INDIVIDUAL SICK SLIPILLNESS INJURY

DATE

LAST NAME - FIRST NAME - MIDDLE INITIAL OF PATIENT

SERVICE NUMBER/SSN GRADE/RATE

ORGANIZATION AND STATION

UNIT COMMANDER'S SECTIONIN LINE OF DUTY

REMARKS

SIGNATURE OF UNIT COMMANDER

MEDICAL OFFICER'S SECTIONIN LINE OF DUTY

DISPOSITION OF PATIENT DUTY QUARTERS

SICK BAY HOSPITAL

NOT EXAMINED OTHER (Specify):

REMARKS

SIGNATURE OF MEDICAL OFFICER

DD FORM 689, MAR 63 PREVIOUS EDITIONS ARE OBSOLETE.