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ADVISORY: When completed, this form contains personally identifiable information and personal health information and should be protected in accordance with DoD 5400.11-R (the DoD Privacy Program). Prepare this form to document events that resulted in or had the potential to result in harm to anyone in the PM system. NOTE: If completed by ASF or other MTF staff follow local MDG incident reporting policy in addition to completing this form. SECTION I - PERSON COMPLETING FORM 1.a. LAST NAME b. FI.

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