Incident Report Form

Defense Logistics Agency

Police Records Management Center

Privacy Act Statement

Authority: 5 U.S.C. 301, Departmental Regulations; 5 U.S.C. 303(b), Oath to Witnesses; 10 U.S.C. 133, Under Secretary of Defense for Acquisition and Technology. 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; Section 21 of the Internal Security Act of 1950 (50 U.S.C. 797); 18 U.S.C. 499, Military, Naval, or Official Passes; 18 U.S.C. 701, Official Badges, Identification Cards, Other Insignia; 18 U.S.C. 716, Police Badges; DOD Instruction 5200.8, Security of Military Installations and Resources; 10 U.S.C. 1580, Emergency Essential Personnel, designation; 10 U.S.C. 1585, Carrying of Firearms; DOD 5210.56, Use of Deadly Force and the Carrying of Firearms by DOD Personnel Engaged in Law Enforcement and Security Duties; CJCSI 3121.01B, Standing Rules of Engagement/Standing rules for the Use of Force for US Forces; 10 U.S.C. 1593, Uniform allowance: civilian employees. National Highway Safety Act of 1966 (23 U.S.C. 401, Highway Safety, et seq.); Section 21 of the Internal Security Act 1950 (50 U.S.C. 797, et seq.); DOD Instruction 5200.8, Security of DOD Installations and Resources; DOD Directive 5105.22; and E.O. 9397 (SSN), as amended.

Purpose: Information is collected to provide several existing functions of the DLA police force mission. This system serves as an enterprise wide system for the collection and storage of police records. The system will track criminal incident data at DLA Headquarters and the major DLA primary level field activities through information sharing to assist in crime prevention strategies, crime trends and criminal activities. The information gathered by the Police officers will be used for official police matters and record keeping purposes only.

Routine Uses: In addition to the DoD �Blanket Routine Uses� which apply to this system of records, the records may be released:

To Federal, state, and local agencies that administer programs or employ individuals involved in an incident or inquiry.

To medical and emergency personnel to make medical and safety determinations about individuals involved in accidents.

To the Department of Labor, Office of Workers' Compensation for the purpose of processing workers' compensation claims.

Disclosure: Voluntary; however, failure to provide the requested data may result in the inability to provide police-related services or benefits.

Rules of Use: Rules for collecting, using, retaining and safeguarding this information are contained in Defense Logistics Agency Notices, S500.30, "Incident Investigation/Police Inquiry Files", S500.40, "DLA Security Force and Staff Records," S500.41, "Vehicle/Traffic Incident Files,", S500.42, "Seizure and Disposition of Property Records," and S500.43, "Firearms Registration Records" located at http://dpclo.defense.gov/privacy/SORNs/component/dla/index.html.

OMB CONTROL NUMBER: 0704-0514

OMB EXPIRATION DATE: XX/XX/XXXX

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0704-0514, is estimated to average 30 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. 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.

You are accessing a U.S. Government (USG) Information System(IS) that is provided for USG-authorized use only. By using this IS (which includes any device attached to this IS), you consent to the following conditions:

• The USG routinely intercepts and monitors communications on this IS for purposes including, but not limited to, penetration testing, COMSEC monitoring, network operations and defense, personnel misconduct(PM), law enforcement(LE), and counterintelligence(CI) investigations.

• At any time, the USG may inspect and seize data stored on this IS.

• Communications using, or data stored on, this IS are not private, are subject to routine monitoring, interception, and search, and may be disclosed or used for any USG-authorized purpose.

• This IS includes security measures (e.g. authentication and access controls) to protect USG interests--not for your personal benefit or privacy.

• Notwithstanding the above, using this IS does not constitute consent to PM, LE or CI investigative searching or monitoring of the content and privileged communications, or work product, related to personal representation or services by attorneys, psychotherapists, or clergy, and their assistants. Such communications and work product are private and confidential. See User Agreement for details.

I Agree to the Terms of the User Agreement