PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91

File: 092496_aug96_decls4_0022.txt
Page: 0022
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








                  16-18:56                                         ff" PATIENT FILE "H                                              01104/91
                                                          PERR@NJ'L DATA - PRIVPL@ ACT OF 1974

                                                         5 U.S.C. 552 (b)(6)
                                                                                                                                 13. F.ODE: A
           1.  WE.,                                                18. AUTHORITY #: 1002AO55 2. SSIL,4:                          3. P            CE: R
           4.  STAT. All               5. GRADE: E05               6. AGET 37Y           7. SEX@. M         B. WT:        170    9. READY DATE:        I
           10. ISO:                    11. PORs                                                                                  12. SPEC CAT:
           '4. REAS REG: DS            15. DATE LAST VISIT.
                                                                                                                                 16. CLASS: 3A
           17. ACCEPT PHYS:                                                                                                      19. AM/M        DATE: NO
           20. APPROV AUTH:                                                              21. CAN'-/IN.Ps                         22. VALID,                ulc     Y3
           23. MU OR16-. A51!0         LISA DISPENSARY DPA4RN                                                                    24. ICAO CRIS:     OEDR
           25. MV DEST: A5100          PCJERENBERG ACH                                                                           26. ICAO DEST:     BDN
           27. MED SPEC 1: SBO         28. DIAS I- 81400 MM FRA-7M OF                    CARPPIL MNE, LP&ECIFIED
           29. FED SPEC 2.,            30. DIAS 2:
           3'.. 10 SPEC 3:             32. DIAS 3.-
           32A. PROCEDLE :
                      34. IV:  1
           35. 02/LPM: N               36. SUCT:         N   37. NS TLrtE: N             38. RESP: N                      39. FCLEY:             N  40. STRYKER: N
           41. INCUB:           N      42. TRACT: N          43. IMBs N                  44. CAST/LDC: N                  45. TRACH:             N  46. FC)I: N
           71. PT BAG TYPE: NS                               72. PT BAB TAB                                               73. PT BAB VT,
           47. SL?P IKFO.-      173 tED GP, CHICOPEE, r.A                                                         ///173  KED//
           1 ///85 EVAC///
           48. i(AX EMM STCPS. Y / 9                         49. MAX # RO@\'S: Y         / 9                              50. ALT REST/MX HT: N
           53. IWATIENT: Y             54. SPEC PROO:     VA       DRLIS     LCML         I(T     NOE X                   55. VA CODE:
           56. ADIIN/GVERSv-AS:
           59. VITAL SIGNS(TEFP/PLUEIRESP/BLOOD PRESS):               M.8         88 /    18 I    100       72
           59. fGB.-                   60. F.CT:             61. ABS:                                       DATE TAKEN:
           62. WBC:                    63. SI/VSI:           64. DEDICATIONS: NONE




           65. HISTORY: FELL ON WRIST - 9                DEC 90 AT 85 EVA@@ - (          31 DEC 90 LATSC)









           66. ATT PHYS: MARLCW                          67. PH#: 000 000 0000                              68. WARDIIPH#: 000 / 000 000 0000
           69.                  BY*                                                                         70. PHI: 000 0000
           74. AUMYR NAKE #I -                                                                              75. STATLIS:                         76. GRADE:
           77. AGE:                                      78. SEX:            78A. WT:                       79. RELATIONSHIP M PATIENT:
            82. BAB WT:
           83. ATRWANT NAIE #2:                                                                             84. STATM:                           85. G.RM-
           86. ABE:                                      97. SEX:            87A. WT:                       BB. RELATIONSHIP TO PATIENT:
           89. BAB TYPE:                                 90. BAB TAG                                        91. BAG WT:
           92. TRANS CRIS PHONE                           EXT:
           93. TRANS DEST PHONE 0:                        EXT:
           94. ETA CRIB KTF(DATE/71,'C                   Ov4O                                               95. ETA DEST KTF(DATEITIME)A 000
           97. OTHER            S:



           51. r.SN #: 0000/001                                                                             52. RON LOC:
           57. VALIDATED BY/REAS FOR HIGHER PRECEDENCE:                   1
           96. AIRCRAFT ITINERARY.                                                           I

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