OMB CONTROL NUMBER: 0702-XXXX
OMB EXPIRATION DATE: XX/XX/XXXX
Privacy Act Statement (PAS)
Authority: The authorities identified in the applicable system of system of records notice are DODI 5105.18 (DoD Intergovernmental and Intragovernmental Committee Management Program), Army Regulation 15-39 (Department of the Army Intergovernmental and Intragovernmental Committee Management Program) and the Survivor Advisory Working Group (SAWG) Charter.
Principal Purpose: Notification of application for two-year SAWG membership. Applications received will be reviewed and presented to the Army Chief of Staff for final selection.
Routine Use: The DOD Blanket Routine Uses found at: http://dpcld.defense.gov/privacy/ may apply to this collection.
In addition, individuals from whom information about them is solicited during administrative proceedings must be provided Privacy Act advisory statements if records of the proceedings will be retrieved by their personal identifiers. 5 U.S.C. § 552a(e)(3). (http://dpcld.defense.gov/Privacy/Authorities-and-Guidance/)
Disclosure: Furnishing the requested personal data is voluntary. However, selection to serve on the committee is reduced as it will be difficult to verify Next of Kin status of deceased Army service members.
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, [email protected] [0702-XXXX]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.
Responses should be sent to Department of the Army, Office of the Chief of Installation Management for the Department of the Army, Soldier & Family Readiness Division ATTN: Megan Coffey Washington, DC 20310 or email to [email protected].
Nominations are being accepted for Army Survivors to serve for the 2017-2019 Army Survivor Advisory Working Group (SAWG) term. The Chief of Staff of the Army established the Army SAWG in 2007 to provide advice and recommendations regarding vital Active Component, Army National Guard, and U.S. Army Reserve Survivor quality of life issues. Advisors also provide an assessment of how current Survivor programs and initiatives may affect the Survivor community.
The Army SAWG is a diverse group of Army Survivors who represent the Total Army and suffered loss in a variety of ways. The Army SAWG charter includes specific demographic requirements in order to represent all Army Survivors.
The Army SAWG application packet includes:
Authorization for Disclosure of Information
Personal data sheet
Personal statement
Sample Army SAWG issue review
Certificate of acknowledgement
Character recommendation from your Survivor Outreach Services coordinator, Survivor organization leader, volunteer organization leader, or employer.
Completed applications will be reviewed by an Army SAWG selection panel. Selected applicants will receive a telephonic interview. The Chief of Staff of the Army will approve new advisor selections and sign an advisor appointment letter.
We encourage interested Army Survivors to apply. Nominations must be submitted using the attached application packet no later than MM DD YYYY to [email protected] for the 2017-2019 Army SAWG term.
Privacy Notice: The main purpose for collecting the information contained in this application is to obtain the information necessary to select members for the Army Survivor Advisory Working Group (SAWG). The SAWG includes members who are government employees and members of military Families who are not government employees. Disclosure of the information requested to non-governmental SAWG members is voluntary. However, failure to disclose the information to non-governmental SAWG members may result in you not being considered for SAWG membership.
Please Initial One of the Options Below:
________I hereby authorize the U.S. Army, through its agents, to release a copy of my application for membership in the Survivor Advisor Working Group (SAWG) to current nongovernmental SAWG members, as part of the application review process. I understand this authorization may be revoked at any time, if requested in writing, except to the extent that action has already been taken.
________I DO NOT consent to the disclosure of my application to non-governmental SAWG members.
Use of Personal Information: The personal information contained in your application may only be used for the purpose of reviewing applications as part of the selection process for
membership in the SAWG. ANY DISCLOSURE OF PERSONAL INFORMATION BY THE RECIPIENT(S) IS PROHIBITED EXCEPT WHEN IT IS PURSUANT TO THE PURPOSES OF
THIS DISCLOSURE. THE GOVERNMENT CANNOT GUARANTEE THAT THE ORGANIZATION OR INDIVIDUAL WILL ABIDE BY THE AGREEMENT TO NOT FURTHER DISCLOSE THE INFORMATION.
__________________________________
Signature of Person and Date
__________________________________
Signature of Person and Date
Title
First name
Last name
Suffix
Nickname
Gender
Defense Enrollment Eligibility Reporting System (DEERS) identification card holder: Yes, No
Street address
Street address 2
City/town
State
Postal code
Country
Home phone
Work phone
Cell phone
Primary e-mail
Alternate e-mail
Preferred contact method: home; work; cell; e-mail
How did you learn about the Army Survivor Advisory Working Group
The deceased’s first name
The deceased’s last name
The deceased’s military rank or civilian grade
The deceased’s Army affiliation: Active Component; Army National Guard; US Army Reserves; Department of the Army Civilian
Number of years the deceased served with the Army
Your relationship to the deceased: spouse; child; step-child; parent; step parent; loco parentis; sibling; step-sibling; parent of the deceased’s dependent child • Date of deceased’s death
Deceased’s place of death
Deceased’s unit or organization at time of death
Cause of death: combat hostile action; combat friendly fire; service connected accident; non-service connected accident; illness; natural causes; homicide; workplace violence; terrorist attack; suicide. (check one)
Describe your experience as part of a survivor group project, the project's outcome and your role
Describe your involvement in any survivor groups, panels, associations, and offices held, if any
Describe your involvement as a survivor in local or national civic/federal organizations or with non-governmental organizations and offices held, if any
Please share links to your published works to include published articles, blogs, twitter handles, Facebook, and TV/internet interviews/videos, if any
Complete a personal statement in 250 words or less. The statement should explain your desire to serve on the Army Survivor Advisory Working Group, how you could impact survivor support and programs, and share a suggestion of a program or policy initiative you believe would positively impact survivor support.
As an advisor, you will review survivor quality of life issues submitted to the Army
Survivor Advisory Working Group for Department of the Army resolution. The Army Staff will prepare information papers for each issue. Using the information papers, advisors will be asked to independently prioritize the issues, meet in person at the Pentagon twice a year to discuss and jointly prioritize the issues, and report the top priorities to the Chief of Staff of the Army at the Army Survivor Advisory Working Group.
DIRECTIONS: Review the three sample Army Survivor Advisory Working Group issues and Army Staff facts below. Provide your written recommendation below on which issue should be reported to the Chief of Staff of the Army for resolution. Conduct additional independent issue research, if needed, to make informed decisions.
Write a maximum 100-word recommendation that supports your prioritized issue.
APPLICANT RESPONSE
Background:
The term of appointment for a member of the Army Survivor Advisory Working Group (SAWG), is a single two-year term.
The Army SAWG is held twice a year in the National Capital Region, with travel funding from the Department of the Army. The SAWG may involve five duty days to include travel, prep sessions, and the SAWG meeting.
As an advisor, you may meet virtually each month to discuss potential SAWG issues, plan meetings, and select new advisors.
I,_______________________________________________________________, acknowledge that:
I am expected to attend each SAWG meeting. Failure to attend more than two SAWG meetings may result in appointment termination. Exemptions are authorized for deployment or health restrictions, with advance written notification.
I am expected to attend virtual advisor meetings. Failure to attend more than four virtual advisor meetings may result in appointment termination. Exemptions are authorized for deployment or health restrictions with advance written notification.
I will acknowledge SAWG tasks emailed by the SAWG point of contact by the designated suspense date. Suspense dates are typically three weeks. Failure to electronically acknowledge more than two SAWG tasks by the suspense date may result in appointment termination. Exemptions are authorized for deployment or health restrictions with advance written notification.
I will not be authorized travel, lodging, meals, and incidental expense reimbursements by the Department of the Army if I live within the Washington local commuting area as defined by Department of Defense Instruction (DoDI) 4515.14, “Washington Local Commuting Area,” 28 Jun 13. These areas include
(but are not limited to): in Virginia: the counties of Albemarle, Arlington, Clarke,
Culpeper, Fairfax, Fauquier, Greene, King George, Loudoun, Madison, Orange,
Prince William, Spotsylvania, and Stafford. It also includes the cities of Alexandria, Fairfax, Falls Church, Fredericksburg, and all cities now and hereafter existing in the geographic area bounded by the outer boundaries of the combined areas of these listed Virginia counties. In the District of Columbia: the entire area within the boundaries of Washington, DC. In Maryland: the counties of Anne Arundel, Baltimore, Calvert, Carroll, Charles, Frederick, Harford, Howard, Montgomery, Prince George’s, St. Mary’s, and Washington. It also includes the city of Baltimore and all cities now and hereafter existing in the geographic area bounded by the outer boundaries of the combined areas of the counties listed above. In Pennsylvania: the county of Adams. In West Virginia: the counties of Morgan, Berkeley, and Jefferson.
I will be authorized travel, lodging, meals, and incidental expense reimbursements by the Department of the Army if I live outside the Washington local commuting area as defined by DoDI 4515.14, “Washington Local Commuting Area,” 28 Jun 13. If my trip includes meals paid for by a senior leader or the government, I will deduct the meals from my reimbursement voucher.
I will read and sign a nondisclosure agreement related to my SAWG work.
It is my responsibility to arrange with my employer or school (if applicable) for my absence to attend SAWG meetings.
I am a competent e-mail and Microsoft Word user.
I will not be reimbursed for installation of broadband or telephone lines, for internet or phone connectivity, or for any hardware associated with conducting official SAWG business.
I will be required to travel and enter a secured government facility. I possess one of the following: a state driver’s license or identification card; U.S. government common access card; DoD identification card for retirees, dependents, and inactive reservists; U.S. passport or passport card; foreign passport; permanent resident card; or alien registration receipt card. I realize state driver's licenses from Minnesota, Washington, Illinois, Missouri, and American Samoa are not “Real ID” compliant and will not be accepted as a form of identification when traveling and entering a secured government facility.
I realize I will deliberate over emotionally charged survivor issues and I am prepared to discuss my own loss and survivor experiences with the SAWG.
_____________________________________
(Signature)
_____________________________________
(Printed or Typed Name)
Please provide a character reference, preferably from your Survivor Outreach Services coordinator, survivor organization leader, volunteer manager, employer, or religious leader (not related to you) who knows you personally and can speak to your strength as a survivor advocate.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Christina Vine |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |