MEDICAL RECORD - SUPPLEMENTAL MEDICAL DATA For use of this form, see requiring document 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the REQUIRING DOCUMENT title and number at the top of the form. This is essential for validation.
3. Enter the ISSUANCE DATE to ensure proper documentation.
4. Complete the MEMBER'S NAME section with first, last, and middle initials, along with their RATE/RANK.
5. In the DIAGNOSIS field, provide a clear description of the medical condition.
6. Specify the CAUSE OF INJURY and recommend the NUMBER OF DAYS for light duty. If more than 30 days, note that a medical board is required.
7. Fill out any restrictions or recommendations regarding activities, ensuring clarity on each limitation.
8. Complete sections related to Sick In Quarters (SIQ), including start time and special instructions.
9. Finally, ensure all signatures are obtained where necessary before submission.

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