DATE: __________________

NAME: _____________________________________________________________________________________________________

NIA #: _____________________________________________ ROSTER#: ______________________________________________

UNIT: _____________________________________________

MEDICAL PROBLEM(S):_____________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

APPROVED BY: _____________________________________________________________________________________________
PRINT NAME SIGNATURE

TO BE COMPLETED BY MEDICAL STAFF

TIME IN: ________________________________

MEDICAL CONDITION: ______________________________________________________________________________________

____________________________________________________________________________________________________________

RECOMMENDATIONS:
_________ Return to Duty

_________ Quarters (24 hrs) (48hrs) (72hrs)

_________ Limited Duty
 
 ____ No Physical Training
____ No Running
 ____ No Hiking
 ____ No Prolonged Standing
 ____ No Recreational Activities
____ No Field Firing
____ No Field Activities
____ No Heavy Lifting
____ No Prolonged Exposure to Heat 
 ____ Hospitalization Required
 ____ If other state: _____________________________________________________________

ALL HOSPITAL REQUEST MUST BE SUBMITED, APPROVED AND COORDINATED THROUGH OPS

MEDICATION (S) PRESCRIBED:_______________________________________________________________________________

TIME OUT: __________________________
CMATT


Coalition Military Assistance Training Team
Kirkush, Iraq

SICK CALL AUTHORIZATION FORM