Free VA Form SF184 - Request for Employee Medical Folder - Federal

NSN 7540-01-271-8649

REQUEST FOR EMPLOYEE MEDICAL FOLDER
(SEPARATED EMPLOYEE)

1. Date of Request

SECTION I - TO BE COMPLETED BY AGENCY'S DESIGNATED MEDICAL RECORDS MANAGER 2. Current Name (Last, first, middle) 2a. Name Under Which Formerly Employed Federally (If different than item 2) 3. Date of Birth (mm/dd/yyyy) 4. Social Security Number

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION NATIONAL PERSONNEL RECORDS CENTER (Civilian Personnel Records) 111 Winnebago Street St. Louis, MO 63118

AGENCY AND BUREAU

SUBMIT IN DUPLICATE FOR EACH FOLDER REQUESTED One will be used to send folder or reply to: MEDICAL RECORDS MANAGER Second copy retained by agency for its suspense files. Third copy is for records center use. 5. PREVIOUS FEDERAL EMPLOYMENT LOCATION FROM TO

6. Ageny Accession Information (Complete items a. through e. If the last separation date in item 5 is prior to September 1, 1984, and the medical records were retired to this Center as part of an agency accession. If the records were not retired by your agency, contact previous employers for assistance.) a. Record Group No. b. Accession No. c. Agency Box No. of e. Description of Folder (Include file number and title.) 7. REASON FOR REQUEST (Check appropriate box.) a. Currently employed 8. Remarks SECTION II - FOR USE BY RECORDS CENTER a. Folder enclosed. b. Folder not located. Insufficient location information. Suggest you contact last Federal employer. c. Folder was sent (Date) To: d. Folder not received. Suggest you contact last Federal Employer e. Other b. Other (Explain) d. Records Center Location No.

DATE

INITIALS

SECTION III - TO BE COMPLETED BY AGENCY'S DESIGNATED MEDICAL RECORDS MANAGER NAME (Type or Print) SIGNATURE TELEPHONE NO. (Include area code)
EXT

Enter complete address to which folder or reply is to be mailed. Include ZIP Code:

STANDARD FORM 184 (1-89) Prescribed by NARA CFR 1228.154(e)