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File: 092496_aug96_decls4_0018.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
16:17*52 PATIENT FILE i*if 01104/91
PERSD'G IL DATA - PRIVACY ACT OF 1974
5 U.S.C. 552 (b)(6)
13. MODE: A
1. NAME- 18. AUTHORITY #., 0365AO32 2. SSAN: 3. PRE R
4. STAT: All S. GRADE: E04 6. AGE- 21Y 7. SEX- K S. WT: i5O 9. READY DATE: 365
10. IS03 11. PC-R.- 12. SPEC CAT-
14. REAS REGI DS 15. DATE LAST VISIT: 16. CM: 3A
17. @T PHYS: JVM 19. APPT/SLRB DATE.- NO
20. APPROY AlfTH: 21. CANC/ItC: 22. VALID: SY.; Y2
23. MTF ORIS: ASISO USA DIPMARY DKBMN 24. ICAB DRIS: BOR
25. rV DEST: A5040 Zl@ GEN HOSP LKMSTLWL 26. ICAD DM : EDAR
27. MED SPEC 1: MM 2B. DIAS 1: 7802 SYNCDPE AND COLLAPSE
29. MM SPEC 2: 30. DIAS 2:
31. MED SPEC 3: 32. DIAG 3:
32A. PROMURE:
33. SPEC DIET.# NI 34. IV:
TUBE: N 38. RESP- N 39. FUEY: N 40. STRYKER: N
4'.. INDJB: N 42. TRACT: N 43. IMM: N 44. CAST/LBC: N 45. TRACHI N 46. MC%': N
7'. PT BAG TYPE: NB 72. Fr BAG TAG #: 73. PT BAG WT:
47. SLIPP INFO: D CO 6/101 Fr CAIPBU, KY /// FLEET 5///
48. MAX EKRTE STOPS. Y / 9 49. MAX # RCNS: Y 9 50. k'T REST/F.AX HI: N
53. INPATIENT: Y 54. SPEC PROS: VA DRLIS ALCDHOL WT NM x 55. VA CODE:
Zb. ADMIN/DVERSEAS.
EB. VITAL SIM(TEr?/PLLSE/RESP/BLMD PRESS): 098.0 70 18 / 110 / 70
59. HGB: 60. HCT- 61. ABS: / DATE TAKEN:
62. Wir.: 63. SI/VSI: 64. MEDICATIONS: D@IN 300ro DID
65. HISTORY: HISTORY CF BLACKOUT WITH LhWkN ORGINS - LAST BLAD(CUT 26 DEC90
PATIENT REGUIRES EEG, CT SCAN AND MD - DOCTOR RECGM@ LA.IMM3.
66. ATT PHYS: PHAM 67. PH#: 894 056 9M 68. WA.RD#/PHS: 904 / 504 959 0450
65. REPORTED BY,. DREYER 70. PHI: 056 90M
74. AnB@kNT NAME *le 75. STATUS., 76. ME:
77. A3Et 78. SEX: 78A. IfT: 79. RELATI(INSHIP TO PATIENT:
60. BAG TYPE: 81. BAG TAB 82. BAB MT:
84. STATUSI 85. GRADE:
96. AGE: 87. SEX: 67A. WT: 88. RAATI MIP M PATIENT.,
89. BAB TYPE: 90. BAG TA3 91. BAG hT:
92. TRANS DRIS PHG\'E EXT:
93. TPAIZ DEST PHCNE 0: E)CT:
94. ETA GRIS MTF(DATE/TIME): 000 95. ETA DEST KT(DATE/TIME): 000
97. OTHER S:
51. )iS.N #: 0000/365 52. RON LOC:
57. VALIDATED BY/REAS FCR HI M 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