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^[[DOASE]]

[[preprinted]]
MEDICAL RECOMMENDATION FOR FLYING DUTY
(Detach Diagnosis for other than medical use of form)

AFSN ^[[FR1206]]
TO: ^[[USSTRICOM]]
FROM: ^[[SGFM]]
HOSP CODE (1-4) ^[[1053]]

1. LAST NAME - FIRST NAME - MIDDLE INITIAL ^[[DAVIS, BENJAMIN O., JR.]]
7. GRADE ^[[Lt General]] 
7A. GRADE (5-6) ^[[09]]
8. AGE (7-8) ^[[54]]

2. CERTIFICATE
(FOR INCOMING FLYING PERSONNEL ONLY)

[ ] I CERTIFY THAT I AM ON FLYING STATUS ACCORDING TO CURRENT ORDERS AND THAT I HAVE HAD NO ILLNESS OR INJURY SINCE LEAVING MY LAST STATION, EXCEPT AS RECORDED BELOW.

[ ] I CERTIFY THAT I HAVE BEEN NOTIFIED OF THE RECOMMENDATIONS BELOW AND UNDERSTAND THE ACTION BEING TAKEN THIS DATE.

I HAVE BEEN OFFICIALLY NOTIFIED THIS DATE THAT:

[ ]I HAVE BEEN GROUNDED (OR EXCUSED) BECAUSE OF PHYSICAL DISQUALIFICATION FOR FLYING DUTY.

[ ^[[checkmark]] ]I AM PHYSICALLY QUALIFIED FOR FLYING DUTY

SIGNATURE OF FLYER ^[[B. O Davis Jr.]]

3. CLEARANCE FOR FLYING DUTY IS GIVEN UNDER THE FOLLOWING CIRCUMSTANCES:

[[ ^[[X]]] ] REPORTING TO A NEW STATION

[ ] ANNUAL MEDICAL EXAMINATION

[ ] OTHER REQUIREMENT FOR CLEARANCE (Specify)

4. DATE FLIGHT CLEARANCE EXPIRES ^[[18 Dec 68]]

5. INDIVIDUAL PRESENTLY SUSPENDED BY

AERO ORDER NO. [[blank space]]
HEADQUARTERS [[blank space]]
PARAGRAPH NO. [[blank space]]
DATE [[blank space]]

6. COMPETENT CERTIFYING AUTHORITY (When box 4, 5, or 6, of item 23 is circled, indicate authority to certify as physically qualified)
[ ] BASE 
[ ] NO. AIR FORCE
[ ] MAJOR COMD
[ ] HQ USAF

9. SSAN (9-17) [[blank space]]
10. ORGN AND MAJOR COMD OF ASGN ^[[USSTRICOM (Hq. Comd)]]
10A. COMD OF ASGN (18) ^[[ [[strikethrough]]??[[/strikethrough]] ^[[HQC]]
11. RATING DESG OR FLYING DUTY ^[[Command Pilot]]
12. COMBAT AIRCREW MEMBER
[ ] YES 
[ ^[[X]]] ] NO
11A. RATING (19) ^[[A]]
12A. COMBAT (20) ^[[2]]
13. FLYING CATEGORY ^[[1Y]]
14. ACTUAL DATE FOUND MEDICALLY INCAPACITATED TO FLY [[blank space]]
13A. CAT (21) ^[[1]]
14A. DATE (22-25) [[blank space]]
15. MONTH IN WHICH FLT RQMTS WERE LAST MET ^[[June]]
16. EST DURATION OF INCAPACITY TO FLY [[blank space]]
17. SERIOUS ILLNESS, IF "Yes", ATTACH SF 88
[ ] YES 
[ ] NO
18. FLYING WITH WAIVER
[ ^[[X]] ] YES 
[ ] NO
19. TOTAL FLYING TIME (26-29) ^[[4095.3]]
20.GLASSES WILL BE WORN WHILE PERFORMING THOSE DUTIES REQUIRING CORRECTED VISUAL ACUITY
[ ^[[X]] ] YES 
[ ] NO
[ ] NA
21. TOTAL DAYS. (No. of days from actual date of incapacitation (Item 14) to date of certification by competent authority as physical qualified to fly) [[right arrow]]
21. TOTAL DAYS (30-32) [[blank space]]
22. DAYS DURATION IN MEDICAL FACILITY (Use figure from AF Form 565 "Total to Date") [[right arrow]]
22. DAYS IN FCLTY (33-35) [[blank space]]

[[3 column table]]
23. TYPE OF ACTION RECOMMENDED | YEAR AND MONTH | CIRCLE ONE (36)

EXCUSAL NOT TO EXTEND BEYOND LAST DAY OF |   | 1
GROUNDING NOT TO EXTEND BEYOND LAST DAY OF |   | 2
SUSPENSION AS OF FIRST DAY OF |   | 3
REMOVAL OF EXCUSAL | [[NA]] | 4
REMOVAL OF GROUNDING | [[NA]] | 5
REMOVAL OF SUSPENSION | [[NA]] | 6
[[/table]]

REMARKS [[blank space]]

24.
P ^[[2]]
U ^[[1]]
L ^[[1]]
H ^[[1]]
E ^[[1]]
S ^[[1]]
[[blank space]] ^[[b]]

DATE ^[[1 Aug 68]]

TYPED/PRINTED NAME AND GRADE OF FLIGHT SURGEON OR FLIGHT MEDICAL OFFICER
^[[MICHAEL P LANDERNEAU CAPT USAF MC FMO]]

SIGNATURE ^[[Michael P Landren]]

25. DIAGNOSIS (State most serious condition first. Specify resultant conditions from any diagnosis).
[[blank space]]

CODES (PRIMARY DG ONLY)
DG (37-40)
BP (41-43)
CA (44-47)

AF FORM 1042 MAY 68
PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE.
TAC-MACDILL AFB, FLA.
[[/preprinted]]