DD Form 3112 Personnel Accountability and Assessment for a Public hea

PERSONNEL ACCOUNTABILITY AND ASSESSMENT FOR
A PUBLIC HEALTH EMERGENCY

OMB No. 0720-0067
OMB approval expires
YYYYMMDD

The principal purpose of this form is to collect information used to protect the health and safety of individuals working in, residing on, or assigned to DoD
installations, facilities, field operations, and commands, and to protect the DoD mission. When authorized by DoD, this form may be used to provide information
about individuals who are infected or otherwise impacted by a public health emergency or similar occurrence or when there is an isolated incident in which an
individual learns they have been exposed to a communicable disease. The information submitted about the Affected Individual will be maintained in accordance
with the Privacy Act of 1974. A Privacy Act Statement is provided on page 3 of this form.

SECTION I: SUBMITTER INFORMATION
1. DATE REPORT SUBMITTED

2. FULL NAME OF SUBMITTER (Last, First, Middle)

3.a. IF OTHER, DESCRIBE

5. JOB TITLE OF SUBMITTER

3. RELATIONSHIP TO THE AFFECTED INDIVIDUAL

4. DoD COMPONENT/OFFICE OF SUBMITTER

6. PHONE NUMBER

7. E-MAIL ADDRESS

SECTION II: AFFECTED INDIVIDUAL INFORMATION
1. NAME (Last, First, Middle Initial)

2. DoD ID# (For facility access records)

3. DoD AFFILIATION

4. BRANCH OF SERVICE (If military)

DRAFT

5. ASSIGNED DoD COMPONENT (Check one and list component)
Office of Secretary of
Defense (e.g. P&R, A&S)
Defense Agency (e.g. DISA,
DMA)
6. PRIMARY WORK LOCATION
NATIONAL CAPITAL REGION (NCR):

Field Activity (e.g. OEA,
WHS)
Military Service (list Branch
of Service)

Other

OCONUS:

CONUS (Other than NCR):

PENTAGON

STATE

COUNTRY

MARK CENTER

MILITARY INSTALLATION

MILITARY INSTALLATION

DHHQ
MILITARY INSTALLATION
LEASED FACILITY
OTHER
FACILITY ACCESS (list all facilities that the Affected Individual has access to):

NO

7. TRAVEL WITHIN THE LAST 30 DAYS? (Outside local commuting area)
LOCATION

YES (List location(s) and date(s) below)

DATE RETURNED FROM TRAVEL

8. TYPE OF CONFIRMED OR POSSIBLE HEALTH/SAFETY ISSUE
COMMUNICABLE DISEASE (i.e. Smallpox, Cholera, COVID-19, etc.)
9. SYMPTOMS (Check one)
SYMPTOMATIC (Exhibiting symptoms)

DATE SYMPTOMS BEGAN

ASYMPTOMATIC (No symptoms)

DATE OF POTENTIAL EXPOSURE

DD FORM 3112, APRIL 2020

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10. CURRENT STATUS (Check one)
SELF-ISOLATING (Provide reason):
CLOSE CONTACT

RECENT INTERNATIONAL TRAVEL

DIRECTED QUARANTINE (By whom?)
HOSPITAL
OTHER (explain)
IF THE AFFECTED INDIVIDUAL IS SELF-ISOLATING OR UNDER QUARANTINE, WHEN DID THEY START?

SECTION III: FOR AGENCY USE ONLY
1. NAME OF CALL TAKER (Last, First, Middle Initial) 2. AFFILIATION/ORGANIZATION

3. PHONE NUMBER

4. E-MAIL ADDRESS

5. STATUS ON RECOVERY AND RETURN

6. NOTES

INSTRUCTIONS
SECTION I - SUBMITTER INFORMATION
This section is to be filled out by either the Affected Individual or the individual
reporting about the Affected individual. It could be filled out by a supervisor,
agency representative, supervisor, a contracting officer representative, or in the
event that the Affected Individual was a visitor to a DoD facility, the DoD employee
who sponsored the individual.

4. Branch of Service: If the Affected Individual is a military Service member,
enter the branch of service.

DRAFT

1. Date Report Submitted: Date report was submitted.

2. Full Name of Submitter: Enter full name of the individual submitting the report.
3. Relationship to the Affected Individual: Check the appropriate block.
4. DoD Component / 5. Office of Submitter: DoD Component and Office of
Submitter are most relevant when the person submitting the information is a
representative from the Affected individual's agency.
6. Phone Number: Enter best contact number.
7. E-mail Address: Enter best contact e-mail address.
Contact information is required in the event there are questions about the
information submitted on the form.

SECTION II: AFFECTED INDIVIDUAL INFORMATION
Accurate completion of this section will inform decisions made about the status of
DoD facilities and spaces that the Affected Infdividual has entered. This
information may be used to make decisions to protect the health and safety of
DoD personnel and facilities. It may also be used to notify other individuals who
may have contacted the Affected Individual.
1. Full Name of Subject: Enter full name of the Affected individual, or individual
affected by the disease or agent.
2. DoD ID #: Enter DoD ID#, which can be found on the back of the individual's
Common Access Card or the front of the individual's Military ID.
3. DoD Affiliation: Enter the Affected Individual's DoD affiliation (military Service
member, civilian, contractor, dependent, family member, retiree, other)

5. Assigned DoD Component: Enter the DoD Component to which the Affected
Individual is assigned. If the Affected Individual is a military Service member, they
may be assigned to their branch of service or to another DoD Component.
6. Primary Work Location: List the PUI's primary work location and the facilities
to which they have access.
7. Travel within last 30 days?: Identify whether or not the PUI has traveled
outside of the local commuting area with the last 30 days. Include the location(s)
and date(s) of travel if applicable.
8. Type of Confirmed or Possible Health/Safety issue: Provide the specific
health/safety issue of the Affected Individual. Communicable diseases may
include: Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow
Fever; and Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo,
South American, and others not yet isolated or named), or Influenza caused by
novel or re-emergent influenza viruses that are causing, or have the potential to
cause, a pandemic.
9. Symptoms: Choose one option; if the Affected Individual has symptoms,
include the date the symptoms began. If the Affected Individual was in contact
with someone with symptoms, include the date of their potential exposure, if
known.
10. Current Status: Choose the current status of the Affected Individual. If they
are self-isolating, include the reason why. If they are under quarantine, include
who directed them to quarantine; provide the date that the quarantine or selfisolation began, if applicable.
SECTION III - FOR AGENCY USE ONLY
This section is for use of the agency that is collecting and processing this form.
1. Name of Call Taker: Individual who is processing the form.
2. Affiliation/Organization: Enter call taker's affiliation and/or organization.
3. Phone Number: Enter best contact number.
4. E-mail Address: Enter best contact e-mail address.
5. Status on recovery and return to work: May be used to input the status of the
Affected Individual's recovery and their return to work status.
6. Notes: This section is for receiving agency to use to include any notes.

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TERMS & DEFINITIONS
Public Health Emergency. An occurrence or imminent threat of an illness or health condition that poses: A high probability of a significant number of deaths in
the affected population considering the severity and probability of the event; A significant number of serious or long-term disabilities in the affected population
considering the severity and probability of the event; Widespread exposure to an infectious or toxic agent, including those of zoonotic origin, that poses a
significant risk of substantial future harm to a large number of people in the affected population; Health care needs that exceed available resources; or
Severe degradation of mission capabilities or normal operations.
Call-Taker. Individual who receives/processes the form on behalf of the installation commander or senior DoD official.
Affected Individual: The individual who has symptoms from or been diagnosed with a communicable disease, or who has been in contact with someone who
has been diagnosed with a communicable disease.
Communicable Disease. An illness due to a specific infectious agent or its toxic products that arises through transmission of that agent or its products from an
infected or affected individual, animal, or a reservoir to a susceptible host, either directly or indirectly through an intermediate animal host, vector, or the
inanimate environment.
Isolation. The separation of sick people with a contagious disease from people who are not sick by medical professionals.
Self-Isolation. When an individual voluntarily separates themselves from people who are not sick to prevent the spread of a communicable disease.
Quarantine. The separation of an individual or group that has been exposed to a communicable disease, but is not yet ill, from others who have not been so
exposed, in such manner and place to prevent the possible spread of the communicable disease.

PRIVACY ACT STATEMENT
Authority: 10 U.S.C. 113, Secretary of Defense; 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. 7013, Secretary of the
Army; 10 U.S.C. 8013, Secretary of the Navy; 10 U.S.C. 9013, Secretary of the Air Force; 10 U.S.C. 2672, Protection of Buildings, Grounds, Property, and
Persons; DoD Instruction 6200.03, Public Health Emergency Management (PHEM) Within the DoD; and DoD Instruction 6055.17, DoD Emergency
Management (EM) Program.

DRAFT

Principal Purpose: To accomplish personnel accountability and conduct status assessments for DoD-affiliated personnel during a public health emergency,
including a pandemic, major public health outbreak, or similar crisis, or when directed by the Secretary of Defense. Information will be used to inform the
agency's response to the emergency, including measures to ensure the safety and protection of the workforce and workplace.
Routine Use(s): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records may specifically be
disclosed outside of DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3), including as follows: To persons, organizations, or governmental entities (e.g., other
Federal, State, territorial, local, or foreign, or international governmental agencies or entities, first responders, American Red Cross, etc.), as is necessary and
relevant to notify them of, respond to, or guard against a public health emergency, or other similar crisis. To contractors, grantees, and others performing or
working on a contract, grant, or similar assignment for the federal government when necessary to accomplish an agency function related to this system of
records.
A complete list of routine uses may be found in the applicable System of Records Notice (SORN), DPR 39 DoD, “DoD Personnel Accountability and
Assessment System” at https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DPR-39-DoD.pdf.
Disclosure: Voluntary; however, failure to provide such information may hinder DoD's ability to effectively respond to the public health emergency or crisis,
thereby increasing the health or safety risk to DoD-affiliated personnel and its facilities. Failure to provide such information may also result in restricting the
Affected Individual's access to DoD facilities.

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 5 minutes 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, to the Department of
Defense, Washington Headquarters Services, at [email protected]. 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.

DD FORM 3112, APRIL 2020

PREVIOUS EDITION IS OBSOLETE.

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