Reserve Annual Screening Questionnaire
This collection of information (COI)
is targeted only to USCG IRR personnel. If you are not a member of
the targeted group, please do not submit information to the Coast
Guard through this form. The Coast Guard will immediately
delete any submissions that it receives from persons who do not fit
into this category.
***THIS FORM IS INTENDED FOR MEMBERS OF THE IRR ONLY, ALL
OTHER RESPONSES WILL NOT BE PROCESSED***
COMPETENCIES, QUALIFICATION CODES, EXPERIENCE INDICATORS
STANDARD OCCUPATION CODE(S)
You may have more than one occupation code.
CIVILIAN EMPLOYER INFORMATION
AVAILABILITY FOR MOBILIZATION
You must notify your chain of command of anything
that prevents you from mobilizing (including temporary conditions).
I am available for mobilization:
If no, check only one below and explain. Checking
"no" MAY mean you cannot be a drilling reservist.
My Federal agency has designated me as a key employee.
* Your Federal Agency has declared in writing that your position is
you cannot be mobilized. This will cause you to lose your
I am employed in a critical civilian occupation.
* An occupation that could be critical to your community at
the same time that a
mobilization is necessary (police, fire department, EMA, local
This MAY affect your SELRES status.
absence would create a community or family hardship.
* A temporary condition makes it impossible for you to
mobilize. The MAY cause
you to lose your SELRES status for the duration of the hardship.
ARE YOU A FIRST RESPONDER?
First responders are the men and women who are
first on the scene in an official capacity as a domestic natural or
manmade disaster unfolds. First responders are generally Sate
and local law enforcement officers (to include SWAT teams, bomb-dog
teams, and bomb squads), firemen (including hazardous material and
search and rescue personnel), and emergency medical technicians.
I have read the above paragraph and:
ACKNOWLEDGEMENT OF POTENTIAL RECALL STATUS
As a member of the U.S. Coast Guard Reserve, I
understand and willingly accept the following obligations:
(1) I am subject to involuntary recall and that I may be required to
report with as little as 48 hours notice. Failure to report as
directed is punishable under Article 86 of the Uniform Code of
Military Justice (UCMJ) and a court-martial may direct punishment up
to and including: dishonorable discharge, forfeiture of all pay and
allowances, and/or confinement for up to one year.
(2) I must comply with the requirements of Chapter 4 (Participation
Standards) of the Reserve Personnel Manual (COMDTINST M1001.28A) and
failure to comply with these standards may result in disciplinary or
administrative action including involuntary recall to active duty or
separation from the service.
(3) I shall plan for contingences in the care and support of my
dependent family members and develop a family care plan if; I am a
single parent, a dual-member couple with dependents, or married with
custody or joint custody of a child whose non-custodial biological
or adoptive parent is not my current spouse, or I otherwise bear
sole responsibility for the care of children under the age of 19 or
for others unable to care for themselves in my absence, or I am
primarily responsible for dependent family members. Failure to have
a family care plan may subject me to disciplinary or administrative
action that can result in my separation from service and is not
justification to avoid involuntarily recall.
(4) If my deployability becomes impaired due to employment, family,
medical, or any other condition(s), or if I am to be out of the
country for greater than 30 days, I shall notify my command
immediately in writing. I will work to resolve such issues through
my chain-of-command, in accordance with Coast Guard policy, and
understand that long-term issues that prevent my deployability can
result in my transfer to the Individual Ready Reserve (IRR), the
Standby Reserve, or administrative separation from the service.
I have read the above paragraphs and:
I understand and accept
I do not accept
I do not understand
Signature (type your full name):
Any "collection of information" as defined in the Paperwork
Reduction Act of 1995 (codified at 44 U.S.C. 3501 et seq) on this
form has not been approved by the Director of the Office of
Management and Budget (OMB) and does not display a valid control
number assigned by the Director. Therefore, no person shall be
subject to any penalty for failing to comply with an such collection
PRIVACY ACT STATEMENT
AUTHORITY: This information is collected under
Title 10 USC 10149 that requires that the USCG continuously screen
Read Reserve members to ensure they are properly skilled and able to
report for active duty if mobilized. Title 10 USC 10205
requires that you report to your chain of command any changed in
address, marital status, number of dependents, civilian employment,
or medical condition (dental, physical, or psychological) that would
prevent you from mobilizing - even temporary conditions.
PRINCIPAL PURPOSE: Screening for mobilization
ROUTINE USE: In addition to those disclosures
generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these
records or information contained therein may specifically be
disclosed outside the DHS as routine use pursuant to 5 U.S.C.
552a(b)3 as follows: The Routine Uses published in the United States
Coast Guard Military Pay and Personnel system of records notice
DISCLOSURE: Disclosure of this information is
voluntary; however, failure to complete this form may affect your
status in the Coast Guard Reserve.