DIVISION SURGEON'S MEDICAL OFFICER INFO SHEET
Name:	:
Rank/DOR:	:
Specialty:	:
UNIT/Position:	:
Duty Station:	:
Pager:	:
OfficeTelephone:	: DSN:
Home phone:	:
Address:	:
Spouse:	:
Children:	:
Date arrived Current Duty Station:	:
Anticipated PCS:	:
Professional interests:	:
Certification (date): Boards:__________ ACLS:___________ ATLS:___________ PALS:___________ NRP:___________ ALSO:___________ Other:___________	Due: Boards:__________ ACLS:___________ ATLS:___________ PALS:___________ NRP:___________ ALSO:___________ Other:___________
Personal interests:	:
Unit:	:
Prior Deployments:	:
POC in emergency:	:
Date of last Eval SF:	:
Date OER due:	:
Rater: Intermediate Rater: Senior Rater:	:
Credentials review due:	:
Profile:	:
EFMB:	:
Special Skills:	:
Medical Conferences & courses since PCS to Current Duty Station	:
Counseling Dates:	:

Other information: (see back)