INDIVIDUAL SICK SLIP - United States Army

INDIVIDUAL SICK SLIP

ILLNESS

INJURY

LAST NAME - FIRST NAME - MIDDLE INITIAL OF PATIENT

DATE ORGANIZATION AND STATION

SERVICE NUMBER/SSN

GRADE/RATE

UNIT COMMANDER'S SECTION IN LINE OF DUTY

REMARKS

MEDICAL OFFICER'S SECTION IN LINE OF DUTY

DISPOSITION OF PATIENT SICK BAY NOT EXAMINED

REMARKS

DUTY

QUARTERS

HOSPITAL OTHER (Specify):

SIGNATURE OF UNIT COMMANDER

DD FORM 689, MAR 63

SIGNATURE OF MEDICAL OFFICER

PREVIOUS EDITIONS ARE OBSOLETE.

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