Download the form
Defense Department form, series DD, number 2164. Full title: DD Form 2164, X-Ray Verification/Certification Worksheet, November 1978. Function: X-Ray Verification/Certification Worksheet. Edition in force: not stated. Publisher status: not stated.
Issued under not stated, with not stated as proponent. A DD number marks a Department-wide instrument: the same blank form serves every military department and the defense agencies, rather than one service alone.
Users include uniformed members of any branch, DoD civilian employees, contractor personnel where authorized, and the administrative staff who process the completed record.
Timing of submission is fixed by not stated and by the implementing guidance of the submitting organization. What follows describes the blank document, not agency procedure.
The download set covers PDF. Document length is 2 pages with about 200 entry fields.
Distribution centres on pdf. Two states exist: fillable, where field boxes accept keyboard input and retain it, and printable, a static blank produced for manual completion. Typed data reproduces cleanly across copies; handwritten data depends on the writer.
What the form asks for
- Action. Press space bar to mark X in first box if required, second box if not required, or third box if taken.
- Location (include building and room number).
- Date and time of service.
- Date next service due.
- 1. Control no. 1 (master control). Manufacturer.
- Model (include type, style, size, focal spots, etc.).
- Serial number (housing).
- 2. Control no. 2 (room control). Manufacturer.
- Model.
- 3. Radiographic tube. Manufacturer.
- Model.
- Serial number.
- Serial number.
- 4. Radiographic tube (auxiliary tube). Manufacturer.
- Model.
- Serial number.
- 5. Fluoroscopic tube. Manufacturer.
- Model.
- Serial number.
- Part 2 - Visual inspection of equipment. 6. Certification labels are affixed and visible. X if no action required.
- Type of action required.
- X if action taken.
- Initial and date.
- 7. Steel counterweight cables. X if no action required.
Order of completion: identification block first, substantive entries second, certification and signature last. The blank is laid out in that sequence and the sequence is not arbitrary — later entries often depend on data established in the header.
The current edition is not stated. Superseded editions of DD forms are frequently rejected at the receiving office, since Department-wide forms change centrally and older layouts lose their field correspondence. Edition date appears in the lower corner of the printed blank.
Instructions printed on the form or in not stated govern individual field entries. Where the two differ, the governing publication controls.
The completed document moves to the office named in not stated or in local guidance. A retained copy is conventional practice.
Related documents are located by series and number. DD forms sit in a single Department-wide sequence, so a form referenced inside DD Form 2164 is normally found by its number alone, without regard to service.
A DD number and a DA number may appear in the same instruction without being related. DA forms belong to the Army alone; DD forms belong to the Department and are administered at Department level. The sequences are independent.
Editions change because the underlying directive changes, because collection requirements are revised, or because Privacy Act language is updated. Checking the edition date at the point of download is the practical response.
This page distributes a published Department of Defense document and describes it. It is not a source of legal advice and makes no representation about acceptance of any completed form. Questions of applicability, eligibility or procedure belong to not stated, the servicing personnel office, or the office named in not stated.
Questions and answers
- What is DD Form 2164?
- DD Form 2164, X-Ray Verification/Certification Worksheet, November 1978
- Which edition is current?
- Not stated by the publisher
- Who is responsible for this form?
- Not stated
- In which formats can it be downloaded?