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File: 092496_aug96_decls4_0019.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
16:18:09 PATIENT FILE 01/04/91
PERSC14 IL DATA - PRIVAP-Y ACT OF 1974
5 U.S.C. 552 (b)(6)
13. MODE: A
18. AlffHORITY S: 1002AO59 2. SS;L4,.@ 3. PRECMCE: R
4. STAT,. All 5. GRACE: E05 6. AGE: 31Y 7. SEX: M B. WT: 185 9. READY DATE: I
10. ISO: It. POR: 12. SPEC CAT:
14. REAS FTES. DS 15. DATE LAST VISIT. 16. CLASS: 2D
17. @ PKfg,. 19. A.DPT/SLRS DATE: NO
20. APPROV AM: 21. CANC/INC: 22. VALID: ac Y3
23. KTF BRIG: A5150 LISA DISPENSARY DKAWA4 24. ICAO CRIS: DEDR
25. KTF DEBT.- A5030 FPA\VM PLRW Rr) rO 26. ICAO DEST: EDAF
27. MED SPEC 1: SDOL 28. DIAG 1: 7242 LLMAM
29. KO SPEC 2., 30. DIAS 2:
31. MD SPEC 3: 32. DIAG 3:
32A. PRCCEDLIRE:
33. SPEC DIET: N/ 34. IV:
35. 02/LPM: N 36. SUCT: N 37. NS TUBE: N 38. RESP, N 39. FCLEY.- N 40. MYKER: N
C: N 45, TRACH. N 46. MM: N
71. PT BAB TYPE: NB 72. PT BAG TAB 73. PT BAG Wr.
47. SLIPP INFO: A IRSP FT CWKL, KY ///173 M-3//
/ ///85 EVAC/f/
49. IIAX MTE SMPS: Y / 9 49. MAX # RONS: Y / 9 50. ALT REST/MAX HT: N
53. INPATIENT: Y 54. SPEC PROS- VA DRUG ALCCH(P@ WT NO%t x 55. VA CODE-.
56. ADMIN/OVERSEAS:
@S. VITAL S164
S(TEr?/PL7,MRESP/BLOOD PRESS): 098.7 82 /15 / 130 76
59. HGB: 0 . 60. HCT: LI. AEG: DATE TAKEN:
62. RTC: 63. SI/VSI: 64. II.EDICATIM* TYLENCI. 3 PO 93-4 PR PP.11
65. HISTCRY- BACK PAIN X 2 YRS- @IUM SINM ARRIVAL IN AOR - DEEK-MTIVE
CHA\SB ON X-RAY - EVAC FCR FLR@.-M STL'DIESIDIMITION.
66. ATT PHYS: SMIT]I 67. PH#. 000 000 0000 68. WARD#/PHO: OOD / 000 000 0000
69. REPORTED BY: @.A.4S 70. PH#: 000 0000
74. ATMANT NP.F- II: 75. STATUS: 76. 6WE:
77. AGE.- 78. SEX: 78A. WT: 79. REIATI MIP TO PATIENT:
60. BAB TYPE: 81. BAB TAG 82. BAG WT:
93. ATTENDANT NAKE 02: 84. STATUS: 65. GRADE:
86. AGE- 87. SEX: 97A. WT: 88. RELATIO)SHIP TO PATIENT:
91. BAB WT:
92. TRANS CRIG PHONE EXT:
93. TRANS DEST PHOIE EXT:
94. ETA OR16 KTF(DATE/Tll'.E). 000 95. ETA DEST MTF(DATEfTIME): 000
97. DWR @S:
51. NSN #: 0000/001 52. RON LCC:
57. VALIDATED BY/REAS FCR HIBPZR PRECEDENCE:
96. AIRCRAFT ITINMRY:
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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