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Use to provide status of significant medical interests affecting the overall medical capability or health of command. Reference: FM 8-10-3.

LINE 1 — DATE AND TIME______________________________(DTG)

LINE 2 — UNIT________________________________________(Unit Making Report)

LINE 3 — LOCATION___________________________________(Reporting Unit UTM or Six-Digit Grid Coordinate With Grid Zone Designator)

LINE 4 — SHIP_________________________________________(Ship Name (if Required))


a. OPERATING__________________________________(Number Beds Operating)
b. NO. OCCUPIED_______________________________(Number Beds Occupied)
c. NO. ARMY___________________________________(Number Army Patients)
d. NO. NAVY___________________________________(Number Navy Patients)
e. NO. MARINE_________________________________(Number Marine Patients)
f. NO. AIR FORCE_______________________________(Number Air Force Patients)
g. NO. EPW ____________________________________(Number EPW Patients)
h. NO. US CIVILIAN_____________________________(Number US Civilian Patients)
i. NO. ALLIED CIVILIAN _________________________(Number Allied Civilian Patients)
j. NO. OTHER __________________________________(Number Other Patients)

LINE 6 — STATUS_____________________________________(Patients Status by Service)

a. NO. RTD_____________________________________(Number RTD in 72 Hours)
b. NO. EVAC ___________________________________(Number EVAC to CONUS)
c. NO. DOW____________________________________(Number DOW)

LINE 7 — DAYS CLASS VIII_____________________________(Days of Class VIII OH)

LINE 8 — DAYS BLOOD________________________________(Days Blood Supply OH)

LINE 9 — CHRONIC PROBLEMS_________________________(Chronic Problems)

LINE 10 — NARRATIVE_________________________________(Free Text for Additional Information Required for Clarification of Report)

LINE 11 — AUTHENTICATION___________________________(Report Authentication)