DD Form 3112 Personnel Accountability and Assessment Notification for

OMB No. 0720-0067
OMB approval expires
20270131

PERSONNEL ACCOUNTABILITY AND ASSESSMENT
NOTIFICATION FOR A PUBLIC HEALTH EMERGENCY

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 constituting a significant public health concern. Only one form per Affected Individual is
required.
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. 137, Under Secretary
of Defense for Intelligence and Security; 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; Public Law 117-82, National Defense Authorization Act for Fiscal Year 2022,
including sections 910 (CrossFunctional Team for Emerging Threat Relating to Anomalous Health Incidents) and 6603 (Anomalous Health Incidents Interagency
Coordinator); DoD Directive 5525.21, Protection of Buildings, Grounds, Property and Persons and Implementation of 2672 of Title 10, United States Code; DoD
Instruction (DoDI) 3001.02, Personnel Accountability in Conjunction with Natural or Manmade Disasters; DoDI 6200.03, Public Health Emergency Management
(PHEM) Within the DoD; DoDI 6055.17, DoD Emergency Management (EM) Program; DoDI 1444.02, Volume 2, Data Submission Requirements for DoD
Civilian Personnel: Nonappropriated Fund (NAF) Civilians; and E.O. 9397, as amended.
PURPOSE: To accomplish personnel accountability and conduct status assessment for the 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 USES: In addition to those disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, these records may
specifically be disclosed outside the DoD as a routine use To contractors, grantees, experts, consultants, students, and others performing or working on a
contract, service, grant, cooperative agreement, or other assignment for the federal government; Office of Personnel Management (OPM); To any person,
organization or governmental entity (e.g., other Federal, State, territorial, local, or foreign, or international governmental agencies or entities, first responders,
American Red Cross, etc.) For a full listing of the Routine Uses, refer to below applicable SORNs hyperlinked below.
APPLICABLE SORN: DoD-0012, Defense Accountability and Assessment Records, (December 16, 2022; 87 FR 77088) https://www.federalregister.gov/
documents/2022/12/16/2022-27145/privacy-act-of-1974-system-of-records
DISCLOSURE: Voluntary. If you choose not to provide the requested information, there may be an administrative delay processing your request and the DHA
may be unable to process it; however, no penalty will be imposed.
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 10 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.
SECTION I: SUBMITTER INFORMATION
1. REPORT DATE
(YYYYMMDD):

Initial

2. REPORT TYPE (Select one):

Corrections

Update

If you are self-reporting, skip to SECTION II
3. SUBMITTER NAME (Last, First, Middle initial):

4. JOB TITLE :

6. RELATIONSHIP TO AFFECTED INDIVIDUAL:

7. If Other, Describe:

8. PHONE NUMBER:

5. OFFICE:

9. E-MAIL ADDRESS:

SECTION II: AFFECTED INDIVIDUAL INFORMATION
1. DOD ID NUMBER:

2. NAME:
LAST:

3. RANK/GRADE: 4. DOD AFFILIATION:

FIRST:
5. PHONE NUMBER:

MIDDLE INITIAL:
6. ALT PHONE NUMBER
(Optional):

9. LOCATION AT TIME OF EXPOSURE:

7. E-MAIL ADDRESS:

10. CONUS/OCONUS TRAVEL WITHIN THE LAST 30 DAYS?
(Outside local commuting area):
No

11. LOCATION:

DD FORM 3112, NOV 2022

8. ALT E-MAIL ADDRESS (Optional):

Yes (List location and date below)
12. DATE RETURNED
(YYYYMMDD):

PREVIOUS EDITION IS OBSOLETE.

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SECTION III: TYPE OF CONFIRMED OR POSSIBLE HEALTH/SAFETY ISSUE
2. NAME OF DISEASE OR BIOLOGICAL
ATTACK:

1. POSSIBLE HEALTH OR SAFETY ISSUE:

If other:
3. DATE TESTED (YYYYMMDD):

Communicable Diseases
(e.g., Smallpox, Cholera, COVID-19, etc.)

4. DATE RESULTS RECEIVED (YYYYMMDD):
5. TEST RESULTS:

Biological Attack/Exposure

Positive

Negative

6. DATE OF POTENTIAL EXPOSURE (YYYYMMDD):
7. SYMPTOM STATUS:

Asymptomatic

8. DATE SYMPTOMS BEGAN
(YYYYMMDD) (If applicable):

Symptomatic

9. CURRENT STATUS (Check one):
ISOLATION:

Date Started
(YYYYMMDD):

QUARANTINE:

Date Started
(YYYYMMDD):

HOSPITALIZED:

Date Started
(YYYYMMDD):

RETURNED TO DUTY/RECOVERED:

Date (YYYYMMDD):
Submitter

10. POINT OF CONTACT FOR CONTACT TRACING (If applicable):
11. IF OTHER, FULL NAME OF POINT OF CONTACT (Last, First, Middle):

13. RELATIONSHIP TO AFFECTED INDIVIDUAL:

Affected Individual

Other

12. ORGANIZATION/OFFICE:

14. PHONE NUMBER:

15. E-MAIL ADDRESS:

SECTION IV: AFFECTED INDIVIDUAL OFFICE INFORMATION
1. ASSIGNED DOD COMPONENT, DEFENSE AGENCY, FIELD ACTIVITY OR MILITARY DEPARTMENT:
Military
Department or
Organization:
Service:
OSD or DoD
OIG:

Organization:

Defense
Agencies or DoD
Field Activity:

Organization:

Joint Staff:

Organization:

Combatant
Command:

Organization:

Other:
2. GEOGRAPHIC WORK LOCATION:
NATIONAL CAPITAL REGION (NCR)
PENTAGON

CONUS (other than NCR)

OCONUS

City:

Country:

State:

Military Installation:

MARK CENTER
RAVEN ROCK (RRMC)
DEFENSE HEALTH HEADQUARTERS (DHHQ)
LEASED FACILITY (Provide Address):

Military Installation:

OTHER:
3. ADDITIONAL DOD FACILITIES AFFECTED INDIVIDUAL ACCESSED AND DATES:

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

DD FORM 3112, NOV 2022

3. PHONE NUMBER:

PREVIOUS EDITION IS OBSOLETE.

4. E-MAIL ADDRESS:
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INSTRUCTIONS
SECTION I - SUBMITTER INFORMATION
This section will be filled out by the individual reporting about the Affected Individual. This may include a supervisor, agency representative, a
contracting officer representative, or if the Affected Individual was a visitor to a DoD facility, the DoD employee who sponsored the individual.
1. REPORT DATE: Submission date in a YYYYMMDD format.
2. REPORT TYPE: Indicate if this is an Initial report, an update to a previously submitted report, or a correction to a previously submitted report.
NOTE: If you are self-reporting, you can skip directly to Section II.
3. SUBMITTER NAME: Enter the full name of the individual submitting the report.
4. JOB TITLE: Describe submitter's job or position, e.g., Training Coordinator.
5. OFFICE: Describe submitter's office within your organization, e.g., Machine Shop.
6. RELATIONSHIP TO THE AFFECTED INDIVIDUAL: Select from one of the choices provided.
7. IF OTHER, DESCRIBE: If the answer to question 5. is 'Other,' describe in the space provided.
8. PHONE NUMBER: Enter the best contact number.
9. E-MAIL ADDRESS: Enter the 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
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. DOD ID#: Enter DoD ID#; the ten-digit number located on the back of the individual's Common Access Card or the front of the individual's
Military ID.
2. NAME: Enter the full name of the Affected Individual (Last Name, First Name, and Middle Initial) i.e., the individual affected by the disease,
agent, or condition.
3. RANK/GRADE: For military members, please provide their rank and pay grade.
4. DOD AFFILIATION: Select from one of the choices provided.
5. PHONE NUMBER: Enter the best contact number.
6. ALTERNATE PHONE NUMBER: Optional: enter alternate office number, Government cell phone, or home number.
7. E-MAIL ADDRESS: Enter the best contact e-mail address. Contact information is required in the event there are questions about the
information submitted on the form.
8. ALTERNATE E-MAIL ADDRESS: Optional: enter any additional optional contact e-mail address.
9. LOCATION AT TIME OF EXPOSURE: At the time of exposure, the Affected Individual may not be at home station (i.e., they were traveling,
deployed, etc.). Enter location at time Affected Individual was exposed.
10. CONUS/OCONUS TRAVEL WITHIN LAST 30 DAYS: Identify whether or not the Affected Individual has traveled within the continental
United States (CONUS) outside of the local commuting area, or internationally (OCONUS) within the last 30 days.
11. LOCATION: Include the location(s) of travel, if applicable.
12. DATE RETURNED: Include the date Affected Individual returned from travel, if applicable.
SECTION III: TYPE OF CONFIRMED OR POSSIBLE HEALTH/SAFETY ISSUE
Provide information on the specific type of health or safety issue related to a public health emergency.
1. POSSIBLE HEALTH OR SAFETY ISSUE: Select from one of the choices provided.
2. NAME OF DISEASE OR BIOLOGICAL ATTACK: Enter name of disease or biological agent of the Affected Individual.
3. DATE TESTED: Provide the Affected Individual's test date in a YYYYMMDD format.
4. DATE RESULTS RECEIVED: Provide the dates the test results were received in a YYYYMMDD format.
5. TEST RESULTS: Select from one of the choices provided.
6. DATE OF POTENTIAL EXPOSURE: If the Affected Individual was in contact with an infected or symptomatic person, include the date of
their potential exposure in a YYYYMMDD format, if known.
7. SYMPTOM STATUS: Choose one option; Symptomatic/Asymptomatic.
8. DATE SYMPTOMS BEGAN: Include the date the symptoms began.
9. 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 isolation began in a YYYYMMDD format,
if applicable.
10. POINT OF CONTACT FOR CONTACT TRACING (if applicable): Point of contact for identifying persons who may have come into contact
with the affected individual. Select one of the options.
11. FULL NAME OF POINT OF CONTACT: If 'Other' is selected in question 12., enter the "Other' Point of Contact (Last Name, First Name,
and Middle Initial).
12. ORGANIZATION/OFFICE: If applicable, provide information about Other Point of Contact's workplace, e.g., XYZ Company, IT Support
Division.
13. RELATIONSHIP TO THE AFFECTED INDIVIDUAL: Enter the point of contact's relationship to the affected individual.
14. PHONE NUMBER: Enter the best contact number.
15. E-MAIL ADDRESS: Enter the best contact e-mail address. Contact information is required in the event there are questions about the
information submitted on the form.

DD FORM 3112, NOV 2022

PREVIOUS EDITION IS OBSOLETE.

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SECTION IV - AFFECTED INDIVIDUAL OFFICE INFORMATION
This section is for information on the Affected Individual's organization and workplace.
1. 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 another DoD Component.
2. GEOGRAPHIC WORK LOCATION: Select from one of the choices provided. Within the NCR, select all locations the Affected Individual is
authorized to access. For CONUS locations outside of the NCR, provide at least one; city, state, or Military Installation. For OCONUS
locations, provide both country and military installation, if applicable.
3. ADDITIONAL DOD FACILITIES AFFECTED INDIVIDUAL ACCESSED AND DATES: List additional Government facilities Affected
Individual accessed while infected or exposed that are not listed under Primary Work Location above. Provide relevant dates.
SECTION V: FOR AGENCY USE ONLY
This section is for the 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-takers affiliation and organization.
3. PHONE NUMBER: Enter the best contact number.
4. E-MAIL ADDRESS: Enter the best contact e-mail address.

TERMS & DEFINITIONS
Affected Individual: An individual who is infected with or exposed to a communicable disease constituting a significant public health concern
or otherwise impacted by a public health emergency.
Asymptomatic: Producing or showing no symptoms., (i.e., An Affected Individual has an illness or condition but does not have symptoms of it
or has recovered from an illness or condition and no longer has symptoms.).
Call-Taker: The individual who receives/processes the form on behalf of the installation commander or senior DoD official.
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.
Contact Tracing: Activities that involve working with an infected individual (symptomatic or asymptomatic) who has been diagnosed with an
infectious disease to identify and provide support to people (contacts) who may have been exposed through contact with the infected individual.
Isolation: The separation of sick people with a contagious disease from people who are not sick. Isolation keeps someone who is infected
with a contagious illness away from others, even in their home.
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.
Quarantine: The separation of a healthy individual or group, exposed to a communicable disease, to prevent further exposure to others. Keeps
someone who might have been exposed to a contagious illness away from others.
Self-Isolation: The voluntary separation of an Affected Individual from people who are not sick, to prevent the spread of a communicable
disease.
Symptomatic: Showing symptoms of disease or injury.

DD FORM 3112, NOV 2022

PREVIOUS EDITION IS OBSOLETE.

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