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[[preprinted form]] MEDICAL RECOMMENDATION FOR FLYING DUTY (Detach Diagnosis for other than medical use of form) DATE ^[[1 Aug 67]] TO: ^[[Commander 13th AF]] FROM: ^[[USAF Hospital Clark AB, Philippines HOSP CODE ^[[P151]] CERTIFICATE [[checked checkbox]] (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. [[checked checkbox]] I CERTIFY THAT I HAVE BEEN NOTIFIED OF THE RECOMMENDATIONS BELOW AND UNDERSTAND THE ACTION BEING TAKEN THIS DATE. [[unchecked box]]I HAVE BEEN OFFICIALLY NOTIFIED THIS DATE THAT I (have been grounded because of physical disqualification for flying duty) (am physically qualified for flying duty). SIGNATURE OF FLYER ^[[B O Davis Jr]] CLEARANCE FOR FLYING DUTY IS GIVEN UNDER THE FOLLOWING CIRCUMSTANCES [[checked checkbox]] 1. REPORTING TO A NEW STATION ^[[1 Aug 67]] 2. ANNUAL MEDICAL EXAMINATION [[checked checkbox]] 3. OTHER REQUIREMENT FOR CLEARANCE (Specify) ^[[Flying Class II w/waiver]] 13. AERO ORDERS [[3 column format]] | INDIVIDUAL PRESENTLY SUSPENDED BY| | AERO | | | HEADQUARTERS | | | PARAGRAPH NO.| | | DATE | | | 13. COMPETENT CERTIFYING AUTHORITY (When box (4), (5) or (6) in item 14 is checked, indicate authority to certify as physically qualified.) | BASE | | NO. AIR FORCE | | MAJOR AIR COMMAND | | HQ USAF | 1. LAST NAME - FIRST NAME - MIDDLE INITIAL ^[[ DAVIS, BENJAMIN O. Jr.]] 2. GRADE ^[[Lt Gen]] CODE ^[[7]] SERVICE NUMBER ^[[FR 1206]] 4. AGE ^[[54]] 5. TOTAL FLYING TIME ^[[4000]] 6. ORGANIZATION AND MAJOR COMMAND OF ASSIGNMENT ^[[13th AF, APO SF 96274 (PACAF)]] CODE ^[[RA]] 7. MONTH IN WHICH FLIGHT REQUIREMENTS WERE LAST MET ^[[-]] 8. RATING, DESIGNATION OR FLYING DUTY ^[[Cmd Pilot]] CODE ^[[A]] 9. ACTUAL DATE FOUND MEDICALLY INCAPACITATED TO FLY (Day, Month, Year) ^[[-]] CODE ^[[-]] 10. ESTIMATED DURATION OF INCAPACITY TO FLY ^[[-]] 11. STANDARD FORM 88 15 ATTACHED ^[[-]] YES ^[[-]] | NO ^[[-]]| 12. SERIOUS ILLNESS (If answer is "yes", attach Standard Form 88) YES ^[[-]] | NO ^[[-]] | 14. TYPE OF ACTION RECOMMENDED (Check one)| MONTH AND YEAR | |(1) EXCUSAL NOT TO EXTEND BEYOND LAST DAY OF | | |(2) GROUNDING NOT TO EXTEND BEYOND LAST DAY OF | | |(3) SUSPENSION AS OF FIRST DAY OF | | |(4) REMOVAL OF EXCUSAL | | |(5) REMOVAL OF GROUNDING | | |(6) REMOVAL OF SUSPENSION | | 16. TOTAL DAYS (Number of days from actual date of incapacitation (item 9)to date of certification by competent authority as physically qualified to fly). DAYS DURATION IN MEDICAL FACILITY REMARKS ^[[This clearance expires: 18 Dec 67 Glasses will be worn while performing those air crew duties requiring the corrected visual acuity.]] TYPED OR PRINTED NAME AND GRADE OF FLIGHT SURGEON OR AVIATION MEDICAL ^[[JOHN T MAHONEY CAPT USAF MC FMO]] SIGNATURE ^[[J Mahoney]]