Appendix B: Example WAG Medical Surveillance Questionnaire Overprint CHRONOLOGICAL RECORD OF MEDICAL CARE HEALTH RECORD WAG Medical Surveillance Questionnaire DATE IDENTIFICATION (Use this space for Mechanical Imprint) PATIENT’S RECORDS MAINTAINED AT: NAME SEX PATIENT’S (Last, First, Middle Initial) RELATIONSHIP TO SPONSOR STATUS RANK/GRADE NAME ORGANIZATION SPONSOR’S STANDARD FORM 600 (REV. 5-84) CHRONOLOGICAL RECORD OF MEDICAL CARE Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45.505
Appendix B: Example WAG Medical Surveillance Questionnaire Overprint HEALTH RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE DATE WAG Medical Surveillance Questionnaire PATIENT’S IDENTIFICATION (Use this space for Mechanical Imprint) RECORDS MAINTAINED AT: PATIENT’S NAME (Last, First, Middle Initial) SEX RELATIONSHIP TO SPONSOR STATUS RANK/GRADE SPONSOR’S NAME ORGANIZATION CHRONOLOGICAL RECORD OF MEDICAL CARE STANDARD FORM 600 (REV. 5-84) Prescribed by GSA and ICMR FIRMR (41 CFR) 201-45.505
PHC_Model_SOP_WAG_Final.docx