AS OF: 00XXX00
PERSONAL INFORMATION PRE-TRAINING 
LAST  FIRST, MI RANK/GRADE SSN AOC/MOS DOB / YYMMDD Place of Birth PEBD[1] HIPAA Complete BMAR Complete
                                   
PERSONAL INFORMATION
HOME ADDRESS CITY STATE ZIP HOR Phone # Cell Phone # Work Phone # E-Mail Address
                                   
NETWORK ACESS AND ID BADGE INFORMATION
Citizenship INVESTI-GATION TYPE INVESTI-GATION DATE SECURITY CLEARANCE DATE OF CLEARANCE HT WT HAIR COLOR EYE COLOR SEX
                                   
IMMUNIZATIONS
HIV Test MMR Rubeola Varicella Dipth- Tet HEP B #1  HEP B #2 HEP B #3 PPD given, read, results  CXR (if +PPD)
                                   
DEPARTMENT OF NURSING INFORMATION Completed by Department
ACLS EXP DATE BLS EXP DATE EMTB EXP DATE License Type RN, LPN and or EMT LICENSE STATE LICENSE EXP DATE DEPT CLINIC or WARD POSITION/ ASSIGNMENT EXIT DATE
                                   
Changes from previous edition
Deletions from previos edition

[1]
pay entry basic date.
Date you entered the service.