Department of defense privacy program, november 16, 2004. In the case of military personnel, the requested information is mandatory because of the need to. Transform passwords almost when there is a violation. Furnishing the information on this form is voluntary, but failure to do so may result in disapproval of this request. The army privacy program army publishing directorate army. Ak reg 690 530 privacy act statement collection of the requested information is authorized by title 5, u. Department of the army privacy impact assessment pia guide. Ssn and personal information in hisher leaders book with the understanding that this information will. Name last, first, middle initial part i administrative data for official use only fouo see privacy act statement in ar 6233. Data required by the privacy act of 1974 eligibility for amedd officer procurement programs miscellaneous documentation for use of this form, see ar 5101. I understand that many laws, regulations, and military customs will govern my conduct and require me to do things under this agreement that a civilian does not have to do. Special compensation for assistance with activities of daily living process, and the attached instructions before completing this form. Cookie disclaimer there may be areas on our websites that require the use of biscuits.
Secnav don cio navy pentagon washington, dc 20350. Privacy act statement army fill out and sign printable pdf. A person designated to make scaadl decisions for the service member. New dod information systems o an information system is a set of information resources organized for the collection, storage, processing, maintenance, use, sharing, dissemination, disposition, display, or transmission of information including automated. Information collected will be used to expedite the selection process of recruiter applicants. The way to complete the online privacy act statement army on the internet.
To the privacy act of 1974 contents shall not be disclosed, discussed, or shared with individuals unless they have a direct needtoknow in the performance of their official duties. Dd form 2005, privacy act statement uconn army rotc. Attach copy yes no duty position yymmdd please circle. To record personal information on an individual who registers their firearms or privately owned weapons pows on fort gordon. Information may be collected from you to provide and document your medical care. Dd form 51 2, travel voucher or subvoucher, may 2011 author. This all inclusive privacy act statement will apply to all requests for personal. This information will be used by supervisors, the usag ansbach at division, and the garrison security.
The information solicited on this form may be made available as a routine use to other government agencies for law enforcement and administrative purposes. I understand that any falsification of this statement is punishable under the provisions of title 18, united states code u. Army records, regardless of media, aremaintained from creation through final disposition in a manner that protects the rights and interests of individuals and the federal. Privacy act statement army senior rotc disenrollment proceedings pam 1454 keywords. I have a right to inspect and receive a copy of my own protected health information to be used or disclosed, in accordance.
Other dod personnel, such as authorized alcohol and other drug screening, counseling, treatment, or other medical personnel who have a need to know, are authorized access to confidential information. Ncoer counseling and support form for use of this form, see ar 6233. Having trouble downloading pdf files or with the pdf editor. Contents shall not be disclosed, discussed, or shared with individuals unless they. Commanders hotline for your issues, concerns or good ideas. Public law 91596, occupational safety and health act of 1970. To provide for documentation of the results of laboratory examinations of a deceased animal for rabies. Dd form 2923 privacy act data cover sheet templateroller. Note that the documentation must be delivered directly to the intended recipient and not left with a third party. If i am separated prior to my ets, i consent to withholding from current pay, final pay, or any other money due me to. To be used on all documents containing personal information. Privacy act statement army fill out and sign printable. This form becomes a part of the services enlisted master file and field personnel file. The unauthorized disclosure may result from criminal and civil penalties.
Privacy act statement signature of the applicant city, country. Army da administrative publications and forms by the army publishing directorate apd. Used by recruiter selection teams when interviewing recruiter applicants. Signatories of this form certify that they will comply with the domestic violence amendment to the gun control act of 1968, army regulations, local regulations and local and state laws on ownership, possession, registration, transportation and safe use of privately owned weapons and ammunition. This form is not an authorization or consent to use or disclose your health information. Use this stepbystep guide to complete the soldiers privacy act statement form quickly and with ideal precision. This is a military form that was released by the u. Indicate whether the individual has an opportunity to decline or opt out of some or all uses of their pii that is collected, maintained, used, or disseminated by the information systems. The purpose of collecting this information is to conduct background checks on visitors to army facilities and installations. Dd form 2005, privacy act statement health care records. Today, tsgt cody smith was the 49th special tactics airman to receive this medal since sept.
The access right cannot be delegated below the level of executive officer and is subject to the limitations on disciplinary and administrative action contained in other parts of this statement. For the purposes of this section, the parent of any minor, or the legal guardian of any individual who has been declared to be incompetent due to physical or mental incapacity or age by a court of competent jurisdiction, may act on behalf of the individual. The appearance of hyperlinks does not constitute endorsement by the united states army recruiting command usarec of this web site or the information, products or services contained therein. In this case, the dd form 2923 should be displayed on the front of the document folder or packet. This form is not an authorization or consent to use or disclose your health. Navy website dod resource locator 45376 sponsored by the department of the navy chief information officer don cio. Guardians agreement to care for a soldiers children in his or her absence. The privacy act of 1974, 5 usc 552a, provides protection to individuals by ensuring that personal information collected by federal. Sworn statement for use of this form, see ar 19045.
However, failure to provide all the requested information could lead to rejection of a soldiers family care plan. Directivetype memorandum dtm17004, department of defense expeditionary civilian. Callers will receive a response within two working days. One of the most important jobs i have is helping my constituents when they are having problems with federal agencies. The social security number and other personal information is required for proper identification of the individual. Read privacy act statement, penalty statement, and. Ranktitle, first mi last name ranktitle, first mi last name signature date y. Enter your official contact and identification details. Form impchawpls1 revised august 2011 see privacy act statement on reverse yymmdd required for asisqi producing courses military training request the proponent of this form is the directorate of plans, training, mobililization and security previous form is obsolete rankgrade profile. All proceeds from the operation of this site are donated to veteran and other charities. The information provided by you in this form will be subject to the following routine uses.
Pay close attention to duty requirements, currency laws, bans on importation. The advanced tools of the editor will guide you through the editable pdf template. Information about the privacy act statement and security. Deliver thisthese documents directly to the intended recipient. Ranktitle, first mi last name ranktitle, first mi last name signature date y m d da form 7433, apr 2009. Army regulation 190, the army physical security program, authorizes the solicitation of personal information to check the records of the national crime information center. Collection of this information is authorized by 10 usc, sections 503 and 30. This information may be disclosed to federal, state, local, or foreign agencies responsible for. The latest technologies high quality electronic pubs and forms view u. The army maintains records during the conduct of army business. Da form 7694 download fillable pdf or fill online privacy statement. Title 10, united states code, sections 30, 50, and 80.
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