In the case of military personnel, the requested information is mandatory because of the need to document all active duty medical incidents in view of future. Do not process, store, or transmit any personally identifiable information pii, unclassifiedfouo or classified information on. The template can be easily available on word and pdf files. There is nothing that will serve and protect the navys. Issued by the epa chief information officer, pursuant to delegation 119, dated 772005 procedures for preparing. Provide an orderly means of discharge for enlisted personnel. Download free printable privacy act statement form samples in pdf, word and excel formats. Navy alcohol and other drug rehabilitation program personnel must take every precaution to protect confidential information as described in paragraph 4. Naval forms online fill out and sign printable pdf template.
Navy website dod resource locator 45376 sponsored by the department of the navy chief information officer don cio. The advanced tools of the editor will guide you through the editable pdf template. To officially report the facts and circumstances supporting the assessment of financial charges for the loss, damage, or destruction of dodcontrolled property. Address commandant of the marine corps arsf headquarters us marine corps 3000 marine corps pentagon rm 2b289 washington, dc 203503000 usmc privacy program coordinator. Dd form 2923 download printable pdf or fill online privacy. It is the policy ofthe department ofthe navy don to ensure a work environment for all employees that is free from discrimination and harassment both. Requests for personal information require a signature and cannot be processed through this. Opnav 523914 rev 92011 replaces rev 72008, which is obsolete page 1 of 4for official use only when filledauthority. Second, if you or your counsel have any objection to any matters introduced or to any proceedings of the board, you or your counsel may state your objection and the reasons for it. Privacy act of 1974 department of navy chief information. Defense privacy and civil liberties office introduction to the privacy act 5 exceptions to the no disclosure to third parties without. These may be completed by the clinic staff or the service member.
Privacy act system of records notices united states navy. To record names, signatures, and social security numbers for the purpose of validating the trustworthiness of. Dd74 dependency statement child born out of wedlock under age 21 dd448 military interdepartmental purchase request dd397 claim certification and voucher for death gratuity payment dd462 bond of person designated to act on behalf of incompetent member or former dd410 telephone service, requisition for dd365 weight and balance personnel, record of dd460. I have a right to inspect and receive a copy of my own protected health information to be used or disclosed, in accordance. The unauthorized disclosure may result from criminal and civil penalties. Do not submit the saarn package without having the following items. This all inclusive privacy act statement will apply to all requests for personal. How and when to write a privacy act statement don cio navy. In this case, the dd form 2923 should be displayed on the front of the document folder or packet. When a suit is filed, the first document that is requested by both the attorneys representing the navy and attorneys on the other side is the jagman investigation. Information pertinent to the following situations, however, must be reported via the chain of command to your commanding officer.
Co is an o4 or above, not under original mso, under initial eight year mso. Navy websites, nor does it share the data obtained through such. Contents shall not be disclosed, discussed, or shared with individuals unless they. Executive order 10450, public law 99474, the computer fraud and abuse act. Coast guard see coast guard aviation medicine manual, chapter 1.
The privacy act of 1974, 5 usc 552a, provides protection to individuals by ensuring that. There is nothing that will serve and protect the navy s. In addition to their being used within the departments of the navy and defense for the purposes indicated above, patient files and records may be used by command officers to commence administrative processing of the patient, if necessary, under opnavinst 5350. Attach the cover sheet to the front of all folders and. Dd form 2005, privacy act statement health care records. Defense privacy, civil liberties, and transparency. We bring you the letter of privacy act cover sheet template that includes the required information of the privacy act that must be read by any third person before forwarding the documents.
Department of homeland security privacy act statement guidance. Note that the documentation must be delivered directly to the intended recipient and not left with a third party. I shall rule finally on all matters of procedure and evidence. Requests for other documents should be sent directly to the department of the navy on the navy web site. Any misuse or unauthorized disclosure of this information may result in both criminal and civil penalties. This form is used to document a members request for verification of military service. The security accreditation level of this site is unclassified and below. A complete listing of department of defense systems of records notices sorns can be found at the sorns index page. Ftsregnav adseps are submitted to pers832 for processing. Secnav don cio navy pentagon washington, dc 20350. Privacy act statement health care records in the case of military personnel, the requested information is mandatory because of the need to document all active duty medical incidents in view of future rights and benefits.
The purpose of this website is to facilitate effective information flow about information managementinformation technology and cybersecurity issues and initiatives occuring within the department of the navy. Ranktitle, first mi last name ranktitle, first mi last name signature date y m d da form 7433, apr 2009. Please see the below table for the sorns associated with the. The following links provide access to all department of defense sorns by dod agency, as well as direct links to navy and marine corps sorns. Nm05002 program system authorization access request navy saarn privacy act statement management and locator system. Transform passwords almost when there is a violation. The purpose of this website is to facilitate effective information flow about information managementinformation technology and cybersecurity issues and initiatives occuring within the department of the. Navy does not use the information associated with cookies to track individual user activity on the internet outside u. Service agreement is used as the contract between a military department army navy air force and an individual selected to enter the active duty health. Privacy act statement form 2 free templates in pdf, word. If the information requested will not be included in a system of records, then a pas is not required. In the case of all other personnel beneficiaries, the requested information is. Use navy it resources in a way that would reflect adversely on the navy.
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