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.

QuestionAnswer
Form NameDd Form 2875
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesddform 2875, 2875, dd form 2875 2020, dd form 2875 fillable pdf

Form Preview Example

DD FORM 2875 - SYSTEM AUTHORIZATION ACCESS REQUEST SAAR "RED" Fields are Mandatory

PRIVACY ACT STATEMENT

AUTHORITY: Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act.

PRINCIPAL PURPOSE: To record names, signatures, and other identifiers for the purpose of validating the trustworthiness of individuals

TYPE OF REQUEST

 

 

USER ID

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SYSTEM NAME (Application Platforms)

 

 

 

LOCATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TC-AIMS II

 

 

 

 

 

 

 

PART I (To be completed by Requestor

 

 

 

 

 

 

 

 

 

1. NAME (Last, First, Middle Initial)

2.

 

ORGANIZATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. OFFICE SYMBOL/DEPARTMENT

4.

 

PHONE (DSN and/or Commercial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

OFFICIAL E-MAIL ADDRESS

6. JOB TITLE AND GRADE/RANK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

 

OFFICIAL MAILING ADDRESS

8. CITIZENSHIP

9. DESIGNATION OF PERSON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

D I have completed annual Information Awareness training.COMPLETION DATE (YYYYMMDD)

11.USER DIGITAL SIGNATURE (or UAM digital signature for ACTIVATION, DELETION or DEACTIVATION requests) 12. DATE (YYYYMMOO)

PART II - ENDORSEMENT OF ACCESS BY UAM (OR USER'S SUPERVISOR).

(If user is a contractor - please provide Company Name, Contract Number and Date of Contract Expiration in Block 15.)

13.JUSTIFICATION FOR ACCESS (FOR UAM OR SUPERVISOR USE ONLY - REQUIRED FOR ALL INITIAL AND MODIFICATION REQUESTS)

14 VERIFICATION OF NEED TO KNOW

 

 

 

I certify that this user requires access as requested.

D

16. ACCESS REQUEST INFORMATION

 

15.ACCESS EXPIRATION DATE (Include Contractor Name and Contract Number)

ADD-ACCESS

 

 

Assigned UIC:

 

Responsible UIC:

 

 

 

 

 

 

Unit Name:

 

 

 

PreferenceUICs:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preference Jobs:

Choosing a Preference Job that begins with double asterisks (**), will require additional approval from AMIS.

Primary Job Role(s):

DODAAC

(Required for Jobs: 40, 45, 46 47, 51, 53, 54)

17. ACCESS REQUEST INFORMATION

PART II - ENDORSEMENT OF ACCESS BY USER'S SUPERVISOR OR UAM (CONT.)

 

18. SUPERVISOR OR UAM NAME

19. SUPERVISOR OR UAM E-MAIL ADDRESS

20. PHONE NUMBER

21.SUPERVISOR OR UAM ORG/DEPT

22. SUPERVISOR OR UAM DIGITAL SIGNATURE

23.DATE (YYYYMMDD)

PART Ill - SECURITY MANAGER VALIDATION OF BACKGROUND INVESTIGATION AND CLEARANCE INFORMATION

24. TYPE OF INVESTIGATION

 

 

 

25. DATE OF INVESTIGATION (YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

26. CLEARANCE LEVEL

 

 

 

27. IT LEVEL DESIGNATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28. VERIFlED BY (Print name)

29. SECURITY MANAGER PHONE

30. SECURITY MANAGER DIGITAL

31. DATE (YYYYMMDD)

 

 

 

 

NUMBER

 

SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART IV - COMPLETION OF REQUEST REVIEW AND ACCOUNT CREATION

32. INFORMATION OWNER DIGITAL SIGNATURE (AMIS)

33. PHONE NUMBER

34.DATE (YYYYMMDD)

35. ACCOUNT PROCESSOR DIGITAL SIGNATURE (ASD)

36. PHONE NUMBER

37.DATE (YYYYMMDD)

AMIS - DD FORM 2875 INSTRUCTIONS

Always use the <TAB> key to advance to the next field

REQUEST DETAIL:

Type of Request. Account request selection. Choose either:

Initial - New account creation (User).

•Modification - To make changes to an existing account (User or UAM). •Deletion - Removing an account from the system (UAM).

•Deactivate - Temporary deactivate an account (Call ASD). •Activate - Reactivate a previously deactivated account (Call ASD).

User ID. Unique, system generated user identifier.

Date of Request. Date request was initiated.

System Name. Application platform to be initiated.

Location. Physical location of the computer to be used with the software.

PART I: The following information is to be provided by the user when establishing or modifying their account. After completing PART I, the user should then provide the form to the UAM.

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

(2)Organization. The user's current organization (e.g. DISA, SDI, DOD, government agency, or commercial firm name).

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

(4)Telephone Number/DSN. The commercial or the Defense Switching Network (DSN) phone number of the user.

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

(6)Job Title/Grade/Rank. The civilian job title, military rank 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, or Contractor.

(10)IA Training and Awareness Certification Requirements. User must indicate they've completed Information Awareness Training date.

(11)User's Signature. User must click in the field to enact a digital signature from their CAC card.

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

PART II: The information below requires the endorsement of the user‘s UAM or government sponsor. After completing PART II, the UAM should forward the Form to the Security Manager.

(13)Justification for Access. A brief statement is required to justify establishment of an initial USER ID. Can also be used to explain the purpose of the request.

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

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

(16)Access Request Information. Used to add access for new accounts or to modify existing accounts.

Unit Name: the user’s assigned UIC name

Assigned UIC: the user’s Assigned Unit ID in the CoC

Responsible UIC: the most senior parent UIC in the CoC for the user is used as the Responsible Unit ID

Preference UICs: subordinate units to the user’s Responsible UIC

Preference Jobs: define the level of access or capability granted to the user within different categories of the TC-AIMS II applications. You must have approval from AMIS before choosing Preference Jobs that begin with double asterisks (**). Use the Job Details Lookup button to view each Job definition in detail.

DODDAC: DODDAC entry required for Job IDs 40, 53 and 54.

Primary Job Role(s): User’s functional job responsibilities.

(17)Name. Repeat data entry of requesting user’s name.

(18)Supervisor or UAM Name. Name of the user’s UAM or Supervisor.

(19)Supervisor or UAM E-mail Address. E-mail address of the user’s UAM or Supervisor.

(20)Telephone Number. The commercial or the Defense Switching

Network (DSN) phone number of the user’s UAM or Supervisor.

(21)Supervisor or UAM Org/Dept. Organization or Department of the UAM or Supervisor.

(22)Supervisor or UAM Digital Signature. The UAM or Supervisor must click in the field to enact a digital signature from their CAC card.

(23)Date. The date that the UAM or Supervisor signs the form.

PART III: Security Manager’s Certification of Clearance. After the Security Manager completes the investigation and signs PART III, the form is forwarded to the AMIS Service Desk (ASD).

(24)Type of Investigation. The user's last background investigation.

(25)Date of Investigation. Date of last investigation.

(26)Clearance Level. The user's current security clearance level.

(27)IT Level Designation. The user's IT designation (Level I, II, or III).

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

(29)Security Manager Telephone Number. The telephone number of the Security Manager or his/her representative.

(30)Security Manager Signature. The Security Manager or their representative indicates that the above clearance and investigation information has been verified.

(31)Date. The date that the form was signed by the Security Manager or his/her representative.

PART IV: Sign-off and completion of request by authorized staffs (request acceptance by the AMIS staff and account creation by the ASD staff).

(32)Information Owner Digital Signature (AMIS). AMIS representative must click in the field to enact a digital signature from their CAC.

(33)Phone Number. Phone number of AMIS representative.

(34)Date. The date the form was signed by the AMIS representative.

(35)Account Processor Digital Signature (ASD). ASD representative must click in the field to enact a digital signature from their CAC.

(36)Phone Number. Phone number of the ASD representative.

(37)Date. The date that the form was signed by the ASD representative.

DD FORM 2875 – DISPOSITION AND FAQs

Request Initiation: For Initial requests, REQUEST DETAIL and PART I of this form is filled out and digitally signed by the user requesting access. For Activation, Deactivation and Delete requests, the UAM will fill out portions of REQUEST DETAIL and PART I of this form. Modification requests can be initiated by the user, or by the UAM. Either the user or UAM fills out portions of REQUEST DETAIL and PART I on this form. However, only the UAM can make the necessary modifications to PART II. After each user digitally signs of this form, they will be forced to save the form using a different name (e.g. Form2875-UserName.pdf).

Form Routing Paths: After initiating a request, the DD Form 2875 should be forwarded by e-mailed, to the next entity required to digitally sign and/or process the form. For INITIAL requests, the form typically passes from the requesting user to the User Account Manager (UAM), then from the UAM to Security Management (JPAS), from JPAS back to the UAM, then from the UAM to the AMIS Service Desk (ASD). For other requests (e.g. Activation, Deactivation and Delete), forms are typically e-mailed directly from the requestor (UAM) to the ASD. NOTE: All e-mails containing PII must be encrypted.

The AMIS Service Desk (ASD) telephone number and e-mail address are:

1 (800) 877-7925

usarmy.belvoir.peo-eis.mbx.amis-service-desk@mail.mil

Form Retention and Dormant Account Policies: All digitally signed DD

Form 2875s received by ASD are kept on file for one year following termination of the user’s account. The Dormant Account Policy states that:

If a user’s account has been inactive for 90 days, an email notice will be sent to the user instructing them to log into their account, or the account will be deactivated at 120 days.

At 120 days, if still no activity, the account will be deactivated.

Accounts not reactivated after 180 days, will be deleted. The user must then submit a new DD Form 2875, to have a new account established.

Watch Dd Form 2875 Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .