Security Levels

National Terrorism Advisory System (NTAS) check current status

Reserve Personnel Management Division

Reserve Annual Screening Questionnaire

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***

BASIC INFORMATION

       


COMPETENCIES, QUALIFICATION CODES, EXPERIENCE INDICATORS


STANDARD OCCUPATION CODE(S)

See http://stats.bls.gov/soc
You may have more than one occupation code.

(N/A if still in this occupation)


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.

         
                * Your Federal Agency has declared in writing that your position is critical and
                you cannot be mobilized.  This will cause you to lose your SELRES status.

         
               
* An occupation that could be critical to your community at the same time that a
                mobilization is necessary (police, fire department, EMA, local government official). 
                This MAY affect your SELRES status.

         
               
* 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:
       

          - I consider myself to be a first responder.
       
  - I do not consider myself to be a first responder.


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:

         
       
 
       
 

(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 of information.

 

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 readiness.
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 applies (DHS/USCG-014).
DISCLOSURE: Disclosure of this information is voluntary; however, failure to complete this form may affect your status in the Coast Guard Reserve.

 

   

 

Last Modified 9/19/2013