirements, which include completing pre- and post-deployment health assessments, receipt of immunizations, and meeting pre-deployment requirements related to tuberculosis screening and pre and post-deployment blood samples. Also, the services did not fully comply with requirements that servicemembers’ permanent medical records include required health-related information, and that DOD’s centralized database includes documentation of servicemember health-related information. Servicemembers in our review at the Army and Air Force installations were generally missing small percentages of pre-deployment health assessments, as shown in figure 1. In contrast, pre-deployment health assessments were missing for an estimated 63 percent of the servicemembers at one Marine Corps installation and for 27 percent at the other Marine Corps installation visited. Similarly, the Navy installation we visited was missing pre-deployment health assessments for about 24 percent of the servicemembers; however, we note that the pre-deployment health assessments reviewed for Navy servicemembers were completed prior to June 1, 2003, and may not reflect improvements arising from increased emphasis following our prior review of the Army and Air Force’s compliance for OEF/OJG. At three Army installations we visited, we also analyzed the extent to which pre-deployment health assessments were completed for those servicemembers who re-deployed back to their home unit after June 1, 2003. Servicemembers associated with these re-deployment samples deployed in support of OIF prior to June 1, 2003. For two of these Army installations—Fort Eustis and Fort Campbell—we estimate that less than 1 percent of the servicemembers were missing pre-deployment health assessments. However, approximately 39 percent of the servicemembers that redeployed back to Fort Lewis on or after June 1, 2003, were missing their pre-deployment health assessments. Post-deployment health assessments were missing for small percentages of servicemembers, except at one of the Marine Corps installations we visited, as shown in figure 2.