Request Army IG Action

TEST ONLY
Do not enter any classified information on this form

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY: 10 U.S.C. 7013, Secretary of the Army; 10 U.S.C. 7020, Inspector General; Inspector General Act of 1978, Public Law 95-452, 92 Stat. 1101 (1978), as amended; DoDD 1030.1, Victim and Witness Assistance; AR 20-1, Inspector General Activities and Procedures.

PRINCIPAL PURPOSE: To secure information sufficient to inquire into the matters presented, to take action to correct deficiencies, and to respond to requesters.

ROUTINE USES: Information is used for official purposes within the Department of Defense; to answer complaints or respond to requests for assistance, advice, or information; by Members of Congress and other Government agencies when determined by the Inspector General to be in the best interest of the Army; and, in certain cases, in trials by court-martial and other military matters as authorized by the Uniform Code of Military Justice.

DISCLOSURE: Voluntary. However, failure to provide complete information may hinder proper identification of the requester, accomplishment of the requested action(s), and response to the requester.

SORN: A0020-1 SAIG, Inspector General Records (January 11, 2002, 67 FR 1447)

Do not enter any classified information on this form

* indicates required field

DO YOU WISH TO REMAIN ANONYMOUS? *

NO
YES

Note: If you file a Inspector General Action Request anonymously, we will be unable to contact you to obtain more information about the case or provide you the results if we conduct an investigation. If you choose to remain anonymous, do not identify yourself below or enter an email. You will not receive an email confirming receipt of your input.

Name

Rank/Title

First

Middle

Last

DOD ID (Leave blank if you do not have a DOD ID)

TELEPHONE (duty, home, and /or cell)

E-MAIL ADDRESS

Email

Confirm

Which Army organization do you fall under?*

UNIT AND COMPLETE MILITARY ADDRESS (if applicable)

Unit

Street

City

State/Region

Country

Zip

PREFERRED MAILING ADDRESS (If different from military address, including ZIP Code)

Street

City

State/Region

Country

Zip

COMPONENT / DUTY STATUS

AD - Active Duty
NG - National Guard (incl. AGR)
AR - Reserve (incl. AGR)
VET - Veteran/Retiree
DAC - Department of the Army Civilian Employee
CIV - Non-Army Civilian (including Family Members)
Other

GRADE/RANK

I do / I do not consent to release my personal information outside of IG channels to the chain of command or other officials (but within DoD channels) in order to resolve the matters listed below. *

I consent
I do not consent

I understand that if I do not release my personal information, my request for assistance may go unresolved.

I do / I do not consent to release the supporting documents I provided to the IG (to exclude this DA Form) outside of IG channels to the chain command or other officials (but within DoD channels) in order to resolve the matters listed below. *

I consent
I do not consent

I understand that if I do not release my documents, my request for assistance may go unresolved.

ARE YOU WILLING TO BE INTERVIEWED? *

YES
NO

What assistance do you need from the IG? (limit 700 characters)*

Do you believe someone has wronged you, or violated a policy, regulation, law, etc?*

NO
YES

(If applicable) Who do you believe did something wrong or wronged you? {Subject(s)/Suspect(s)}

(Please fill out the information below as completely as possible)

Name (Subject 1)

Rank/Title

First

Middle

Last

(If applicable) Does the subject/suspect belong to any of the categories below?

Phone:

Unit/Address

Unit

Street

City

State/Region

Country

Zip

COMPONENT / DUTY STATUS

AD - Active Duty
NG - National Guard (incl. AGR)
AR - Reserve (incl. AGR)
VET - Veteran/Retiree
DAC - Department of the Army Civilian Employee
CIV - Non-Army Civilian (including Family Members)

GRADE/RANK

Please list the rank, name, unit and contact information of any other subjects (limit 200 characters)

What did the subject do, or fail to do, that was wrong? (limit 700 characters)

What rule, regulation, or law do you believe the subject(s) violated? (Limit 500 characters)

Have you sent your complaint to a Member of Congress? (If yes, please provide information below)*

NO
YES

Name(s) of Congressperson(s) and date(s) you contacted them (Limit 250 characters)

When did the incident occur? Provide dates and times, if possible. (Limit 200 characters)

Where did the incident take place? What location, command, etc.? (Limit 300 characters)

Why do you think the incident took place? (Limit 800 characters)

How have you tried to resolve the problem? (Limit 800 characters)

Who else do you believe has information regarding this request? Add contact information if possible. (Limit 500 characters)

This information is submitted for the basic purpose of requesting assistance, correcting injustices affecting the individual, or eliminating conditions considered detrimental to the efficiency or reputation of the Army. Those who knowingly and intentionally provide false statements on this form are subject to potential punitive and administrative action (UCMJ Art 107 or 18 U.S.C. 1001).

SIGNATURE (leave blank if anonymous)

DATE

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