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Army IG Action Request Form
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY:
10 U.S.C. 7013, Secretary of the Army; 10 U.S.C. 7020, Inspector General; Inspector General Act of 1978, Public Law 95-452, 92 Stat.1101 (1978), as amended; DoDD 1030.1, Victim and Witness Assistance; AR 20-1, Inspector General Activities and Procedures.
PRINCIPAL PURPOSE:
To secure information sufficient to inquire into the matters presented, to take action to correct deficiencies, and to respond to requesters.
ROUTINE USES:
Information is used for official purposes within the Department of Defense; to answer complaints or respond to requests for assistance, advice, or information; by Members of Congress and other Government agencies when determined by the
Inspector General to be in the best interest of the Army; and, in certain cases, in trials by court-martial and other military matters as authorized by the Uniform Code of Military Justice.
DISCLOSURE:
Voluntary. However, failure to provide complete information may hinder proper identification of the requester,
accomplishment of the requested action(s), and response to the requester.
SORN:
A0020-1 SAIG, Inspector General Records (January 11, 2002, 67 FR 1447)
1. LAST, FIRST, MIDDLE INITIAL
2. GRADE/RANK
3. DOD ID
4. COMPONENT/DUTY STATUS
5. PREFERRED CONTACT TELEPHONE (DUTY, HOME, AND/OR CELL)
6. E-MAIL ADDRESS(ES)
7. UNIT AND COMPLETE MILITARY ADDRESS (POINT OF CONTACT/TELEPHONE IF APPLICABLE)
8. PREFERRED MAILING ADDRESS (IF DIFFERENT FROM MILITARY ADDRESS, INCLUDING ZIP CODE)
9. SPECIFIC ACTION REQUESTED (WHAT DO YOU WANT THE IG TO DO FOR YOU?)
10. HAVE YOU CONTACTED YOUR CHAIN OF COMMAND OR ANY AGENCY CONCERNING THIS REQUEST? (EXPLAIN FOR BOTH YES AND NO RESPONSES.)
Yes
No
Explain for both Yes and No
11. INFORMATION PERTAINING TO THIS REQUEST (BE SPECIFIC AND DETAILED. LIST ANY SUPPORTING DOCUMENTATION OR ENCLOSURES IF APPLICABLE.)
12. I do/ I do not consent to release my personal information outside of IG channels (but within DoD official channels) in order to resolve the matters listed above. I understand that if I do not agree to release my personal information, my request for assistance may go unresolved.
I consent
I do not consent
*
13. I do/I do not consent to release the supporting documents I provided to the IG (to exclude this DA Form) outside of IG channels to the chain command or other officials (but within DoD channels) in order to resolve the matters listed above. I understand that if I do not release my documents, my request for assistance may go unresolved.
I consent
I do not consent
*
This information is submitted for the basic purpose of requesting assistance, correcting injustices affecting the individual, or eliminating conditions considered detrimental to the efficiency or reputation of the Army. Those who knowingly and intentionally provide false statements on this form are subject to potential punitive and administrative action (UCMJ Art 107, 18 USC 1001).
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