PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91

File: 092496_aug96_decls4_0016.txt
Page: 0016
Total Pages: 31

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







                  16:17:19                                               PATIENT FILE                                                01/04/91
                                                             PBSOVL DATA - PRIVACY ACT OF 1974

                                                                  5 U.S.C. 552 (b)(6)
                                                                                                                               13.   KDDE% A
               NARE:                                              19. AUTH-.RITY #: 0365AO35 2. SSAN-.@                        3.    PRECMCE: R
               STATs All               5. BRADE: E04              6. ABE.- 22Y           7. SEX: M          S. WT-.   155      9.    READY DATE: 365
          10.  ISO.&                   11. PG.R.,                                                                              12.   SPEC CAT.,
          14.  REAS REG- DS            15. DATE LAST VISIT:                                                                    16.   CLASS: 3A
          17.  ACCEPT PHYS,            JM                                                                                      19.   APPT/Sl)RG DATE: NO
          20.  APPROV AIJTH:                                                         21. CANC/Itr-,.                           22.   VLIID:                SMF     Y2
          23.  MTF BRIG., A5150        USA DISPENSARY   DWM4                                                                   24.   ICAO CRIS:     CEDR
          25.  eff DEST: A5100               ERG ACH                                                                           26.   ICAO DEST,     EDDN
          27.  FED SPEC 1: SOD         2B. DIAS 1. 71783 D-D      DISRUPTION OF ILNMIOR CRUCIATE LISAMff
          Z9.  rED SPEC 2-             30. DIAS 2:
          31.  RED SPEC 3:             32. DIAS 3:
          32A. PROCEDURE:
          33.  SPEC DIET:     W                                                      34. IV:
7:        N    37.  NS TUBE: N         38.  RESP, N                         39. FCLEY:          N     40. MRYKER: N
          4!.  INAIB:       N          42. TRACT- N          43.  IKED- N            44.  CAST/LGC: N 1                   45. TRACH-.         N     46. r.CN: N
          71.  PT BAG TYPE,            NB                    72.  PT BAS TAG                                              73. PT BAB WT:
          47.  Su?P lit@Ut K4r-16 ENSR TLN-MW BE //               FLEET 5///

          4B.  KAX ENRTE STCPS.- Y / 9                       49.  MAX 4 FZON$T V         9                                50. ALT RESTIPAX KT, N
          53.  IMPATIENT: Y            54. SPEC PROS:        VA   D%S        LICOKOL      WT      K3KE X                  55. VA CODE:
          55.  ADIIN/GVERS M
          @s.  VITAL SIGNS(TErJ'/PLP-SFJRESP/BLCOD PRESS). 096.4                   72     12 /    110       60
          59.  ICB:                    60. HIT:              61. ABB.-                                      DATE TAKM:
          62.  WBC:                    63. St/VSI-.          64. TOICATIM:
          K'-.%'E



          65. HISMRY: S/P ACL REPAIR - PATIENT REINJL?D RISK @ 31 DEC 90 -
          PATIENT REGUIRES Kh'-PE SURGMY AND REHAB








          1>6. ATT PliYS: WILKERS                       67. PR#, 473 647 3674                           68.   WARD#/PH': 364         736 473 6743
          69.  REPORTED BY: DREYER                                                                      70.   PH#. 849 @q849
          74.  ATTENDANT NKN.E #I:                                                                      75.   STATUS:                           76. GRADE:
          77.  AGE:                                     78. SEX:             78A. WT:                   79.   RELATIONSHIP M PATIENT:
          83.  RAS rfPE:                                St. RAS TAG 1:                                  B2.   BAB WT.,
 STATUS:                           85. MEE:
          86.  ABE:                                     87. SEX:             87A. WT:                   88.   RELATICNSHIP M PATIENT:
          89.  BAB TYPE:                                90. BAG TAG                                     91.   BAB WT:
          92.  TRANS ORIS FliG%E #s                          EXT:
          93.  TM     DEST PHM #:                            EXT:
          94.  ETA ORIS MTF(DATE/TIME): 000                                                             95.   ETA DEST KTF(DATE/TIKE): 000
          97.  MNER



          5!.  MSN #: 0000/365                                                                          52.   R@'.1 LOC.
          57.  VALIDATED BY/REAS FOR HI&.ER PREMENCE:
          96.  AIRCRAFT ITINSMY:

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