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U.S. DEP A RTME NT OF
HOMELAND SECURITY
U.S. COAST GUARD
C G-5684 (R ev . 06/04)
MEDICAL BOARD REPORT COVER SHEET
SECTION A. TO BE COMPLETED BY CONVENING AUTHORITY
1. FROM:
TO :
CO M M ANDE R (CGPC--adm - 1)
USCG P ersonnel Commmand
4200 Wilson Blvd., Suite 1100
Arlington, VA 22203-1804
VIA:
2. NAME:
3. DUTY STATION (Include Address & Phone Number)
While awaiting final action,
Member transferred to:
Work #:
Home #:
4. SSN: 5. GRADE/RATE
6. MEMBER STATUS
ACTIVE
RESERVE
(NOE Attached)
7. SEX
MALE
FEMALE
8. LENGTH OF ACTIVE DUTY SERVICE:
YEARS
MONTHS
9. CAUSE OF INJURY
(N/A for illness)
10. LOD INVESTIGATION
(Must be attached to the board)
YES
NO
11. SEPARATION FROM SERVICE PENDING:
VOLUNTARY SEPARATION OR RETIREMENT-EXPECTED DATE:
INVOLUNTARY/MANDATORY SEPARATION - EXPECTED DATE:
12. DISCIPLINE PENDING
YES
NO
13. EXPIRATION OF ENLISTMENT
14. COPY OF RETENTION LETTER ATTACHED IAW CHAPTER 17 PERSMAN
(Submit original command endorsement directly to OPM-1 or EPM-1 with c opy attached
to med board.)
YES
NO
15. CONVENING AUTHORITY
RANK SERVICE SIGNATURE
SECTION B. TO BE COMPLETED BY MEDICAL UNIT
16. DATE OF BOARD
EPTE CODES: 1. NOT AGGRAVATED BY SERVICE - EPTE 2. AGGRAVATED BY SERVICE - EPTE 3. DNEPTE
ICD-9-CM DIAGNOSIS
EPTE (Origin)
16a. PRIMARY DIAGNOSIS:
16b. SE COND DIAGNOSIS:
16c. THIRD DIAGNOSIS:
16d. FOURTH DIAGNOSIS:
16e. FIFTH DIAGNOSIS:
16f. SIXTH DIAGNOSIS:
17. REMA RKS
LIMITED DUTY EXPIRES ON:
LIMITATIONS ARE:
18. ENCLOSURES:
COMMAND ENDORSEMENT
EXTRACTS FROM HEALTH RECORD
LINE OF DUTY INVESTIGATION
NOTICE OF ELIGIBILITY FOR RESERVIST (CG-4671)
COPY OF DD-2808 & DD- 2807-1 M EPS & CAPE M AY
COPY OF REQUEST FOR RETENTION LETTER
W/COMMAND ENDORSEMENT
CG-4920 (PATIENT'S STATEMENT OF RIGHTS
SIGNED MEM BER'S REBUTTAL
OTHER
19. BOARD MEMBERS RANK SERVICE SIGNATURE
SENIOR MEMBER
(Must be a physician)
MEMBER
ALTERNATE MEMBER
or PSYCHIATRIST
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