DOJ-OGR-00025669.jpg

The image is a scanned document with various fields of information printed on it. The top of the document has a heading that reads "Medical Staff Psychological Evaluation Update". Below this header are checkboxes next to words such as "Approve" and "Deny", suggesting that someone must decide whether or not to approve an evaluation update. There is also a place for the name of a person, presumably the applicant or evaluator, labeled "Dr. James E. Smith". The bottom part of the document includes fields for dates and signatures, indicating where it would be signed by relevant parties after review.