U.S. DOD Form dod-va-3831a

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U.S. DOD Form dod-va-3831a
CHEST X-RAY
TUBERCULIN TEST
ANTISMALLPOX
BLOOD TEST OR COUNT
DATE OF BIRTH
DEPARTMENT, SERVICE AND/OR DIVISION
GENERAL PHYSICAL
ADDRESS (Number, street, city, State and ZIP code)
EMPLOYEE’S NAME (Last, first, middle initial)
SOCIAL SECURITY NUMBER
LABORATORY TESTS
SEX
ROOM NUMBER
MARITAL STATUS
POSITION TITLE
EXTENSION
SUPERVISOR’S NAME
HOME PHONE
SUPERVISOR’S EXTENSION
PHYSICIAN’S ADDRESS (Number, street, city, State, and ZIP code)
PHYSICIAN’S NAME (Last, first, middle initial)
OTHER
OFFICE PHONE
DRUG SENSITIVITIES
TIME
DATE
IN
HISTORY, FINDINGS, DIAGNOSIS,
EXAMINATION OR TEST REQUIRED
3831a
EXAMINED OR
TREATED BY
OUT
PRIVACY ACT NOTICE: Section 7901 of Title 5, United States Code, is the basic legal authority for
providing occupational health services to Federal employees. Office of Management and Budget
Circular A-72 provides for the maintenance and control of employee health records. Provision of this
VA FORM
APR 1992(R)
TREATMENT, HEALTH, GUIDANCE OR
EXAMINATION AND TEST RESULTS
information is voluntary. However, the VA needs this information to develop and maintain an efficient
employee health program, to assist employees in case they suffer a medical emergency at work, and to
develop statistical medical reports for the Office of Personnel Management.
EMPLOYEE HEALTH RECORD
IN
TIME
0UT
REVERSE OF VA FORM 3831a, APR 1992(R)
DATE
HISTORY, FINDINGS, DIAGNOSIS,
EXAMINATION OR TEST REQUIRED
TREATMENT, HEALTH, GUIDANCE OR
EXAMINATION AND TEST RESULTS
EXAMINED OR
TREATED BY
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