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File: 092496_aug96_decls4_0013.txt
Subject: PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91
Unit: ARCENT
Parent Organization: CENTCOM
Box ID: BX000460
Folder Title: MEDSTAT- SITREPS - JANUARY - 1
Document Number: 10
Folder SEQ #: 2
16 16.- 35 o" PATIENT FILE 01/04/91
P@MVL DATA - PRIVACY ACT OF 1774
5 U.S.C. 552 (b)(6) 13. M3DE: A
1. NAME: 18. AUTHORITY *: 1002AOI2 2. SSAN: 3. PRECEDDA: R
4. STATT All 5. G.WE.- E09 6. ASE: 44Y 7. SEX: M 8. WT: 190 q. READY DATE. 2
10. ISO: 11. POR: 12. SPEC CATs
14. REAS R:G: DS 15. DATE LAST VISIT: 16. CLASS: 3A
17. ACCEPT PHYS: M 19. APPT/SLIRG DATE: NO
20. APPROV AUTH: 21. CAN'-/ItF.: 22. VALID: LlfK Y3
23. KTF CR16: A5150 USA DISPBMY DKk@ 24. ICAO BRIST OSR
25. KTF DM: A5030 FPAILVMT ARMY REG ?S 26. ICAO DEST: EDAR
27. MD PM It M 28. DIAS I-. 5UII DIVERTICULITIS OF COLON
29. MED SPEC 2., MMS 30. DIAS 2.o 5641 IP.RITABU CC'.ON
31. MED SPEC 3: 32. DIAS 3:
32A. PROCULRE.
33. SPEC DIET: NI 34. IV:
39. FMU: N 40. STRYKER: N
41. lNaM: N 42. TRACT: N 43. M: N 44. CAST/LDC: N 45. TRACH: N 46. M04: N
7',. Fq NG TYPE- ta 72. PI BAS TAB 4- 73. PT BAG Z-
47. SUPP I.VG: *"DESERT S41 REPORTED FROM 28 CM
48. PAX EN.M STOPS: Y / 9 49. PAX # RM: Y 9 50. PILT REST/MAX IfT: N
5-7. I.VATIENT: Y 54. SPEC PROO: VA D.RUS ALCOHOL WT NC'v'E X 55. VA COD--@i
Z6. AD.4IN/OVERSEAS:
.3. VITAL SIM(TEKO/PUMRESP/BLOOD PRESS): 098.6 88 16 / 130
57. HGB, 60. HCTT 61. Mt I f I DATE T@,.
62. WBC: 63. SI/VSI.- 64. MEDICATIONS: KO.NSYL 'TAB BID, LLPRECANO OTK2iT P
R';, L(R.OTIL 2TAB PO DID
65. HISTORY: PT NONE FLI%".TIONAI- DUE TO SEVERE L. DIJAD PAIN, M DIPL@- . NO Ikc
ECTICLS CYTOLMY FUM.
66. ATT PHYS-. MM 67. PKI- 000 000 0000 68. WAPL#IPR#, 000 000 000 0000
69. REPORTED BY: EMNT ". PH#: 000 0000
74. ATT@OA%7 NAME #I: 75. SRATLIS: 76. 6MMs
77. AGEO 78. FJ: 78A. WT: 79. RELATIONSHIP TO PATIENT:
80. BAS TYPE: 81. BAS TAB 82. BAG WT:
84. STATLIS: 85. MEs
86. A55: 97. SEX: 87A. WT: 80. RELATIMSIP M PATILNT:
89. Bri TYPE% 90. BAR TAB 4. 91. BAS WI-.
92. TRi!L49 CRIB PH04E EXT:
93. TRANS DEST PICIC EXT:
3@. ETA BRIG MTF(DATE/Tl?',E): 000 95. ETA DEST KTF(DATE/TIME): 000
97. OTIER CC@:
51. ?E4 1, 52. RGII L(IC:
57. VALIDATED BY/FtFAS FOR HIMO PRECEDENCE:
96. AIRCRAFT ITINERARY:
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Document 31 f:/Week-31/BX000460/MEDSTAT- SITREPS - JANUARY - 1/personal data privacy act of 1974 4 jan 91:09209615580712
Control Fields 17
File Room = aug96_declassified
File Cabinet = Week-31
Box ID = BX000460
Unit = ARCENT
Parent Organization = CENTCOM
Folder Title = MEDSTAT- SITREPS - JANUARY - 1
Folder Seq # = 2
Subject = PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91
Document Seq # = 12
Document Date =
Scan Date =
Queued for Declassification = 01-JAN-1980
Short Term Referral = 01-JAN-1980
Long Term Referral = 01-JAN-1980
Permanent Referral = 01-JAN-1980
Non-Health Related Document = 01-JAN-1980
Declassified = 20-SEP-1996