PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91

File: 092496_aug96_decls4_0005.txt
Page: 0005
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








                 16:14:11                                   *t" PATIENT FILE                                           01/04/91
                                                           PERSU'A'@ DATA - PRIVACY ACT 0-- 1974
                                                                      5 U.S.C. 552 (b)(6)
                                                                                                                   13. MODE: A
             1. NkE.                                       18. ALP.CRITY #: 1002AO51 2. SSi%14:                    3.  PRECEDENCE: R
             4. STAT: All          5. GRADE: E04           6. ASP-: 25Y          7. SEX: N         S. WT:   170    9.  READY DATE.      I
             10. ISO:              11. PDR-                                                                        12. SPEC CAT:
             1,. REAS REG: DS      15. DATE LAST VISIT:                                                            16. CLAM: 3A
             :7. AOCEPT PHYS:      JFRB                                                                            19. APPT/SLIRS DATE: N3
             20. APPROY AUTH-                                               21. CANC/INC:                          22. VLI ID:              X      Y3
             23. KTF BRIG, A5150   LISA DISPENSARY DWMN                                                            24. ICAB CRIG:     OUR
             25. MV DEST: F5070    LISACM@. WIESBADEN 6-c                                                          26. ICAO DEST:     EBAF
             27. PS SPEC 1: SOO    2B. DIAS 1: 81500 CLOSED FRA6-WE OF      KETACA.RPAL BC.NE(S), SITE MMIFIED
             29. 14.ED SPEC 2i     30. DIAS 2:
             31. MED SPEC 3-       32. DIAG 3:
             32A. PROCEDB.RE:
             33. @C DIET:          NI                                       34.  IV:
             35. 02/LPM: N         36. SIL'7.   N          37. NS ME. N     38.  RESP: N                      39.  FOLEY:     N       40. STRYKER: N
42. TRACT: N           43. IMED: N      44.  CAST/LOC- N                  45.  TRADI:     N       46. M04: N
             71. Pi BAB TYPE-                              72. PT BAG TAB   #:                                73.  PT BAG WT:
             47. SUPP INFO: 248TH TRANS 00 PHOENIX,        AZ /// 85TH EVAC ///

             48. VAX ENRTE STOPS: Y / 9                    49. FAX I ME: Y       9                            50.  ALT REST/FAX HT: N
             53. INPATIENT: Y      54. SPEC PROS:          VA DRL'S   ALMHOL     WT     NM x                  55.  VA COD@-:
             56. ADIIN/WBSW.-
             .9. VITA'@ SIG'Z(TeP/PLLSEIRESPIROOD PREM). 098.6 1            60   18 /   106        74
             5?. HGB:              60. HIT:                61. ABST                                DATE TAKEN-
             62. W'BC.             63. SI/VSI:             64. MOICATIONS: NO.N'E




             55. HISTCRY:          LD7 @ID FRACTURE CLRFORY IN CAST - PATIENT CAKNOT PUT ON PR
             OTECTIVE FASK         -    WHEN PATIENT FELL DLIRlh'3 DO@N DL'RING PT.








             66. ArT PHYS:         IELD         67. PH#: 473 893 8498                        68.   WARD#/PP.I: 349 / 894 394 38W
             69. REPORTED BY: @O                                                             70.   PH#: 473 8847
             7,. ATTENDANT Kk@ 01:                                                           75.   STATUS.                       76. GRADE:
             77. AGE:                           78. SEXI              78A. WT-               79.   RELATIONSHIP TO PATIENT:
             ED. BAS TYPE:                      81. BAB TAB                                  82.   BAG WT:
             83.A    W             NW@ #2:                                                   84.   STATUS:                        85. ME:
             86. A.3E:                          87. SEX:              87A. WT.-              88.   REI-ATIMMIP TO PATIENTT
          91.   BAG WT-
             92. TPA4S LIRIS       PHM                     EXT:
             93. TPA'S DEST PHC:LC 1:                      EXT:
             94. ETA [IRIS MTF(DATE/TI?E): 000                                               95.   ErA DEST M7(DATEITIME): 000 t
             97. OTHER @:



             5'.. ME.4 #: 0000/001                                                           52.   R04 LOC:
             57. VAI.IDATED BY/REAS FOR HIGHER PRECEDENCE:
             96. AIRCRA.-T 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