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, dd2875, how to form saar, form 2875

12

Form Preview Example

SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)

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 requesting

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

ROUTINE USES: 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)

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 Annual Information Awareness Training.	DATE (YYYYMMDD)

11. USER SIGNATURE	12. DATE (YYYYMMDD)

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
OTHER

16. VERIFICATION OF NEED TO KNOW				16a. ACCESS EXPIRATION DATE (Contractors must specify Company Name, Contract Number,
I certify that this user requires access as requested.				Expiration Date. Use Block 27 if needed.)
I certify that this user requires access as requested.

17. SUPERVISOR'S NAME (Print Name)				18. SUPERVISOR SIGNATURE		19. DATE (YYYYMMDD)

20. SUPERVISOR'S ORGANIZATION/DEPARTMENT

20a. SUPERVISOR'S EMAIL ADDRESS

20b. PHONE NUMBER

21. SIGNATURE OF INFORMATION OWNER/OPR

21a. PHONE NUMBER

21b. DATE (YYYYMMDD)

22. SIGNATURE OF IA OR APPOINTEE

23. ORGANIZATION/DEPARTMENT

24. PHONE NUMBER

25. DATE (YYYYMMDD)

DD FORM 2875, AUG 2009	Page 1 of 3
	PREVIOUS EDITION IS OBSOLETE.

26.NAME (Last, First, Middle Initial)

27.OPTIONAL INFORMATION

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

28. TYPE OF INVESTIGATION

28a. DATE (YYYYMMDD)

28b. CLEARANCE LEVEL

29.VERIFIED BY (Printed Name)

30.SECURITY MANAGER TELEPHONE NUMBER

31. SECURITY MANAGER SIGNATURE

32.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, AUG 2009	PREVIOUS EDITION IS OBSOLETE.	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 Information 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.

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

(19)Date. Date supervisor signs the form.

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

(20a) E-mail Address. Supervisor's e-mail address.

(20b) Phone Number. Supervisor's telephone numberTex

(21)Signature of Information Owner/OPR. Signature of the functional appointee responsible for approving access to the system being requested.

(21a) Phone Number. Functional appointee telephone number.

(21b) Date. The date the functional appointee signs the DD Form 2875.

(22)Signature of Information Assurance Officer (IAO) or Appointee. Signature of the IAO or Appointee of the office responsible for approving access to the system being requested.

(23)Organization/Department. IAO's organization and department.

(24)Phone Number. IAO's telephone number.

(25)Date. The date IAO signs the DD Form 2875.

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

C. PART III: Certification of Background Investigation or Clearance.

(28)Type of Investigation. The user's last type of background investigation (i.e., NAC, NACI, or SSBI).

(28a) Date of Investigation. Date of last investigation.

(28b) Clearance Level. The user's current security clearance level (Secret or Top Secret).

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

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

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

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

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 "FOR OFFICIAL USE ONLY" 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 IAO. Recommend file be maintained by IAO adding the user to the system.

DD FORM 2875, AUG 2009

PREVIOUS EDITION IS OBSOLETE.

Page 3 of 3

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Step 1: The first step should be to hit the orange "Get Form Now" button.

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

how to form saar spaces to fill in

Provide the requested particulars in the field PART II ENDORSEMENT OF ACCESS BY, AUTHORIZED, PRIVILEGED, UNCLASSIFIED, CLASSIFIED (Specify category), OTHER, I certify that this user requires, 16, a 20, a and 20, b

Filling in how to form saar part 2

The application will require data to effortlessly prepare the box 21, a 21, b DD FORM 2875, PREVIOUS EDITION IS OBSOLETE, and Page 1 of 3.

step 3 to finishing how to form saar

The space PART III - SECURITY MANAGER is for you to add each side's rights and obligations.

Completing how to form saar part 4

Finalize by reviewing the following sections and submitting the required details: PART III - SECURITY MANAGER, 28, a 28, b PART IV - COMPLETION BY AUTHORIZED, SYSTEM, ACCOUNT CODE, DOMAIN, SERVER, and APPLICATION.

Finishing how to form saar step 5

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