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Use to request evacuation of sick and wounded personnel by other than USAF fixed-wing assets. Reference: FM 8-10-6.

LINE 1 — DATE AND TIME______________________________(DTG)

LINE 2 — UNIT________________________________________(Unit Making Report)

LINE 3 — LOCATION___________________________________(UTM or Six-Digit Grid Coordinate With MGRS Grid Zone Designator) of Pickup Site Location; Encrypt if Using Non-Secure Means of Communication)

LINE 4 — RADIO FREQUENCY___________________________(Radio Frequency at Pickup Site; Call Sign, and Suffix)

LINE 5 — NUMBER OF PATIENTS(P)______________________(Number of Patients by Precedence. Report Only Applicable Information and Encrypt the Brevity Codes:
If two or more categories must be reported in the same request, insert the word BREAK between each category.)

LINE 6 — SPECIAL EQUIPMENT__________________________(Encrypt the Applicable Brevity Codes.
A — None
B — Hoist
C — Extraction Equipment)

LINE 7 — NUMBER OF PATIENTS(T)______________________(Total Number of Patients by Type. L + # of PNT — Litter / A + # of PNT — Ambulatory)

LINE 8 — SECURITY OF PICK-UP SITE____________________(N — No Enemy Troops in Area
P — Possibly Enemy Troops in Area (approach with caution)
E — Enemy Troops in Area (approach with caution)
X — Enemy Troops in Area (armed escort required))


_____________________________________________________(Specific Information Regarding Patient Wounds by Type)

LINE 10 — METHOD OF MARKING AT PZ_________________(Encrypt the Brevity Codes:
A — Panels
B — Pyrotechnic signal
C — Smoke Signal
D — None
E — Other)

LINE 11 — PATIENT NATIONALITY ______________________(Number of Patients in Each
Category Need Not be Transmitted. Encrypt Only the Applicable Brevity Codes:
A — US Military
B — US Civilian
C — Non-US Military
D — Non-US Civilian
E — EPW)

LINE 12 — NBC CONTAMINATION ______________________(NBC Contamination; Use Brevity Codes:
N = Nuclear
B = Biological
C = Chemical
U = Unknown
A = All Clear)

LINE 13 — TERRAIN DESCRIPTION ______________________(Description of Terrain Features at the Proposed Pick-up Site)

LINE 14 — AUTHENTICATION___________________________(Report Authentication)

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