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Date of Report Request:
Name of Individual Being Monitored:
Date of Birth of Individual Being Monitored:
Employee ID (if applicable):
Base Meeting or Peer Appointment ABSENCES: (for 'None' enter '0')
I have been in contact with this airman on the following dates since the last report:
Airman Sobriety Date:
Airman has a 12-Step Sponsor: YesNo
Airman is working step:
Further comments are appreciated to assist with oversight and monitoring by IMS and Psychiatrist: (Consider asking questions such as: How has your recovery improved over past 6 months? -or- Describe what is different about you today because you are sober? Ask for specifics.)
To the best of my knowledge this airman has remained totally abstinent. I have no concerns. I agree to notify the IMS of any changes.
Position or Job Title:
Leave this empty:
Your legal name
Your email address
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Document Name: Peer Report
Agree & Sign