PERSONAL DATA PRIVACY ACT OF 1974 4 JAN 91

File: 092496_aug96_decls4_0010.txt
Page: 0010
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








                  .6:15:34                                         *w PATIENT FILE                                                  01/04/91
                                                          PERSC,@ DATA - PRIVACY ACT OF 1974

                                                                        5 U.S.C. 552 (b)(6)
                                                                                                                                 13. MODE. A
                                                                   18. AUM
              WEI                                                              ITY #: 0364AOI4 2. SSP.14:                        3. PRECEEN:E: R
          4.  STAT:    All            5.  GRADE, E05               6. AGE: 25Y          7. SEX- N             8. WT:      160    9. READY DATE: 3tA
          10. ISO:                    11. POR:                                                                                   12. SPEC CAT-
          14. REAS RES: DS            15. DATE LAST VISIT:                                                                       16. CLASS. 3A
          17. ACCEPT    PHYS:                                                                                                    19. APPT/SLIRS DATE: NO
          20. I%OPRDY AUTH:                                                          21. CAKC/ M:                                22. Vkl ID:                UAX    Y3
          23. MTF BRIG: A5150         USA DISPENSARY WMN                                                                         24. ICAO DRIS:    DBR
          25. KTF DEST-. A5040        20  GEN hW LAQMM                                                                           26, ICAO DEST:    EDM
          27. ?4a SPEC 1: SOD         2B. DIAG 1: 8472 UM SMIN
          29. rZD SPEC 2.             30. DIAS 2:
          31. ?S SPEC 3:              32. DIAG 3:
          32A. PRCCEOLRE:
          33. SPEC DIET:           N/                                                34. IVi
/LPM: N               36. SLICT.-  N          37.  NS TUBE: N        38.  RESP: N                         39. FOLEY.,       N      40. STRWM: N
          41. INCM-                N  42. TRACT: N            43.  IK:D: N           44.  CAST/LO@@: N                    45. TRADI:        N      46. KON: N
          71. PT BAG TYPE, NB                                 72.  PT BAG TAB     0:                                      73. PT BAG WT-
          47. SUPP INFO: HANBLRM, GE                                                                              //SUB   JIM@Ro//
            //FLEET 5//
          48. TAX EMM STOPS: Y /          9                   49.  tAX # RCNgt     Y / 9                                  50. ALT REST/rAX HI: N
          53. IHPATIENT.- Y           54. SPEC PROS:      VA       DRUB      XML          WT     NC&E X                   55. VA CODE:
          55. ADIIN/OVERSEAS,.
          tS. VITAL SlbM(TEMP/PLP-SE/RESP/BLCOD PRESS).- 098.8                     72 /   20 /    140         80
          59. HGB:                    60. lr.T*.              61. ADS:                                  I DATE TMO:
          62. WBC:                    63. SI/VSI.,            64. MEDICATIONS: TYLEN'3L #3       2 TABS 94-6H Pk4




          55. HISTC-RY: INJUIRED BACK h'HILE IN TOLIN 15 DEC. S%a THEN MKPLAIN'RS CF LUMBAR
          PAIN.








          66. ATT PHYS: STEVENS                    67. PHO: 999 999 9999                                68.   WARD#/Pflt: 999 / 999 999 9999
          69. REPCRTED BY: SST ABBOTT                                                                   70.   PNI: 999 9999
          74. ArfEM4T @ #I:                                                                             75.   STATUS-                          76. G.OME:
          77. ffic-:                               78. SEX:                  78A. WT:                   79.   RDATICISHIP TO PATIENT:
          80. GAS TYPE:                            81. GAS TAG                                          82.   BAB WTs
 83. ATTENDANT            NAME #2:                                                             84.   STATLIS:                         85. ME:
          86. AGE:                                 97. SEX:                  87A. WI:                   88.   RELATIONSHIP TO PATIENT:
          89. BAG TYPE:                            90. BAG TAG                                          91.   BAG WT:
          92. TRA14S CRIS PHONE 1:                        EXT:
          93. TRA.'S DEST          PHONE #:               EXT,.
          94. ETA CRIS KW(DATEtTIF.E): 000                                                              95.   ETA DEST KW(DATEfTIME): 000
          97. OTHER                -



          5:. 'iSk #: 0000/364                                                                          52.   RON LO@':
          57. VA'-IDATED BY/REAS FOR HI M          PRECEDEfiM
          96. AIRCRAFT ITMSARY:

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