------------------ MY HEALTHEVET PERSONAL INFORMATION REPORT ------------ *************CONFIDENTIAL************* Produced by the Blue Button (v12) 02 Dec 2011 @ 1028 This summary is a copy of information from your My HealtheVet Personal Health Record. Your summary contains information that you entered and may also include a copy of some of the information in your VA medical record as it becomes available in My HealtheVet. Please let your health care team know if you have questions about your health information. For some Veterans, information from the Department of Defense (DoD) is available. You will see this in VA Blue Button as DoD Military Service Information. Name: MHVVETERAN, ONE A Date of Birth: 01 Mar 1948 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 02 Dec 2011 @ 1028 User Request Type: Download only my selected data from My HealtheVet File Name: mhv_MHVVETERAN_20111202.txt Data Types Selected: My HealtheVet Account Summary Demographics DoD Military Service Information --------------------- MY HEALTHEVET ACCOUNT SUMMARY --------------------- Source: VA Authentication Status: Authenticated Authentication Date: 19 Aug 2010 Authentication Facility ID: 979 Authentication Facility Name: SLC10 TEST LAB VA Treating Facility Type ---------------------------- ----------- DAYT29 M&ROC AUSTIN HDR INT OTHER AUSTIN PSIM OTHER ----------------------------- DEMOGRAPHICS ---------------------------- Source: Self-Entered First Name: ONE Middle Initial: A Last Name: MHVVETERAN Suffix: Alias: MHVVET Relationship to VA: Patient, Veteran, Employee Gender: Male Blood Type: AB+ Organ Donor: Yes Date of Birth: 01 Mar 1948 Marital Status: Married Current Occupation: Truck Driver Mailing or Destination Address: 123 Anywhere Road Mailing or Destination Address2: Apartment 123 Mailing or Destination City: Anywhere Mailing or Destination State: DC Mailing or Destination Country: United States Mailing or Destination Province: Mailing or Destination Zip/Postal Code: 00001 Home Phone Number: 000-010-0101 Work Phone Number: 000-020-0202 Pager Number: 000-030-0303 Cell Phone Number: 000-040-0404 FAX Number: 000-050-0505 Email Address: mhvveteran@emailaddress.com Preferred Method of Contact: Email EMERGENCY CONTACTS Contact First Name: Two Contact Last Name: MHVVeteran Relationship: Home Phone Number: 000-010-0101 Work Phone Number: 000-060-0606 Extension: Cell Phone Number: 000-070-0707 Address Line 1: 123 Anywhere Road Address Line 2: Apartment 123 City: Anywhere State: DC Country: United States Province: Zip/Post Code: 00001 Email Address: twomhvveteran@domain.com Contact First Name: Three Contact Last Name: MHVVeteran Relationship: Home Phone Number: 000-010-0101 Work Phone Number: 000-080-0808 Extension: Cell Phone Number: 000-090-0909 Address Line 1: 123 Anywhere Road Address Line 2: Apartment 123 City: Anywhere State: DC Country: United States Province: Zip/Post Code: 00001 Email Address: threemhvveteran@domain.com --------------------- DOD MILITARY SERVICE INFORMATION --------------------- Source: DoD Last Updated: 02 Dec 2011 @ 1013 NOTE: This report may not show your complete DoD Military Service Information. For more information go to the FAQ tab. -- Regular Active Service Service Begin Date End Date Character of Service Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 06/11/2005 03/26/2007 Honorable COL Army 02/22/2009 02/21/2010 Honorable COL Army 04/10/2010 04/08/2011 Honorable COL -- Reserve/Guard Association Periods Service Begin Date End Date Character of Service Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Guard 01/11/1987 08/24/1993 Unknown Army Reserve 08/25/1993 10/25/2004 Unknown COL Army Reserve 03/27/2007 10/31/2008 Unknown COL -- Reserve/Guard Activation Periods Service Begin Date End Date Activated Under (Title 10, 32, etc.) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 11/10/2001 11/09/2002 Army Reserve 04/14/2003 10/13/2004 Army Reserve 10/24/2004 10/25/2004 Army Reserve 03/27/2007 10/24/2007 Army Reserve 02/04/2008 10/31/2008 -- Deployment Periods Service Begin Date End Date Conflict Location - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 03/01/2004 03/31/2004 OEF ZZ Army 01/01/2007 03/26/2007 OEF IZ -- DoD MOS/Occupation Codes -- Note: Both Service and DoD Generic codes may not be present in all records Service Begin Date Enl/Off Type Svc Occ Code DoD Occ Code - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 01/16/1975 Officer Duty 35B00 3A Army Reserve 01/16/1975 Officer Primary 35D00 3A Army Reserve 03/31/2002 Officer Duty 35D 3A Army Reserve 03/31/2002 Officer Primary 35D 3A Army Reserve 06/30/2002 Officer Duty 00A 9E Army Reserve 11/30/2002 Officer Duty 01A 9E Army Reserve 10/31/2003 Officer Duty 35D 3A Army 06/11/2005 Officer Primary 35D5K 3A Army 05/31/2006 Officer Duty 35D 3A Army Reserve 03/27/2007 Officer Primary 35D5K 3A Army Reserve 06/27/2007 Officer Duty 35D5K 3A Army 02/22/2009 Officer Duty 35D00 3A Army 02/22/2009 Officer Secondary 66HD5 6E18 Army 02/22/2009 Officer Primary 35D5K 3A -- Military/Combat Pay Details Service Begin Date End Date Military Pay Type Location - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 03/01/2004 03/31/2004 02 Army 01/01/2007 02 Army 01/01/2007 01 IZ -- Separation Pay Details Service Begin Date End Date Separation Pay Type - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- Retirement Periods Service Begin Date End Date Retirement Type Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 11/01/2008 02/21/2009 F COL Army 02/22/2010 04/09/2010 F COL Army 04/09/2011 F COL -- DoD Retirement Pay Service Begin Date End Date Dsblty % Pay Stat Term Rsn Stop Pay Rsn - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 10/31/2008 11/30/2008 00 1 C Z Army 12/01/2008 00 1 W Z Army 03/01/2010 07/31/2010 00 1 C Z Army 08/01/2010 00 5 W B Army 05/01/2011 05/31/2011 00 1 C Z Army 06/01/2011 00 1 W Z Translations of Codes Used in this Section: Service Occupation Codes 00A Officer Duties Unassigned 01A Officer Officer Generalist 35B00 Officer Land Combat Support Systems (LCSS) Test Specialist 35B00 Officer Strategic Intelligence (RC) 35D Officer Air Traffic Control Equipment Repairer 35D Officer All Source Intelligence 35D Officer Meteorological Equipment Repairman 35D00 Officer Air Traffic Control Equipment Repairer 35D00 Officer All Source Intelligence 35D00 Officer Meteorological Equipment Repairman 35D5K Officer Air Traffic Control Equipment Repairer 35D5K Officer All Source Intelligence 35D5K Officer Meteorological Equipment Repairman 66HD5 Officer Medical Surgical Nurse 66HD5 Officer Observation Airplane Technical Inspector DoD Occupation Codes 3A Officer Intelligence, General 9E Officer Other Military Pay Type Code 01 Combat Zone Tax Exclusion (CZTE) 02 Hostile Fire/Imminent Danger 03 Hazardous Duty incentive Separation Pay Type Code 01 Separation Pay 02 Readjustment Pay 03 Non-Disability Severance Pay 04 Disability Severance Pay 05 Discharge Gratuity 06 Death Gratuity 07 Special Separation Benefit 08 Voluntary Separation Incentive Pay 09 Voluntary Separation Pay (VSP) Retirement Type Code A Mandatory B Voluntary C Fleet Reserve D Temporary Disability Retirement List E Permanent Disability Retirement List F Title III G Special Act H Philippine Scouts Retired Pay Status Code 1 Receiving retired pay 2 Eligible, not receiving pay 3 Eligible, not receiving direct SBP remittance 4 Terminated 5 Suspended Retired Pay Termination Reason Code C Pay condition terminated S Pay terminated for the reason reported in the Stop Payment Reason Code W Not terminated Stop Payment Reason Code A Member died B Recalled to Active Duty C Removed from TDRL, returned to Active Duty D Removed from TDRL, returned to Civilian E Pay suspended, failure to report for TDRL physical F Civil Service retirement waiver G VA compensation waiver H Dual compensation, pay cap offset J Refused retired pay K Pay suspended, whereabouts unknown L Suspected death M Pay suspended, miscellaneous Z Not applicable -------------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------