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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]]