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File: 092496_aug96_decls4_0024.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:IR:25 PATIENT FM .. 01/04/91
PERSOYL DATA - PRIVACY A"-T OF 1974
5 U.S.C. 552 (b)(6)
13. MDDE: A
1. NW: 18. AUMITY 0: 1002AD76 2. SSAN:mm 3. PRECEDENCE: R
4. STAT: All 5. GRADE: WOS 6. AGE, 37Y 7. SEX.- M 8. 6T: 14B 9. READY DATE: 2
10. ISO: 11. POR: 12. SPEC CAT:
14. REAS RES: DS 15. DATE LAST VISIT: 16. MM: 3A
17. A@ PHYS: 19. APPT/SURB DATE- NO
20. APPROV AUTH: 21. rA\,C/l@- 22. YPILID- x Y5
23. KTF CRIS: A5150 USA DISPENSARY @V 24. ICAO DRIG: GEDR
25. KTF DEST, A5040 21@ BEN HOSP LA 26. ICAO DEST: ECAR
27. MD SPEC I.@ SSCV 28. DIAS I -. 4462 HV@ITIVITY P.NGIITIS
29. NED SPEC 2: 30. DIAS 2-
31. MD SPEC 3: 32. DIAS 3-.
32A. PROCEDUREI
33. M DIETT W 34. IV:
39. FOIP: N 40. STRYKERI N
41. Itaffli N 42. TRACT.- N 43. IMED: N 44. W/LBC: N 45. TRADI: N 46. MON: N
71. PT BAB TYPE: 6 72. PT M TAB 0. 73. PT BAB LIT,
47. SUPP IttM: HiT 2/17 CAV 101 ABt FT CILIVBELL, KY 1/44 toll
//28 CSH//
48. MAX EVM STCPS: Y 9 49. MAX # RMi Y 9 5D. ALT REST/rAX HT-. N
53. INPATIENT: Y 54. SPEC PROG- VA DRLIG ALCMM VT KO.\E X 55. VA CODE-
56. ADMIN/@EAS:
59. VITAL SIG'4S(TEYP/PLP@E/RESP/BLLOD PRESS): 098.6 72 12 / 120 80
59. HBB. 60. ICT.- 61. ABS- I I I DATE TAKei-,
62. WBC. 63. SI/VSI- 64. MEDICATICIS- PREDIISCME 40MG PO DAILY
65. HISM: EPISODIC IIZED , ARTRLBIAS PARESTHESIAS. OROLOGY
EVAL RE@;DED @.ATOLOGY EVA. FOR COT.NMIVE TISMFR. DISEASE. EVAL TO C
CNSU FCR MMTOLOSY EVAL AND DETEMNATICV OF FLIGHT STATLIS.
66. ATT ?JiYg: YOST b7. PHO: 999 999 9999 ba. WWI/pH#: 999 / 999 999 9m
69. REPORTED BYi SbT ABBOTT 70. PHS: 999 99?9
74. ATTENDANT %IT #I: 75. STATUS.- 76. GRADE:
77. ABE: 78. SEX- 7BA. WTt 79. RELATIONSHIP TO PATIM:
81. BAB TAG 82. BAG WT.
83.A NAME #2: 84. STATUS: 85. GRADE.
e6. AGE: 97. SEX- 87A. WT: 88. RELATIC.NSHIP TO PATIENT:
B9. BAB TYPE: 90. BAB TAG 91, BAB WT.-
92. TRA.'IS DRIS PHO\'-P EXT:
93. TPASS DEST Pko\'E EXT:
94. ETA G.RIS KTF(DATEtTIt'E)- 000 i 95. ETA DEST ?U(DATEtTIKE): 000
97. OM CCMFB'RS.
5@. MSV O.- 00001002 52. Ra@ LOC:
57. VALIDATED BY/REAS FOR HIGHER PRECEDENCE: f
96. AIRCK-T 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