Pas & Adn

Department of Defense Suicide Event Report
OMB Control Number: 0720-0058
Expiration Date: 03/31/2018

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.

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 0720-0058.
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.)

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 Routine 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.

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?

For Official Use Only
Form Number: DD2996
Edition Date: 20150301

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