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pdfPrescribed by: DoDI 8910.01, DoDM 8910.01
INFORMATION COLLECTION REQUEST
COORDINATION SUMMARY SHEET
1. OMB CONTROL NO.
(or placeholder)
0704-0553
2. TITLE
3. COMPONENT
Naval Hospital Rota Access to Care Survey (OMB Fast Track Generic Clearance)
DHA
4. ACTION OFFICER
a. NAME
b. PHONE NUMBER
LCDR Jason Galk
c. E-MAIL ADDRESS
314.727.3565
jason.s.galka.mil@health.mil
5. PRA LIAISON
a. NAME
b. PHONE NUMBER
Amanda Grifka
571-329-1420
c. E-MAIL ADDRESS
amanda.b.grifka.civ@health.mil
d. SIGNATURE
e. DATE (YYYYMMDD)
GRIFKA.AMANDA.BETH.1525770539
Digitally signed by GRIFKA.AMANDA.BETH.1525770539
Date: 2024.09.05 12:42:13 -04'00'
20240905
6. COORDINATION
a. COORDINATOR
b. COORDINATION
REQUIRED (Yes/No)
PRIVACY OFFICER (SORN, PAS,
PAA, SSN Justification/Plan)
RECORDS MANAGER/
RECORDS ADMINISTRATOR
(Records Schedule/ Disposition)
https://www.archives.gov/records-mgmt/
agency/departments/defense.html
YES
c. COORDINATOR REMARKS
No PAS is required, PII such Name and
Number will be collected however the
information will not be stored in a SOR
d. COORDINATOR SIGNATURE
e. DATE
(YYYYMMDD)
signed by
BROWN.LUCH Digitally
BROWN.LUCHELL.C.126
ELL.C.1266908 6908195
20240905
Date: 2024.09.05 12:37:31
195
-04'00'
YES
CHIEF INFORMATION OFFICER
(PIA/Data Security)
DPAC (Surveys - Methodology &
Scientific Review)
dodhra.mc-alex.dpac.mbx.dod-surveyreview@mail.mil
HRPP OFFICIAL/INSTITUTIONAL
REVIEW BOARD (Research)
FORMS MANAGER (Forms
Assessment)
GENERAL COUNSEL (For
Incentive/Gifts)
RDD (For DD Forms Only)
Air Force Survey Office (complete
before DPAC for surveys to AF
personnel)
afpc.dsys.af.surveyoffice@us.af.mil
7. ADDITIONAL REMARKS
DD FORM 3128, MARCH 2021
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File Type | application/pdf |
File Title | DD Form 3128, "Information Collection Request Coordination Summary Sheet" |
Author | WHS |
File Modified | 2024-09-09 |
File Created | 2021-03-25 |