Dd Form 2875 – Fill Out and Use This PDF

DD Form 2875 is a United States Military form. It's used to apply for discharge under full honorable conditions, as well as a host of other reasons.

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Dd Form 2875 PDF Details

Dd Form 2875 is a document used in the United States military to provide information about an individual's medical history. The form can be used for a variety of purposes, including during the enlistment process, as part of a physical examination, or when seeking medical treatment. The form is divided into sections that cover personal information, allergies and sensitivities, previous medical conditions, medications taken, and other health-related information. Completing dd form 2875 accurately and completely is important for ensuring that you receive the best possible care while in the military.

In the table, there's some good information in regards to the dd form 2875. It is advisable that you read through this information before you begin filling out the PDF.

Question	Answer
Form Name	Dd Form 2875
Form Length	3 pages
Fillable?	Yes
Fillable fields	1
Avg. time to fill out	57 sec
Other names	dd form 2875, dd form 2875 fillable pdf, how to form saar, dd 2875

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12. DATE (YYYYMMDD)

UNCLASSIFIED

SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)

OMB No. 0704-0630 OMB approval expires: 20250531

The public reporting burden for this collection of information, 0704-0630, is estimated to average 5 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.

PRIVACY ACT STATEMENT

AUTHORITY: Executive Order 10450; and Public Law 99-474, the Computer Fraud and Abuse Act

PRINCIPAL PURPOSE(S): To record names, signatures, and other identifiers for the purpose of validating the trustworthiness of individuals requesting access to Department of

Defense (DoD) systems and information. NOTE: Records may be maintained in both electronic and/or paper form

ROUTINE USE(S): None.

DISCLOSURE: Disclosure of this information is voluntary; however, failure to provide the requested information may impede, delay or prevent further processing of this request.

TYPE OF REQUEST							DATE (YYYYMMDD)
INITIAL	MODIFICATION	DEACTIVATE	USER ID

SYSTEM NAME (Platform or Applications)					LOCATION (Physical Location of System)
Military Recruiter Information Suite (MRIS)					DMDC, Seaside, CA

PART I (To be completed by Requester)

1. NAME (Last, First, Middle Initial)				2. ORGANIZATION

3. OFFICE SYMBOL/DEPARTMENT				4. PHONE (DSN or Commercial)

5. OFFICIAL E-MAIL ADDRESS				6. JOB TITLE AND GRADE/RANK

7. OFFICIAL MAILING ADDRESS				8. CITIZENSHIP		9. DESIGNATION OF PERSON
				US	FN	MILITARY		CIVILIAN
				OTHER		CONTRACTOR

10.IA TRAINING AND AWARENESS CERTIFICATION REQUIREMENTS (Complete as required for user or functional level access.)

I have completed the Annual Cyber Awareness Training. DATE (YYYYMMDD)

11. USER SIGNATURE

PART II ENDORSEMENT OF ACCESS BY INFORMATION OWNER, USER SUPERVISOR OR GOVERNMENT SPONSOR (If individual is a contractor - provide company name, contract number, and date of contract expiration in Block 16.)

13.JUSTIFICATION FOR ACCESS

14.TYPE OF ACCESS REQUESTED

AUTHORIZED	PRIVILEGED

15. USER REQUIRES ACCESS TO:		UNCLASSIFIED		CLASSIFIED (Specify category)
OTHER

16. VERIFICATION OF NEED TO KNOW			16a. ACCESS EXPIRATION DATE (Contractors must specify Company Name, Contract Number,
I certify that this user requires			Expiration Date. Use Block 21 if needed.)

access as requested.
17. SUPERVISOR'S NAME (Print Name)			17a. SUPERVISOR'S EMAIL ADDRESS		17b. PHONE NUMBER

17c. SUPERVISOR'S ORGANIZATION/DEPARTMENT			17d. SUPERVISOR SIGNATURE		17e. DATE (YYYYMMDD)

18. INFORMATION OWNER/OPR PHONE NUMBER			18a. INFORMATION OWNER/OPR SIGNATURE		18b. DATE (YYYYMMDD)

19. ISSO ORGANIZATION/DEPARTMENT			19b. ISSO OR APPOINTEE SIGNATURE		19c. DATE (YYYYMMDD)

19a. PHONE NUMBER

DD FORM 2875, MAY 2022				UNCLASSIFIED	Page 1 of 3

PREVIOUS EDITION IS OBSOLETE.

UNCLASSIFIED

20.NAME (Last, First, Middle Initial)

21.OPTIONAL INFORMATION

SITE INFORMATION:
Site ID: __________	Site Name: ____________________________________________________________

POSITION REQUESTING:

Project Officer Level 1: ____

Project Officer Level 2: ____

Project Officer Level 3: ____

Project Officer Level 4: ____

Site Security Manager: ____

MY PERSONAL DoD ID Number: _________________________________

(Found on the back of your CAC)
SUB-SYSTEM REQUESTING ACCESS TO: RMIS User: ____			RAHS User: ____ REDD User: ____
REPLACEMENT INFORMATION:
The PO or SSM I am replacing:
NAME: ________________________________________

PART III - SECURITY MANAGER VALIDATES THE BACKGROUND INVESTIGATION OR CLEARANCE INFORMATION

22. TYPE OF INVESTIGATION				22a. INVESTIGATION		22b. CONTINUOUS EVALUATION (CE) DEFERRED
				DATE (YYYYMMDD)		INVESTIGATION

22c. CONTINUOUS EVALUATION (CE) ENROLLMENT DATE				(YYYYMMDD)	22d. ACCESS	LEVEL

23. VERIFIED BY (Printed Name)	24. PHONE NUMBER			25. SECURITY	MANAGER SIGNATURE			26. VERIFICATION DATE
								(YYYYMMDD)

PART IV - COMPLETION BY AUTHORIZED STAFF PREPARING ACCOUNT INFORMATION

TITLE:		SYSTEM					ACCOUNT CODE

		DOMAIN

		SERVER

		APPLICATION

		FILES

		DATASETS

DATE PROCESSED (YYYYMMDD)		PROCESSED BY (Print name and sign)
								DATE (YYYYMMDD)

DATE REVALIDATED (YYYYMMDD)		REVALIDATED BY (Print name and sign)
								DATE (YYYYMMDD)

DD FORM 2875, MAY 2022

UNCLASSIFIED

Page 2 of 3

PREVIOUS EDITION IS OBSOLETE.

INSTRUCTIONS

The prescribing document is as issued by using DoD Component.

A. PART I: The following information is provided by the user when establishing or modifying their USER ID.

(1)Name. The last name, first name, and middle initial of the user.

(2)Organization. The user's current organization (i.e. DISA, SDI, DoD and government agency or commercial firm).

(3)Office Symbol/Department. The office symbol within the current organization (i.e. SDI).

(4)Telephone Number/DSN. The Defense Switching Network (DSN) phone number of the user. If DSN is unavailable, indicate commercial number.

(5)Official E-mail Address. The user's official e-mail address.

(6)Job Title/Grade/Rank. The civilian job title (Example: Systems Analyst, GS-14, Pay Clerk, GS-5)/military rank (COL, United States Army, CMSgt, USAF) or "CONT" if user is a contractor.

(7)Official Mailing Address. The user's official mailing address.

(8)Citizenship (US, Foreign National, or Other).

(9)Designation of Person (Military, Civilian, Contractor).

(10)IA Training and Awareness Certification Requirements. User must indicate if he/she has completed the Annual Cyber Awareness Training and the date.

(11)User's Signature. User must sign the DD Form 2875 with the understanding that they are responsible and accountable for their password and access to the system(s).

(12)Date. The date that the user signs the form.

B. PART II: The information below requires the endorsement from the user's Supervisor or the Government Sponsor.

(13)Justification for Access. A brief statement is required to justify establishment of an initial USER ID. Provide appropriate information if the USER ID or access to the current USER ID is modified.

(14)Type of Access Required: Place an "X" in the appropriate box. (Authorized - Individual with normal access. Privileged - Those with privilege to amend or change system configuration, parameters, or settings.)

(15)User Requires Access To: Place an "X" in the appropriate box. Specify category.

(16)Verification of Need to Know. To verify that the user requires access as requested.

(16a) Expiration Date for Access. The user must specify expiration date if less than 1 year.

(17)Supervisor's Name (Print Name). The supervisor or representative prints his/her name to indicate that the above information has been verified and that access is required.

(17a) E-mail Address. Supervisor's e-mail address.

(17b) Phone Number. Supervisor's telephone number.

(17c) Supervisor's Organization/Department. Supervisor's organization and department.

(17d) Supervisor's Signature. Supervisor's signature is required by the endorser or his/her representative.

(17e) Date. Date the supervisor signs the form.

(18)Phone Number. Functional appointee telephone number.

(18a) Signature of Information Owner/Office of Primary Responsibility (OPR). Signature of the Information Owner or functional appointee of the office responsible for approving access to the system being requested.

(18b) Date. The date the functional appointee signs the DD Form 2875.

(19)Organization/Department. ISSO’s organization and department. (19a) Phone Number. ISSO’s telephone number.

(19b) Signature of Information Systems Security Officer (ISSO) or Appointee. Signature of the ISSO or Appointee of the office responsible for approving access to the system being requested.

(19c) Date. The date the ISSO or Appointee signs the DD Form 2875.

(21)Optional Information. This item is intended to add additional information, as required.

C. PART III: Verification of Background or Clearance.

(22)Type of Investigation. The user's last type of background investigation (i.e., Tier 3, Tier 5, etc.).

(22a) Investigation Date. Date of last investigation.

(22b) Continuous Evaluation (CE) Deferred Investigation. Select yes/no to validate whether or not the user is currently enrolled for “Deferred Investigation” in the Continuous Evaluation (CE) program.

(22c) Continuous Evaluation Enrollment Date. Date of CE enrollment. Leave blank if user is not enrolled in CE.

(22d) Access Level. The access level granted to the user by the sponsoring agency/service (i.e. Secret, Top Secret, etc.). Access level refers to the access determination made on the basis of the user’s individual need for access to classified information to perform official duties; a determination separate from the user’s eligibility determination.

(23)Verified By. The Security Manager or representative prints his/her name to indicate that the above clearance and investigation information has been verified.

(24)Phone Number. Security Manager’s telephone number.

(25)Security Manager Signature. The Security Manager or his/her representative indicates that the above clearance and investigation information has been verified.

(26)Verification Date. Date the Security Manager performed the background investigation and clearance information verification.

D. PART IV: This information is site specific and can be customized by either the DoD, functional activity, or the customer with approval of the DoD. This information will specifically identify the access required by the user.

E. DISPOSITION OF FORM:

TRANSMISSION: Form may be electronically transmitted, faxed, or mailed. Adding a password to this form makes it a minimum of e CONTROLLED UNCLASSIFIED INFORMATION” and must be protected as such.

FILING: Original SAAR, with original signatures in Parts I, II, and III, must be maintained on file for one year after termination of user's account. File may be maintained by the DoD or by the Customer’s ISSO. Recommend file be maintained by ISSO adding the user to the system.

DD FORM 2875, MAY 2022

PREVIOUS EDITION IS OBSOLETE.

Page 3 of 3

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To be able to create the dd form 2875 fillable PDF, provide the information for each of the segments:

Provide the requested particulars in the field OFFICE SYMBOLDEPARTMENT, PHONE DSN or Commercial, OFFICIAL EMAIL ADDRESS, JOB TITLE AND GRADERANK, OFFICIAL MAILING ADDRESS, CITIZENSHIP, DESIGNATION OF PERSON, MILITARY, CIVILIAN, OTHER, CONTRACTOR, IA TRAINING AND AWARENESS, I have completed the Annual Cyber, DATE YYYYMMDD, and USER SIGNATURE.

The application will require data to effortlessly prepare the box TYPE OF ACCESS REQUESTED, AUTHORIZED, PRIVILEGED, USER REQUIRES ACCESS TO, UNCLASSIFIED, CLASSIFIED Specify category, OTHER, VERIFICATION OF NEED TO KNOW, I certify that this user requires, a ACCESS EXPIRATION DATE, SUPERVISORS NAME Print Name, a SUPERVISORS EMAIL ADDRESS, b PHONE NUMBER, c SUPERVISORS, and d SUPERVISOR SIGNATURE.

The space NAME Last First Middle Initial, and OPTIONAL INFORMATION is for you to add each side's rights and obligations.

Finalize by reviewing the following sections and submitting the required details: PART III SECURITY MANAGER, TYPE OF INVESTIGATION, a INVESTIGATION, DATE YYYYMMDD, b CONTINUOUS EVALUATION CE DEFERRED, INVESTIGATION, c CONTINUOUS EVALUATION CE, d ACCESS LEVEL, VERIFIED BY Printed Name, PHONE NUMBER, SECURITY MANAGER SIGNATURE, VERIFICATION DATE, YYYYMMDD, PART IV COMPLETION BY AUTHORIZED, and ACCOUNT CODE.

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