After Session: _______

Qual: Div FLAG (Place)

Volunteered: _______

Date: 22 Feb 80

Medical: _______

Time: 12:00 pm

PC or Pre-OT Name: Pat Smith

Last Grade Attained: Purification R/D

Grade, Course or Action Being Attested: _______

PC's Statement (write down exactly what PC says): I had a great session!

TA Position & any BD: 2.3

PC Indicators: VGIs

State of Needle: F/N (Wide)

F/N Indicated to PC: Yes

Signature of Examiner: Mark Brown

ROUTE THIS FORM TO TECH SERVICES WHICH ROUTES IT INTO THE FOLDER.

WHEN ILLNESS REPORTED MAKE THIS OUT WITH A CARBON UNDER IT AND ROUTE ORIG TO T/S AND FOLDER AND CARBON TO MO OR QUAL SEC.

RUSH ROUTE ANY ROLLER COASTER LATER REPORT OR SICK RPT TO FOLDER TO PREVENT C/S ERRORS.