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MEDICAL RECOMMENDATION FOR FLYING OUTY
For use of thig.dorm, peo AR 40-501; the propanent agency is the Office af The Surgean General
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APR SF
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TYPE FLYING DiuTyY PERFORMED
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SMGAN ZATION
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CERTIFICATION
(Minimum of three blocks must be ohec ked)
Leertify that Damon tying status according, toa current orders
Lecertify that [have an ouiftcoral waiver of medical disquatifieation for Mying duties
Leertify that [have been notified of the recommendat:
as below sad understand the action tawen this date.
[hase a medical disqualification for fying duty
“
fammediatty qualiied to perform Byanp duties.
Sienatughot Atmiaty
go UA Te MEOIIAL. CULE AA ANCE
ME O.WAL ILL ARANCE IS GRANTED FOR THE FOLLOWING REQUIREMENT
FEPORTING TO NEW STATION
:
OTHER
WAING TU OOF
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;MESICAL EXAMINATION
:
Give (uit explana ty none RESMA RS)
ME CIECAL
DISGUALIFICA Thus
THERES
AFTER AIRCRAFT ACCIOEN™
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FOR FLYING Ow TY
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ACTION RECOMMENDED
DiS’, UALIF YING AC TIONS
QUALIFYING AC Ios
ESTIMATE YU LURATION OF INCAPACITY TG €OY (Giveduration | TT TERMINATION OF MESICAL RESTRIC TUN EFFECTIVE
.
¢ Vear. Apumth, fiay)
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MEDICAL
RESTRICTION EFFECTIVE
(Year, Month, Day)
15.DA TERMINATIONOFSUSPENSION EF FECTIVE bear. Wath,fay)
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UA SUSPENSION EFFECTIVE
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