(4) Injuries or diseases caused by chemical or bacteriological agents or by
ionizing radiation. Enter the information required in paragraph (2) above. In addition,
state the name of the agent or type of ionizing radiation if known. If not known, give
anything that is known about the physical, chemical, or physiological properties of the
agent such as odor, color, or physical state. Also state the date, time, and place where
contamination took place, the time interval between contamination and treatment, and
the nature of the treatment. If the casualty was affected by ionizing radiation, record the
(a) The approximate distance from the source.
If the exposure was to external gamma radiation.
(c) The actual or estimated dosage (for example, "est 150 rad" or
"measured 200 rad").
(d) If exposure was caused by an airburst, ground burst, water surface
burst, or underwater burst.
d. Block 15. Enter either "yes" or "no" based upon instructions given by the
physician or physician assistant.
e. Blocks 16 and 17. Mark the appropriate box to indicate whether the patient
was injured caused by enemy action, injured not caused by enemy action, sick caused
by enemy action, or sick not caused by enemy action. The term "sick" refers to any
f. Blocks 20 and 22 through 26. Enter treatment given at the facility. Block 32
or a supplemental FMC (paragraph 4-8) can be used as needed.
g. Block 27. Enter the disposition of the patient.
(1) If the patient is transferred to another MTF, enter "Transfer to (name of
MTF)." If the facility is not known, enter the general destination and the means of
If the patient is RTD following treatment, enter "Duty."
If the patient died at the facility, enter "Died."
If the casualty was CRO (treated as an outpatient) and RTD, enter
If the casualty was dead upon arrival, enter "CRO-death."