AF IMT Form 3047 The Air Force Ready Reserve Stipend Program (Afrrsp) Health Status Questionnaire

AF IMT Form 3047 or the "The Air Force Ready Reserve Stipend Program (afrrsp) Health Status Questionnaire" is a form issued by the U.S. Air Force IMT (Information Management Tool).

The form was last revised in May 1, 1989 and is available for digital filing. Download an up-to-date AF IMT Form 3047 in PDF-format down below or look it up on the U.S. Air Force IMT (Information Management Tool) Forms website.

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THE AIR FORCE READY RESERVE STIPEND PROGRAM (AFRRSP) HEALTH STATUS QUESTIONNAIRE
AUTHORITY: 44 United States Code (U.S.C) 3101; 10 U.S.C. 133, 2120 through 2130, 8013, and 8032; and Executive Order (E.O.) 9397.
PRINCIPAL PURPOSES: To certify periodic health status of members of the Ready Reserve of the Air Reserve Components (ARC) of the United States Air Force.
ROUTINE USES: To certify health status of members as a requirement for continued participation in the professional training program and/or Ready Reserve of the
ARC. The social security number (SSN) provides positive identification.
DISCLOSURE IS VOLUNTARY: If the participant fails to provide the information, including the SSN, the USAFR may medically disqualify the participant for
continued participation in the professional training program and/or Ready Reserve of the ARC.
NAME (Last, First, Middle Initial)
SSN
AFR 160-43 requires you to report immediately to HQ ARPC/SG any serious illness or injury, period of hospitalization, chronic health problem, or change in health
status that may result in the following: Any absence from your professional training program, or any factor adversely affecting your ability to fulfill your Reserve Service
Obligation (RSO) and the continued participation in the Ready Reserve of the ARC. You should complete the questions listed below and return this form to HQ
ARPC/SG, Denver CO 80280-5000. If additional space is required, you may use the reverse of this form or additional paper.
1. DURING THE PAST YEAR, HAVE YOU RECEIVED TREATMENT FOR A MENTAL CONDITION? (lf yes , specify when, where, and give details.)
2. DURING THE PAST YEAR, WERE YOU DENIED LIFE INSURANCE? (if yes, state reason and give details.)
DURING THE PAST YEAR, WERE YOU ADVISED TO HAVE ANY OPERATIONS? (If yes, describe.)
3.
4. DURING THE PAST YEAR, HAVE YOU BEEN A PATIENT IN ANY TYPE OF HOSPITAL?
(If yes, specify when, where, why, name of physician, and a
complete address of the hospital.)
AF IMT 3047, 19890501, V1
THE AIR FORCE READY RESERVE STIPEND PROGRAM (AFRRSP) HEALTH STATUS QUESTIONNAIRE
AUTHORITY: 44 United States Code (U.S.C) 3101; 10 U.S.C. 133, 2120 through 2130, 8013, and 8032; and Executive Order (E.O.) 9397.
PRINCIPAL PURPOSES: To certify periodic health status of members of the Ready Reserve of the Air Reserve Components (ARC) of the United States Air Force.
ROUTINE USES: To certify health status of members as a requirement for continued participation in the professional training program and/or Ready Reserve of the
ARC. The social security number (SSN) provides positive identification.
DISCLOSURE IS VOLUNTARY: If the participant fails to provide the information, including the SSN, the USAFR may medically disqualify the participant for
continued participation in the professional training program and/or Ready Reserve of the ARC.
NAME (Last, First, Middle Initial)
SSN
AFR 160-43 requires you to report immediately to HQ ARPC/SG any serious illness or injury, period of hospitalization, chronic health problem, or change in health
status that may result in the following: Any absence from your professional training program, or any factor adversely affecting your ability to fulfill your Reserve Service
Obligation (RSO) and the continued participation in the Ready Reserve of the ARC. You should complete the questions listed below and return this form to HQ
ARPC/SG, Denver CO 80280-5000. If additional space is required, you may use the reverse of this form or additional paper.
1. DURING THE PAST YEAR, HAVE YOU RECEIVED TREATMENT FOR A MENTAL CONDITION? (lf yes , specify when, where, and give details.)
2. DURING THE PAST YEAR, WERE YOU DENIED LIFE INSURANCE? (if yes, state reason and give details.)
DURING THE PAST YEAR, WERE YOU ADVISED TO HAVE ANY OPERATIONS? (If yes, describe.)
3.
4. DURING THE PAST YEAR, HAVE YOU BEEN A PATIENT IN ANY TYPE OF HOSPITAL?
(If yes, specify when, where, why, name of physician, and a
complete address of the hospital.)
AF IMT 3047, 19890501, V1

Download AF IMT Form 3047 The Air Force Ready Reserve Stipend Program (Afrrsp) Health Status Questionnaire

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