SECRET (When Filled In)
REQUEST FOR MEDICAL EVALUATION
DATE OF REQUEST: 25 August 1976
NAME (Last, First, Middle): Vescio, James S.
POSITION TITLE: Records Admin Officer
OFFICE, DIVISION, BRANCH: G-12
EMPLOYEE'S EXT.: 652
7. PURPOSE OF EVALUATION
[ ] PRE-EMPLOYMENT
[ ] ENTRANCE ON DUTY
[ ] ON STANDBY
[ ] SPECIAL TRAINING
[X] ANNUAL
[ ] RETURN TO DUTY
[ ] FITNESS FOR DUTY
[ ] MEDICAL RETIREMENT
[ ] HOSPITALIZATION
[ ] OVERSEAS ASSIGNMENT
- ETO: _______
- STATION: _______
- TDY OR PCS: _______
- TYPE OF COVER: _______
- NO. OF DEPENDENTS TO ACCOMPANY: _______
- NO. OF DEPENDENTS REPORT OF MEDICAL HISTORY ATTACHED: _______
[ ] RETURN FROM OVERSEAS
- STATION: _______
- NO. OF DEP'S: _______
OVERSEAS PLANNING EVALUATION (Box Must Be Checked):
[ ] YES
[X] NO
COMMENTS:
Annual Exam Completed.
DATE: 4 October 1976
SIGNATURE OF CHIEF OF MEDICAL STAFF: William T. Colder, CHS/PFO
SECRET
FORM 259 (Revised 1/73)