DoDSER Suicide Event Report

In the event the individual responsible for submitting DoDSER data collects information from a member of the public while on duty with the intent of inputting the data into the DoDSER application, the DoDSER Data Collector will provide him or her with the Privacy Act Statement:

PRIVACY ACT STATEMENT

This statement serves to inform you of the purpose of collecting personal information for inclusion in the Department of Defense Suicide Event Report (DoDSER) and how it will be used.

AUTHORITY

10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 8013, Secretary of the Air Force; 10 U.S.C. Chapter 55, Medical and Dental Care; 29 CFR Part 1960, Basic Program Elements for Federal Employee Occupational Safety and Health Programs and Related Matters; DoDD 6490.02E, Comprehensive Health Surveillance; DoDD 6490.14, Defense Suicide Prevention Program; AR 600-63, Army Health Promotion, Rapid Action Revision 7 Sep 10, Paragraph 4-4 Suicide prevention and surveillance; OPNAV Instruction 1720.4A, Suicide Prevention Program, 5.d, Reporting; AFPAM 44-160, The Air Force Suicide Prevention Program, XI, Epidemiological Database and Surveillance System; and E.O. 9397 (SSN), as amended.

PURPOSE

To collect information on suicides and instances of self-harm behaviors (including suicide attempts and suicidal ideations) that occurred among active military personnel, reserve military personnel, and members of the National Guard, with the goal of preventing future occurrences.

ROUTINE USES

Use and disclosure of these records outside of DoD may occur in accordance with the DoD Blanket Route Uses and as permitted by the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)).

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses and discloses of PHI include, but are not limited to, treatment, payment, and healthcare operations.

DISCLOSURE

Voluntary. However, any information you provide may assist DoD in promoting the health of the Armed Forces.

The following PAS may be provided in lieu of the above PAS when collecting information from an individual over the telephone.

I am about to request information on suicides or instances of self-harm behavior (including suicide attempts and suicidal ideations) that may have occurred among active military personnel, reserve military personnel, or members of the National Guard. This information may be collected into the Department of Defense Suicide Event Report (DoDSER). You are not required to provide any information, but any information you provide may assist DoD in promoting the health of the Armed Forces.

The authorities permitting this collection include 10 U.S.C. 136 and 10 U.S.C. Chapter 55. The information you provide may be disclosed for reasons compatible with why it was collected and when permitted by the HIPAA Privacy Rule and other applicable privacy laws. Would you like to know more about the authorities, purposes, routine uses, or disclosures, or receive a paper copy of the full Privacy Act Statement?

If the individual (the interviewee) requests additional information about the authorities, purposes, routine uses, or disclosures, that section of the above PAS is read. If the individual requests a paper copy of the PAS, the individual may choose whether to withhold any responses until a paper copy of the above PAS has been provided.

AGENCY DISCLOSURE STATEMENT

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, 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, Executive Services Directorate, Directives Division, Information Collections Branch, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (The OMB Control Number is 0704-TBD)[Insert OMB Control Number once it is assigned]. 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.