PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91

File: 092496_aug96_decls4_0027.txt
Page: 0027
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








                    16.20:08                                               PATIENT FILE                                               01/04/91
                                                               MzU@ DATA - PRIVACY ACT OF 1974

                                                                   5 U.S.C. 552 (b)(6)
                                                                                                                                13.   FBDE: A
                1. NAME:                                          18. NJTP.-3RlTY #: 1002AO78 2. rA4:                           3.    PRECEDDZCE: R
                4. STAT:  All          S.  ME: E04                 6. ASE: 21Y          7. SEX.- M            S. WT.    170     9.    READY DATE:        2
           .0.  ISO:                   11. POR:                                                                                 12.   SPEC CAT:
           14.  REAS RES: DS           15. DATE LAST VISIT:                                                                     16.   CLASS: 3A
           17.  AMM PHYS.,                                                                                                      19.   APPT/SURB DATE: N3
           20.  ikOPROV AUTH:                                                         21. CA,%C/INC@.                           22.   VALID:                 JY.@@  Y5
           23.  MTF CRIS: A5150        LroA DISPENSARY DFA@                                                                     24.   ICAO CRIB:     DEDR
           23.  M7 DEST: F5070         LOM@' WIESBADEN GE                                                                       26.   ICAO DEST:     EDAF
           27,  ?B SPEC 3. SOO         28. DIAS 1. 7241        PAIN IN TMCJC SPITZ
           29.  @ SPEC 2-              30. DIAG 2:
           31.  MED SPEC 3:            32. DIAG 3:
           32A. PROCEDLRE:
           33. SPEC DIET:              NI                                              34.  IV:
       N         37. NG TLIBE: N         38.  RESP: N                        39.  FC@:         N       40. STRYKER: N
           41.  INCUB.       N         42. TRACT: N            43. IIO: N              44.  CAST/LCC: N                    45.  TRACH:       N       46. MC'4.- N
           71.  PT BAB TYPEI NB                                72, PT BAB TAB                                              73.  PT BAB WT.
           47,  SLPP INFO: HSC 426 SNS 101 AB, FT              CA?PBELL, KY                                       1/44 MD//
           1128 CSH//
           A.   MAX ERM STCPS: Y / 9                           49. r.AX # RO%'SI   Y  / 9                                  50.  Al-T REST/MAX RT.- N
           53.  ItJ'ATIEttr: Y         54. SPEC PRGO,          VA  ERLr3      LMHUL         WT     NONE X                  55.  VA GODE:
           56.  ADMIN/DVMEAS:
           .8.  VITAL SIGNS(TEV/PLP3E/RESP/BLOn.D PRESS): 097.6                    64 /     16 /    90        62
           59.  HBBI                   60. ICT.                61. ABB.-                    i            I DATE TAKEN:
           62.  WBC-.                  63. SI/VSI:             64. KEDICATIDNS% Nj.,Z




           65.  HISTORY: 120D P@           FELL ON PATIENT'S BACK AT FT tWBEa, KY IN SEP 90. S
           'ILL WITH @ PAIN. REQUEST B@T SCA-4 A?@ F,,ql M OJT DIAG\'GSIS.








           66.  ATT PWS.- HOPKIN3M                   b7.       PR#: 999 "9 9999                          b8.  WA@IPH#:          "9 / 999 9" 9999
           69.  REPORTED BYs SBT ABBOTT                                                                  70.  Plit: 999 9999
           74.  AnBMP.4T @- #I:                                                                          75.  STATUS:                           76. GRADE.*
           77.  ABE:                                 78.       SEX:           78A. VT:                   79.  RAATIC"&IP M PATIENTs
 BAB WT-
           B3.  ATTWkliT     Nk'E #2:                                                                    84.  STATLIS:                          85. GRADE.%
           86.  AGE:                                 87.       SEX:           Er7A. 6'T:                 88.  RELATIONMIP TO PATIENT:
           89.  BAB TYPEJ                            90.       RAS TAB #.o                               91.  BAB WT.*
           92.  TRANS DRIS   Pii@kt                            EXT:
           93.  TRANS DEST   PH04E                             EXT:
           94.  ETA ORIS KrF(DATE/TIM-:). 000                                                            95.  ETA DEST MV(DATEITIME). 000 1
           97.  OTHER                  to



           51.  14SI #. 0000/002                                                                         52.  RON LOC:
           57.  VALIDATED BY/REAS FOR HI             PRECEEN:E:
           96.  AIRCRAFT ITINMRY:

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