Army personnel are required to complete the DA Form 3975, which is also known as the Individual Augmentee Request for medical and dental care. This form must be completed in order to request medical or dental support while performing duty as an individual augmentee. The form can be downloaded from the Army's website, and it should be filled out completely and accurately. Supporting documentation may also be required, so it's important to submit a well-organized request. The DA Form 3975 must be submitted to the patient administration center of the military treatment facility where care is being requested. If you have any questions about completing the form or need additional assistance, don't hesitate to contact your unit representative or healthcare provider.
| Question | Answer |
|---|---|
| Form Name | Da Form 3975 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 1998, sittee, VCR, YYYYMMDD |
6. RELATIONSHIP OF VICTIM TO OFFENDER (For multiple offender relationships, enter |
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VICTIM |
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Accessory |
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Principle |
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the subject's number) |
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INVOLVEMENT |
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Conspiracy |
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Solicit |
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AA Spouse |
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AV |
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BL Homosexual Relationship |
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INJURY TYPE (Check up to five) |
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AB Child |
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AZ Friend |
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BN Extended Family |
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B Broken Bones |
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O Major Injury |
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AC Sibling |
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BA Neighbor |
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BY Employee |
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I Possible Internal |
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T Tooth Loss |
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AD Parent |
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BB Com. Law Spouse |
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BZ Employer |
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L Severe Laceration |
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U Unconsciousness |
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AE |
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BC Acquaintance |
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BX Stranger |
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M Minor Injury |
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Z None |
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AF Step Child |
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BD |
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CA Otherwise Known |
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DD FORM 2701 PROVIDED VICTIM |
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AG Grandparent |
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BE Boy/Girlfriend |
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CB Relationship Unknown |
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YES |
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NO |
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AH |
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BF Child of Boy/Girlfriend |
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VO Offender |
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IF NOT PROVIDED, WHY NOT? |
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AK Grandchild |
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BH Former Spouse |
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Declined |
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Not Required |
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SECTION V - PERSONS RELATED TO REPORT (For additional persons related to report, complete DA Form
1a. |
PERSON RELATED TO REPORT NUMBER |
1b. |
STATUS |
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Civil Authorities |
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Complaint |
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Military Police |
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Sponsor |
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Witness |
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1c. |
NAME (Last, First, Middle Name, Jr., Sr., III) |
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SSN/FNN/ALIEN REG NO. |
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CITIZENSHIP |
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US |
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Resident Alien |
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1f. CATEGORY |
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1g. DOB (YYYYMMDD) |
1h. POB (City, State, County) |
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1i. GRADE |
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1j. HOME PHONE |
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A Army |
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C Coast Guard |
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F Air Force |
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1k. |
WORK PHONE |
1l. NICKNAMES/ALIAS |
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1m. COMPONENT |
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G Nat'l Guard |
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H Public Health |
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R Regular |
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V Reserves |
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M Marine |
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1n. |
DRIVER LICENSE NUMBER |
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1o. IS LICENSE |
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State (Specify) |
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Other |
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N Navy |
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Foreign |
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O NOAA |
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International |
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P Family Member |
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2a. |
ORGANIZATION, UIC, AND STREET ADDRESS |
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2b. |
INSTALLATION/CITY |
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2d. |
ZIP/APO |
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Q Civil Service |
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R Civilian |
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2c. |
STATE/COUNTRY |
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2e. |
UNIT PHONE |
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S Contractor |
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T Other Gov. Empl. |
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3a. |
RESIDENCE STREET ADDRESS |
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3b. |
INSTALLATION/CITY |
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3d. |
ZIP/APO |
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U Foreign Nat'l Empl. |
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V Other Foreign Nat'l |
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3c. |
STATE/COUNTRY |
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W Retired Military |
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4a. DD FORM 2701 PROVIDED |
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4b. IF NOT PROVIDED, WHY NOT? |
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5. NUMBER OF VICTIMS AND WITNESSES NOTIFIED |
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VICTIM/WITNESS |
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Declined |
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Not Required |
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WITH DD FORM 2701 |
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YES |
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NO |
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SECTION VI - PROPERTY |
(For additional Property, complete DA Form |
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1a. |
ITEM NO. |
1b. CODE |
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1c. |
QUANTITY |
1d. |
VALUE |
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1e. DESCRIPTION |
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1f. |
SERIAL NUMBER |
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1g. DATE RECOVERED |
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1h. DATE RETURNED |
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1i. SECURITY |
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1j. PROPERTY OWNERSHIP |
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(YYYYMMDD) |
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(YYYYMMDD) |
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S Secured |
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A Federal |
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E Foreign Govt. |
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1k. |
PROPERTY LOSS TYPE (Check all that apply) |
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U Unsecured |
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B State |
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F Private |
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1 None |
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5 Recovered |
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Z Unknown |
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C City |
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U Unknown |
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2 Burned |
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6 Seized |
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D County/Borough |
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3 Counterfeited/Forged |
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7 Stolen |
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4 Damaged/Destroyed/Vandalized |
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PROPERTY DESCRIPTION CODE TABLE |
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01 |
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Aircraft |
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12 |
Farm Equipment |
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23 |
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02 |
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Alcohol |
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Firearms |
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24 |
Other Motor Vehicles |
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03 |
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Gambling Equipment |
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25 |
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36 Tools/Hand and Power |
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Heavy Construction Equip. |
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Radio/TV/VCR |
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Household Goods |
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27 |
Audio/Visual Recording |
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38 Vehicle Parts/Accessories |
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06 |
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Jewelry/Precious Metals |
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Recreational Vehicle |
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39 Watercraft |
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Computer Hard/Software |
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Livestock |
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29 |
40 OTHER (Specify) |
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08 |
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Consumable Goods |
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19 |
Merchandise |
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09 |
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20 |
Money |
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31 |
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10 |
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Drugs/Narcotics (See below) 21 |
Negotiable Instruments |
32 |
41 Pending Inventory |
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11 |
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Drugs/Narcotics Equipment |
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33 |
42 Special Category |
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DRUG/NARCOTIC MEASURES |
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PAGE 4, DA FORM 3975, DEC 1998 |
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PAGE |
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OF |
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APD V1.01
SECTION VII - NARRATIVE
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1. ENCLOSURES |
2. DISTRIBUTION |
3. NAME |
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4. |
GRADE |
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5. |
TITLE OF REPORTING OFFICIAL |
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6. |
SIGNATURE |
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PAGE 5, DA FORM 3975, DEC 1998 |
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PAGE |
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OF |
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APD V1.01