Medical Recommendation for Flyer Duty A4186 - DA Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  TO

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  FROM

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  LAST NAME

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  FIRST NAME

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  MI

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  SSN

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  GRADE

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  DATE OF BIRTH

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  ORGANIZATION

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  TYPE FLYING DUTY PERFORMED

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  MEDICAL CLEARANCE IS RECOMMENDED FOR THE FOLLOWING REASON(S): (Check one or more)

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  TERMINATION OF TEMPORARY MEDICAL SUSPENSION

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  MEDICAL EXAMINATION

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  REPORTING TO NEW DUTY STATION

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  AFTER AIRCRAFT MISHAP

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  TERMINATION OF MEDICAL DISQUALIFICATION

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  PENDING ISSUE OF WAIVER FOR MEDICAL DISQUALIFICATION

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  ISSUE OF WAIVER FOR MEDICAL DISQUALIFICATION

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  OTHER (Explain under remarks)

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  REQUIRED TO WEAR GLASSES WHILE FLYING OR OTHER DUTIES REQUIRING CORRECTED VISUALL ACUITY.

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  EFFECTIVE DATE

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  DATE CLEARANCE EXPIRES

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  REMARKS

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  THE FOLLOWING ACTION IS RECOMMENDED:

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  TEMPORARY MEDICAL SUSPENSION

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  TEMPORARY MEDICAL SUSPENSION FOLLOWING A/C MISHAP

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  PERMANENT MEDICAL DISQUALIFICATION

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  PERMANENT MEDICAL DISQUALIFICATION FOLLOWING A/C MISHAP

• ...and More!