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File: 092496_aug96_decls4_0023.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
16:19.10 PATIENT FILE 01/04/91
PMKNAL DATA - PRIVACY ACT OF 1974
5 U.S.C. 552 (b)(6) 13. MODE: A
1. NAME.- 18. AUTHORITY #% 036OA041 2. rAN 3. PRECEDMM.- R
4. STAT: All S. GRADE: C04 6. AGE: 27Y 7. SU: M S. MT: 160 9. READY DATE: 360
10. ISO: 11. POR: 12. SPEC CAT:
14. REAS REG,. DS 15. DATE LAST VISIT: 16. CLASS: 3A
17. ACCEPT PHYS,. M 19, (LPPT/SLTiS DATE: NO
20. APPROV ALR: 21. CKN:IINC: 22. VALID: Tv'H Y6
23. MTF DRIS: A5150 USA DISPDWY D.@4 24. ICAO DR16: BEDR
25. KTF DEST, A5030 FRi%ItVM ARKY REG MED 26. ICAO DEST. EDAF
27. MED SPEC 1: STJ 28. DIAS 1. 6089 LTMECIFID DISORDER CF NU BBITAI@ ORGANS
29. M SPEC 2: 30. DIAS 2:
31. rLD SPEC 3i 32. DIAG 3:
32A. PR[r.EOL'RE:
33. SPEC DIET: NI 34. IV:
39. FDM: N 40. STRYKER: N
41. INCUB: N 42. TRACT: N 43. IF.ED-. N 44. CAST/LOC.- N 45. TRACH: N 46. rON: N
71. PT BAB TYPEs NB 72. PT BAB TAB 73. PT BAB 67:
47. SIJPP IWGI HHE 24AD 3/69 FT STEWART, GA // COWORT
48. KAX STOPS: Y 9 49. KAX t RUNS: Y / 9 50. ALT REST/KAX HT. N
53. INPATIENT: Y 54. SPEC PROS: VA DEM WT NONE X 55. VA CODE:
56. ADMIN/OVERSEAS:
58. VITA'- SIrN@'S(TEKO/@/RESP/BLCOD PRESS): Ogr7.0 64 / 20 / 110 80
59. HBR.- 60. H.T.- 61. ABBs DATE TAKE]I:
62. WBC: 63. SI/VSI: 64. MMICAT104So ELAVIL 25MG PC HS, ?.OTRIN 60OFS PO
TID
65. HISMRY: Mff OF AOR FCR PAIN EVALUATION/CUNIC
bb. ATT PliYSo CHRISTIAN 67. PK: 000 DOD 0000 68. WARD#/PHI.- 000 / 000 000 0000
69. REPORTED BY: DREYER 70. PH#: 000 0000
74. ATTENDANT NK #I: 75. STATUS: 76. ME.-
77. ABE: 78. SEX: 78A. WT: 79. RELATIONSHIP TO PATIENT:
80. BAB TYPE: 61. BAB TAB 82. BAB WT:
83. ATrMik4T N;L%E #2: 84. STATLIS., 85. GRADE:
86. AGE- 87. SEX-. 07A. WT- 88. RELATIO.6HIP TO PATIENT-.
89, BAG TYPE: 90. BAG TAB 91. BAB WT:
912. TRANS CRIS PH',.NE EXT:
93. TRA.,IS DEST PHCNE EXT:
94. ETA CRIS KTF(DATE/TIrE): 000 95. ETA DEST KTF(DATE/TIME): 000
97. OTHER S:
51. rsN #. OOMIMO 52. RO.4 LrC:
57. VA.IDATED BY/REAS FOR Hlbl-ER PRECEDENCE:
96. AIRCRAFT ITINMY:
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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