Request For Employee Medical Folder
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1NSN 7540-01-271-8649
REQUEST FOR EMPLOYEE MEDICAL FOLDER
1. Date of Request
(SEPARATED EMPLOYEE)
SECTION I - TO BE COMPLETED BY AGENCY'S DESIGNATED MEDICAL RECORDS MANAGER
2. Current Name (Last, first, middle)
2a. Name Under Which Formerly Employed Federally (If different than item 2)
3. Date of Birth (mm/dd/yyyy)
NATIONAL ARCHIVES AND RECORDS ADMINISTRATION
NATIONAL PERSONNEL RECORDS CENTER ANNEX
4. Social Security Number
1411 Boulder Boulevard
Valmeyer, IL 62295
SUBMIT IN DUPLICATE FOR EACH FOLDER REQUESTED
One will be used to send folder or reply to:
MEDICAL RECORDS MANAGER
Second copy retained by agency for its suspense files.
Third copy is for records center use.
5. PREVIOUS FEDERAL EMPLOYMENT
AGENCY AND BUREAU
LOCATION
FROM
TO
6. Ageny Accession Information (Complete items a. through e. If the last separation date in item 5 is prior to September 1, 1984, and the medical records were retired
to this Center as part of an agency accession. If the records were not retired by your agency, contact previous employers for assistance.)
a. Record Group No.
b. Accession No.
c. Agency Box No.
d. Records Center Location No.
of
e. Description of Folder (Include file number and title.)
7. REASON FOR REQUEST (Check appropriate box.)
b. Other (Explain)
a. Currently employed
8. Remarks
SECTION II - FOR USE BY RECORDS CENTER
a. Folder enclosed.
d. Folder not received. Suggest you contact last Federal Employer
b. Folder not located. Insufficient location information. Suggest you
e. Other
contact last Federal employer.
c. Folder was sent (Date)
To:
DATE
INITIALS
SECTION III - TO BE COMPLETED BY AGENCY'S DESIGNATED MEDICAL RECORDS MANAGER
NAME (Type or Print)
SIGNATURE
TELEPHONE NO. (Include area code)
EXT
Enter complete address to
which folder or reply is to
be mailed.
Include ZIP Code:
STANDARD FORM 184 (1-15)
Prescribed by NARA CFR 1228.154(e)
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Parent category: Medical