In this case, the dd form 2923 should be displayed on the front of the document folder or packet. The privacy act of 1974, 5 usc 552a, provides protection to individuals by ensuring that personal information collected by federal. Secnav don cio navy pentagon washington, dc 20350. Have completed the necessary training with regards to security awareness and safeguarding personally identifiable information. Information about the privacy act statement and security.
Do not process, store, or transmit any personally identifiable information pii, unclassifiedfouo or classified information on this system. Used by recruiter selection teams when interviewing recruiter applicants. Privacy act statement army fill out and sign printable. Information collected will be used to expedite the selection process of. No agency shall disclose any record which is contained in a system of records by any means of communication to any person, or to another agency, except pursuant to a written request by, or with the prior written consent of, the individual to whom the record pertains, unless disclosure of the record would be. Today, tsgt cody smith was the 49th special tactics airman to receive this medal since sept. Army, and to allow army officials to maintain discipline, law and order through investigation of complaints and incidents. Ssn and personal information in hisher leaders book with the understanding that this information will. The privacy act, passed by congress in 1974, establishes certain controls over what personal information is collected by the federal government and. If you forwarded less dollars than you owe, the statement will read as.
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. Sworn statement for use of this form, see ar 19045. Privacy act statement army fill out and sign printable pdf. Read privacy act statement, penalty statement, and. The unauthorized disclosure may result from criminal and civil penalties. This form is not an authorization or consent to use or disclose your health information. To provide detailed information necessary for army officials and commanders to discharge their responsibilities for maintaining discipline, law and order through investigation of complaints and incidents and possible criminal prosecution, civil court action, or regulatory order. For block 20, the ges govrep shall list the applicable contract number which applies to the individual in block 1.
Collection of this information is authorized by 10 usc, sections 503 and 30. This data is used to provide human resource management and succession planning for the army s senior military leaders. No agency shall disclose any record which is contained in a system of records by any means of communication to any person, or to another agency, except pursuant to a written request by, or with the prior written consent of, the individual to whom the record pertains, unless disclosure of. The information may be disclosed to the agency contractors, grantees, experts, consultants, or volunteers who have been engaged by the agency to assist in the performance of a service. 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. The latest technologies high quality electronic pubs and forms view u. Navy website dod resource locator 45376 sponsored by the department of the navy chief information officer don cio. Information, which discloses that any crime or illegal act is about to take place.
The army privacy program army publishing directorate. A person designated to make scaadl decisions for the service member. No agency shall disclose any record which is contained in a system of records by any means of communication to any person, or to another agency, except pursuant to a written request by, or with the prior written consent of, the individual to whom the record pertains subject to 12 exceptions. Employees who violate security regulations or make unauthorized use of dod interest. By completing and signing this form, individual authorizes fort gordon or gillem. Leader guide to protecting personally identifiable.
Army da administrative publications and forms by the army publishing directorate apd. Cookie disclaimer there may be areas on our websites that require the use of biscuits. To be used on all documents containing personal information. You must at least complete the first portion on who you are and when and where you deployed. Information collected will be used to expedite the selection process of recruiter applicants. 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. Do not process, store, or transmit any personally identifiable information pii, unclassifiedfouo or classified information on. The security accreditation level of this site is unclassified and below. United states army human resources command soldiers first. Sep, 2010 secnav don cio navy pentagon washington, dc 20350.
Dd form 2005, privacy act statement health care records. Issued by the epa chief information officer, pursuant to delegation 119, dated 772005 procedures for preparing. Dd form 2923 download printable pdf or fill online privacy. All proceeds from the operation of this site are donated to veteran and other charities. To obtain information about individuals who seek access to fort gordon or gillem enclave for employment, recreation or other purposes. To document and certify student enrollment and graduation data. I have a right to inspect and receive a copy of my own protected health information to be used or disclosed, in accordance. In the case of military personnel, the requested information is mandatory because of the need to. You are entitled to a copy of this privacy act statement.
If i am separated prior to my ets, i consent to withholding from current pay, final pay, or any other money due me to. 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. Introductionto theprivacyact defense privacy and civil. If monitoring of this or any other dod interest computer system reveals a possible violation of criminal statutes, this evidence and any other related information, including identification information about the user, may be provided to law enforcement officials. An individuals privacy is a f u n d a m e n t a l l e g a l r i g h t t h a t m u s t b e r e s p e c t e d a n d p r o t e c t e d. Attach the cover sheet to the front of all folders and. 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. If you do not understand a question, please discuss the question with a health care provider. The data provided will be used to update your military personnel record. Contents shall not be disclosed, discussed, or shared with individuals unless they. Making a false statement or claim against the us government is punishable by courtsmartial. Below is a list of the most current united states army cadet command forms, checklists, policies, pamphlets, sops and regulations. Note that the documentation must be delivered directly to the intended recipient and not left with a third party.
Defense privacy and civil liberties office introduction to the privacy act 5 exceptions to the no disclosure to third parties without. Privacy act statement and advisories allow the individual to make an informed decision about providing their data. This could be a person designated by the service member, a courtappointed guardian, or a personal representative in accordance with dod 6025. Information, which discloses a past crime, illegal act, or incident, which places the command or any of its members in jeopardy. I understand that any falsification of this statement is punishable under the provisions of title 18, united states code u. Ranktitle, first mi last name ranktitle, first mi last name signature date y m d da form 7433, apr 2009. The advanced tools of the editor will guide you through the editable pdf template.
The army maintains records during the conduct of army business. 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. To document potential criminal activity involving the u. Payment by check is made to travelers only when eft payment is not directed. Transform passwords almost when there is a violation. This data is used to provide human resource management and succession planning for the armys senior military leaders. The way to complete the online privacy act statement army on the internet.
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