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REQUEST FOR MEDICAL EVALUATION

1. DATE OF REQUEST: 10 February 1971
2. NAME (Last, First, Middle Initial): Beck, James A. (T)
3. POSITION TITLE: Career Agent
4. OFFICE, DIVISION, BRANCH: Op. Officer
5. EMPLOYEE'S GRADE: GS-16
6. EMPLOYEE'S SERIAL NO.: 08-16

7. PURPOSE OF EVALUATION:
[ ] PRE-EMPLOYMENT
[ ] ENTRANCE ON DUTY
[ ] TDY STANDBY
[ ] SPECIAL TRAINING
[ ] ANNUAL
[ ] RETURN TO DUTY
[ ] FITNESS FOR DUTY
[ ] MEDICAL RETIREMENT
[ ] HOME TDY
[ ] OVERSEAS ASSIGNMENT
[ ] ETD
[ ] STATION: San Francisco
[ ] TYPE OF COVER
[ ] NO. OF DEPENDENTS TO ACCOMPANY
[ ] NO. OF DEPENDENTS REPORT OF MEDICAL REPORT ATTACHED
[ ] RETURN FROM OVERSEAS
[ ] ETD
[ ] STATION
[ ] NO. OF DEP'S

8. OVERSEAS PLANNING EVALUATION (This block must be checked):
[ ] YES
[ ] NO

9. REQUESTING OFFICER:
SIGNATURE: Ruth A. Stanford
TITLE: PO/Personnel
ROOM NO. & BUILDING: 191

10. COMMENTS:
Subject will retire effective 31 March 1971. He will come to Headquarters and be available for a medical examination on 22 March. Please schedule the medical during that week. D is requesting approval for him to enter the HQ building.

11. REPORT OF EVALUATION:
Qualified Executive Annual
DATE: 31 March 1971
SIGNATURE OF CHIEF OF MEDICAL STAFF: Peter Zowcka, CMS/Apco

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