(Important Note: This form is handled exactly as per HCO PL of 26 Jan AD20 and no examiner may examine unless starrate on that PL, and HCO B 5 Mar 71 (C/S Series 25) and an e-meter course. Students and pcs can be very upset if this post's duties are not done correctly and org pc and course results ruined.)

• After Session: _______
• Qual: Div FLAG (Place)
• Volunteered: _______
• Date: 22 Feb 80
• Medical: _______
• Time: 12:00 pm
• PC or Pre-OT Name: Pat Smith
• Last Grade Attained: Purification R/D
• Grade, Course or Action Being Attested: _______
• PC's Statement (write down exactly what PC says): I had a great session!
• TA Position & any BD: 2.3
• PC Indicators: VGIs
• State of Needle: F/N (Wide)
• F/N Indicated to PC: Yes
• Signature of Examiner: Mark Brown

ROUTE THIS FORM TO TECH SERVICES WHICH ROUTES IT INTO THE FOLDER.

WHEN ILLNESS REPORTED MAKE THIS OUT WITH A CARBON UNDER IT AND ROUTE ORIG TO T/S AND FOLDER AND CARBON TO MO OR QUAL SEC.

RUSH ROUTE ANY ROLLER COASTER LATER REPORT OR SICK RPT TO FOLDER TO PREVENT C/S ERRORS.