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File: 092496_aug96_decls4_0017.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
PATIENT FILE 01/04191
PER-CQML DATA - PRIVACY ACT CF 1974
5 U.S.C. 552 (b)(6)
13. MODE: A
18. ALRHGRITY #: 0364AOI5 2. SSAN:@ 3. PRECBENCE- R
4. STAT: All S. GRADE- E03 6. AeE.- 23Y 7. SEX: N 8. WT- 148 9. READY DATE. 364
10. ISO: It. POR: 12. SPEC CAT:
14. REAS REG: DS 15. DATE LAST VISIT: 16. aM i 3A
17. ACCEPT PHYS: 19. APPT/SLRB DATE: .40
20. APPROV AUTH: 21. CAWINC: 22. VALID: LMK Y3
23. KrF CRIS: A5150 LSA DISPENSARY DFA4RAN 24. ICAO ORIG: CDR
25. NTF DEST: A5040 Z13 GEN HOSP 26. ICAO DEST: EDA.R
27. P@EI) SPEC 1-. 900 28. DIAS 1: 7242 LLWASO
29. MZD SPEC 2: 30. DIAG 2:
31. PS SPEC 3: 32. DIAG 3e.
32A. PROCEDURE.
33. SPEC DIET: N/ 34. IV:
N 3B. RESP: N 39. FOM: N 40. STRYKER: N
41. INCIJB: N 42. TRACT- N 43. IMED: N 44. CAST/LOC: N 45. TRADit N 46. MD'4: N
71. PT BAB TYPE: 72. PT BAB TAG t. 73. PT BAB WT:
47. SUPP TWO.- FT BDNINS, GA //SUB JMO/i
//FLEET 5//
48. FAI ENRTE STCPS, Y / 9 49. KAX # RCNS: Y 9 50. ILIT REST/KAX RT- N
53. INPATIENT: Y 54. SPEC PROS: VA DRLra ALCDIML WT NM X 55. VA CODEs
56. ADMINIOVERSEAS:
58. VITAL SIGW(TEKO/PLr.BE/RESP/BLCdJD PRESS): 096.9 88 12 / 140 1 88
59. HGB: 60. R-7: 61. ARG: / DATE TAKEN-
62. WBC: 63. SI/YSI: 64. MEDICATIONS- TYLENIL #3 2 TABS 94H PRN
65. HISTGRY: PATIENT IN.TM LEFT Kk'@ WHILE @CRKINS IN Ti%%X 25 DEC.
Sial INJL.RY.
66. ATT PHYS: FRASSICA 67. PHI: 999 999 9999 68. WARD#/PH#: 999 1 999 999 9999
69. REPORTED BY: SOT ABBOTT 70. Pi6: 999 9999
74. ATTENDA4T KM #I: 75. STATUS: 76. G.WE-
77. ABE: 78. SEX: 78A. WT: 79. RELATIONSHIP TO PATIENT:
80. BAG TYPE: 81. BAG TAG 82. M WT:
84. STATLIS: 85. GRADE.
86. ABE: 87. SEX: 87A. WT: 88. RELATIONSHIP TO PATIENT-
69. BAB TYPE-. 90. BAB TAB 91. BAB WT:
92. TRANS CRIS PHOkl #s EXT:
93. TRA.4S DEST PHM #: EXT:
94. ETA OR16 WIDATE/Tiri); 000 95. ETA DEST ?.U(DATE[Tlrc): 000
97. GM Be
51. MS.N #i OOOD/364 52. Rf.q LO@@s
57. VALIDATED BY/REAS FCR H16w.ER PFTECEDENCE:
96. AIRCRAFT ITIN-=MY:
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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