Appendix
notification of injury
Date ____________
SUBJECT: Notification of Medical Care and/or Hospitalized Beyond the End of Training Periods.
THRU: The Adjutant General State of ________.
TO: NGB-ARS, Washington, DC 20310.
In accordance with paragraph 8, NGR 40-3, notification of medical care is furnished below:
Name: _______________________________
SSN: _______________________________
Grade: _______________________________
Parent unit and station: _______________________________
Type and inclusive dates of training: _______________________________
Date and place of incident: _______________________________
Diagnosis: _______________________________
LOD status: _______________________________
Name and distance of nearest Federal medical facility: _______________________________
Name and address of medical facilities utilized: _______________________________
Estimated cost and duration of treatment: _______________________________
Summary of incident: _______________________________
_______________________________
32 C.F.R. §564.40
32 U.S.C. 318-320 and 502-505