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File: 092496_aug96_decls4_0028.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
16:20:25 ffn PATIENT FILE H" 01104/91
PBM\'AL DATA - PRIVACY A.T GF 1974
5 U.S.C. 552 (b)(6)
13. ICDE: A
1. WE: 18. ALU.MITY #: 1002AO82 2. SBAN: @ 3. PRECEDENCE: R
4. STAT: All 5. GRADE: EOB 6. AGE: 42Y 7. SEX: M B. WT: 150 9. READY DATE-. 2
10. ISO: 11. POR: 12. SPEC CAT:
14. REAS RES,. DS 15. DATE LAST VISIT: 16. CLASS: 3A
17. AMEPT PHYS. 19. APPT/SLRS DATE. NO
20. APPROV AUTH: 2t. CA.%'C/IN.': 22. VLIO: I imc 1 Y5
23. @ CRIS, A5150 USA DISPENSPLRY DRA..@ 24. ICAD CRIS: DOR
25. MTF DEST: F5070 LTBAFRME WIESBADEN BE 26. ICAO DEST: DAr
27. P.-3 SPEC 1: SOOL 28. DIAS I- 7242 LUMBAM
29. ?B SPEC 2: 30. DIAS 2:
31. Ka SPEC 3: 32. DIAS 3-
32A. PROCED@'RE:
53. SPEC DIET: W 34. IV:
E: N 38. RESP: N 39. FOLEY: N 40. STRYKER: N
'I. INM: N 42. TRACT: N 43. IF@ED-. 1 44. CASTILOC: N 45. TRADI.- N 46. MCN: N
71. PT BAB TYPE: NB 72. PT BAG TAG 73. PT BAB W'To.
47. SUPP INFO: HSB 1/32 IMF 101 FT CA*BELL, KY //44 KED//
//28 CSH//
'S. ?AX EL
@ STOPS: Y 9 49. MAX # RONS: Y 9 50. ALT FtEST/MX HT. N
53. INPATIENT: Y 54. SPEC PROS. VA DRUG @OL WT NONE x 55. VA CODE:
--S. AD.IIN/CVMFtQ:
58. VITAL SI M(TEMP/PLrLSE/RESP/B'@OOD PRESS): 098.6 64 16 / 110 82
59. HSB: 60. iCT- 61. ADS.- DATE TAKEN,
62. AC: 63. SI/VSI: 64. MOICATIENS: MOTRI,% BOOP.6 TID, FLEXERIL IOMB TID
65. HISTCRY: ONE YEAR HISTOW RECLMM LBP. WDM SINCE ARRIVAL. NOT RESMIZI
'@3 TO TREATKW.
6o. ATr PifYS: STOW-AL 67. P)I#, 999 999 9999 68. MOIF140., 999 / 999 979 9999
69. REPORTED BY, SST ABBOTT 70. pH#: 999 9999
7.'. ATrENDPL'iT ';AE #I: 75. STATUS: 76. MOE:
77. AGE: 78. SEX: 78A. WT- 79. RAATIMVIP TO PATIENT:
ZO. BAB TYPE: 81. BAB TAG 82. BAB NT:
84. STATUS: 85. GRADE:
Eb. AGE. 87. SEX: 87A. WT: 88. RR-ATI(I',SHIP TO PATIENT:
S9. BAB TYPE. 90. BPS TAB 91, BAB Ifr.
92. TRA.NS ORIS PHO,'C #t EXT-
93. TRANS DEST PH@@K-: 1: EXT-
9,. ETA DR16 MTF(DATE/Tir.E): 000 1 95. ETA DEST MV(DATE/TlFa-): 000
97. O@'.M CO.MENTS:
5@. MEN S. 00001002 52. RON LOC.
57. VALIDATED BY/REAS FOR HMER PRECEDENCE:
96. AIRCRAFT ITI%MRY: I
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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