b. Enter the casualty's identification information in Blocks 1, 2, and 3.
Information may be secured from the patient or from such things as identification tags
and the casualty's uniform.
Block 1. Enter the casualty's name in last name, first name, middle
(2) Block 2. Enter the casualty's SSN if the casualty is a member
of the US Armed Forces. If the casualty is a member of a foreign military,
including a prisoner of war, enter the casualty's military service number. If the casualty
is not military, leave the block blank.
(3) Block 3. Enter the abbreviation of the casualty's grade (SGT, CPT, and
so forth). Approved abbreviations are listed in AR 310-50.
c. Enter a description of medical care given in Blocks 20 through 26. If
additional space is needed, use Block 32 on the back of the form. If Block 32 is used,
reference the block being continued.
To record information on the back of the form, remove the card and the
carbon paper from the book, turn the duplicate copy so the reverse side is up,
place the carbon paper on top of the duplicate copy with the carbon side
facing the duplicate copy, and place the card on top of the carbon paper with
the reverse side of the card facing up.
(1) Block 20. Enter a brief description of the medical care rendered other
than the application of a tourniquet and administration of medication listed in Blocks 22
through 26. If any drugs, antibiotics, or blood plasma was administered, record the
name of the item administered, the dosage administered, and the time and date it was
administered. Enter the time using the military 24-hour system, such as 1550.
(2) Block 21. Enter "yes" if a tourniquet was applied or "no" if a tourniquet
was not applied. If "yes" is entered, also enter the time and date that the tourniquet was
(3) Blocks 22 through 26. If the indicated drug [morphine, tetanus toxiod, or
antitetanic serum (tetanus antitoxin)] was administered, enter the required information.
Note that there is room to record up to three administrations of morphine (blocks 22, 23,
(a) Record the dosage in column "a" across from the appropriate drug.
(b) Record the time and date the drug was administered in column "b"
across from the appropriate drug.