PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91

File: 092496_aug96_decls4_0004.txt
Page: 0004
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








                  16.13:56                                         H" PATIENT FILE                                                  01/04/91
                                                          PERSOXT DATA - PRIYtr-Y ACT CF 1974

                                                                        5 U.S.C. 552 (b)(6)
                                                                                                                                 13. MODET A
              1. NAVE:                                           19. AUT)J.GRITY #: 1002AO53 2. SEP,14:@                         3. PRECEDOM: R
              4. STATE All           3.  GRADET E04              6. AGE: 27Y             7. SEX: M          B. WT:    190        9. READY DATE,.      I
              10. IM:                11. POR:                                                                                    12. SPEC CAT:
              14. R:AS REG: DS       15. DATE LAST VISIT:                                                                        16. CM-. 3A
              17. ACCEPT PHYST                                                                                                   19. APPT/@RS DATE: ND
              20. APPROV AUTH:                                                      21. CA,%C/I%'Z:                              22. VAI@ID:               in@-   Y3
              23. MTF CRIB- A5150 LSA    DISPENSARY D@                                                                           24. ICAB DRIG:    OOR
              25. Mrr DEST* A5040    2t@ BEN H3SP LTLIMSRM                                                                       26. ICAO DEST:    EDAR
              27. MED SPEC I.- SM    20. DIAS 1: 7242         LLMAGO
              29. KO SPEC 2-         30. DIAS 2.,
              31. MED SPEC 3:        32. DIAS 3:
              32A. PROCEDURE:
              33. SPEC DIET:         NI                                             34. TV-
 38.  RES.P: N                        39. F[P@EY:       N     40. STRYKER: N
              41. INCUB:             .4 42. TRACT: N          43. IM.ED: 4          44.  CAST/Lg@@. N                    45. TRACH:        N     46. MON: N
              71. PT BAG TYPE: NB                             72. PT BAB TAS                                             73. PT BAG WT-
              47. SUPP I*'Oi 988 SLIPPLY,    MIN GA                                                             ///173   KED//
              / ///85 EVA:///
              48. IIAX ERM STGN: Y / 9                        49. F.AX # RC%S: Y         9                               50. ALT FZESTI?IAX HT: .4 1
              53. INPATIENT: Y       54. SPEC PROS:       VA     DRUG       ALCCHU@      NT       NM        X            55. VA CODE:
              56. ADMIN/@SEAS:
              59. VITAL SIM(OP/PLLSE/RESP/BLCM PREM): 096.8                        60    16 /     92        60
              59. HGB:               60. HCT:                 61. ADS:                                      DATE TAKEN:
              62. WrL:               63. SI/YSI:              64. 4alCATILNS: MOTRIN BOOYZ TID




              65. HISTORY: L LFPER EXTREMITY PAIN & PARE@IA - EXkli SUGGESTIVE C-8
              RADICLLG?ATHY - EVAC M EISE*IOWER AMC FO.1 TREATKW.








              66. ATT PHYS: LEEDI                  67. PHt.- 000 000 0000                              68.  WkRD#/PH#; 000 / 000 000 0000
              69. REPORTED BY:           'S                                                            70.  PH#: 000 0000
              74. ATTENDfLN7 NArt #I-                                                                  75.  STATUS:                            76. MDE:
              77. AGE:                             78. SEX:                 78A. WT.                   79.  RELATIONSHIP M PATIENT:
              80. BAB TYPE:                        81. BAB TAG                                         82.  BAB WT:
                                          84.  STATLIS.                           85. SM:
              86. AGE:                             97. SEX:                 07A. WT:                   88.  RELATIONSHIP TO PATIENT:
              89. BAB TYPE:                        90. BAS TAB 1:                                      91.  BAB WT:
              92. TRANS BRIG         PH.I%E               EXT:
              93. TRANS DEST         PHONE                EXT:
              9,. ETA CRIS ?ff(DATEITIKE). 000                                                         95.  ETA DEST KTF(DATE/TIME): 000
              97. OTHER CO @:



              51. rSN #: 0000/001                                                                      52.  REN LGC:
              57. VAI.IDATED BY/REAS FOR HIGHER PRECEDENCE:
              %. AIRCRART ITINERARY:

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