Technical Exhibit 3 - Forms FY23.pdf

IMDR-ES FORM 2, JAN 2016 PREVIOUS EDITION IS OBSOLETE

APPLICATION FOR SPONSORSHIP

PRIVACY ACT STATEMENT: The information you provide is covered by the Privacy Act of 1974, Title 5, U.S.C. 552a.

AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; Army Regulation 190-13, The Army Physical Security Program and E.O. 9397 (SSN).

PRINCIPAL PURPOSE(S): To record personal data and vehicle information to ensure positive identification of personnel authorized access to the installation/restricted areas; to conduct criminal background checks through local and national law enforcement databases; to maintain accountability for issuance and disposition of access passes.

ROUTINE USES: The DoD Blanket Routine Use set forth at the beginning of the Army's compilation of systems of records notices may apply to this system.

DISCLOSURE: Voluntary. However, failure to provide the requested information will result in denial of access to the installation.

Request sponsorship for the following individuals:

Last Name

First Name

Middle Initial

Date of Birth

ID Type

ID Number

ID State *See Reverse*

Vehicle Make

Vehicle Color

Vehicle Plate

State

Relationship

Justification:

DATE OF REQUESTED ACCESS (DD/MMM/YYYY) TIME OF REQUESTED ACCESS

FROM TO FROM TO

DAYS REQUESTED ACCESS MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

SPONSOR’S INFORMATION:

LAST NAME: _ _ _ FIRST NAME: MI:

RANK/GRADE: __ ORGANIZATION: _ _ TELE:

ADDRESS: _ _ EMAIL: _ _

I acknowledge as a Sponsor that the name(d) individuals have official business to conduct on Fort Drum

(Sponsor’s Signature) Date

The above individuals are approved / disapproved for issuance of Friends of the North Country Local Access Badge.

Approving Official Printed Name Approving Official Signature

SECTION BELOW IS FOR USE BY INSTALLATION ACCESS CONTROL OFFICE

NCIC-III DATE: CLEARED / FAILED (circle one) CONTROL #

NCIC-III Officer Printed Name NCIC-III Officer Signature

IMDR-ES FORM 2, JAN 2016 PREVIOUS EDITION IS OBSOLETE

APPLICATION FOR SPONSORSHIP INSTRUCTIONS

USE: The information contained in the application will serve as input data to conduct a NCIC-III background check as required by AR 190-13. If you do not type the information on this form insure that your writing is neat and legible to avoid any mistakes, confusion, or delays when conducting checks and preparing passes.

It is essential that all users of this form provide the required information according to the instructions below:

Last Name: self-explanatory.

First Name: self-explanatory.

Middle Initial: self-explanatory.

Date of Birth: DDMMMYYYY (example: 05 FEB 1965)

ID Type: Driver’s License; Passport; School ID; etc.

ID Number: may be letters and numbers depending on identification.

ID State: State that issued ID. DoD, like all other Federal agencies is prohibited from accepting non-compliant DL, therefore visitor control centers will no longer accept a non-REAL ID driver’s license or identification card for physical access from Illinois, Minnesota, Missouri, and Washington. Therefore, unless the individual possesses one of the following authorized government issued identification cards, they will not be granted unescorted access on Fort Drum: U.S. passport, permanent resident card / alien registration receipt card, employment authorization document with photo, school identification card with photo, U.S. Military or draft record, U.S. Coast Guard Merchant Mariner Cards, Transportation Worker Identification Card, Native American Tribal Document.

Vehicle Make: Ford, Chevy, Toyota, etc.

Vehicle Color: Red, Blue, Black, White, etc.

Vehicle Plate: The alphanumeric license plate displayed on the vehicle.

State: The state that issued the plate displayed on the vehicle.

Relationship: The connection between the individual being sponsored and the sponsor (mother, father, son, daughter, friend, contractor, etc.)

Justification: Explain the reason (bonafide need) why the individual(s) need access to Fort Drum.

Dates of Requested Access: DDMMMYYYY (example: 05 FEB 1965) for From and To.

Times of Requested Access: 24 hour clock (1300; 2315; etc.) for From and To.

Days Requested Access: Check the box for each applicable day of the week.

Sponsor’s Information: self-explanatory.

Sponsor’s Signature and date: self-explanatory. Electronic signature preferred.

mailto:usarmy.drum.imcom-atlantic.mbx.des-acp@mail.mil

8.

11b. TYPE OF LOCATION

17.16.

11a. EXACT LOCATION OF ACCIDENT (Detailed enough to locate site)

5.

2.

18a.

18b.

14. DOB (YYYYMMDD)13. SOCIAL SECURITY NUMBER (SSN)

FOR USACRC USE ONLY

c. DAYb. MONTHa. YEAR

11c. GRID COORDINATES OR LAT/LONG

ACCIDENT

OCCURRED

(Check one)

7.

25a. OSHA 300 Log Case Number:

21b. CONTINUOUS WORK w/o SLEEP:

21a. TIME BEGAN WORK:

23. DAYS LOST/RESTRICTED (not counting day of injury) 24. TREATED IN

19b. IF OFF DUTY (if on leave/pass)

Not reported

Shoulder i.

Wrist

15. GENDER (Check)

19a. DUTY STATUS AT TIME OF ACCIDENT (Check one)

TIME OF

ACCIDENT (Local Military Time)

1. CHECK ONE

TECHNICAL REPORT OF U.S. ARMY GROUND ACCIDENT

For use of this form, see DA Pamphlet 385-40; the proponent agency is OCSA.

28. CAUSE OF INJURY/OCCUPATIONAL ILLNESS

(Number in order of severity) (No more than 3)

3b. BRANCH (Armor, Infantry, etc.)

Active Army

RANK OR GRADE

SECTION A - ACCIDENT INFORMATION

SECTION B - PERSONNEL INFORMATION

4. DATE OF ACCIDENT

3a. UNIT NAME AND MILITARY ADDRESS (Accountable Unit)

REQUIREMENTS CONTROL SYMBOL

CSOCS-308

ACCIDENT OCCURRED

DURING (Check one)

WERE EXPLOSIVES OR AMMUNITION

INVOLVED (Causal or Contributing Role)

27. CLASSIFICATION AT TIME OF

ACCIDENT (Check)

ADDRESS (Use Official Address for All Military or Government Personnel) (If different than Block 3, add UIC.)

NGB ADT

USAR IDT

Army Civilian

Army Contractor

Nonappropriated Fund

(NAF)

Other U.S. Military

ROTC

Dependent

NGB Tech

NGB IDT

NGB AT

NGB ADSW

NGB AGR

29. BODY PART(S) AFFECTED

(Number in order of severity) (No more than 3)

30. TYPE OF INJURY/ILLNESS

(Number to Correspond with Block 29)

USAR AT

USAR ADT

USAR FTM

Foreign Nat. Direct Hire

Foreign Nat. Indirect Hire

Foreign Nat. KATUSA

Public

26. SEVERITY OF ILLNESS/INJURY (Check most severe) a.

b.

c.

g.

e.

f.

Struck Against

Struck By

Fell from Elevation

Fell from Same Level

Rubbed/Abraded

Bodily Reaction d.

h.

i.

j.

k.

l.

m.

n.

o.

p.

q.

r.

s.

t.

u.

v.

w.

a.

b.

c.

d.

e.

f.

g.

Overexertion

Exposure

External Contact

Ingested

Inhaled h.

i.

j.

k.

l.

Nose

Jaw

Neck

Trunk

Chest

Heart

Back

Arm e.

f.

g.

h.

i.

j.

k.

l.

m.

n.

a.

b.

c.

d.

Body (General)

Head

Forehead

Eyes Fingers

Leg

Knee

Ankle

Foot

Toes p.

q.

r.

s.

t.

u.

v. Other (Specify)

DA FORM 285, FEB 2009

Fatal (Date of Death

Permanent Total Disability. Person can never again do gainful work.

Permanent Partial Disability. Person loses or can never again use a body part Days Away from Work. Person misses one or more workdays; bed rest/on quarters.

Restricted Work Activity. Person is temporarily unable to perform regular duties; job transfer/light duty/profile.

First Aid Only. Person has one-time treatment of minor injury. (No lost work days.)

Medical Treatment Beyond First Aid. Loss of consciousness, needle stick, etc.

a.

c.

d.

e.

f.

g.

b.

10.

9.IF ON POST, NAME OF

INSTALLATION/FACILITY

6. PERIOD OF DAY

(Check one)

UIC (Unit Identification Code) (6-Digit Code of Unit Having Accident)a.

b.

ORIGINAL

CHANGE

a. Dawn

c. Dusk

b. Day

d. Night

a. On Post

b. Off Post

a. Combat

b. Non-Combat

Yes (See DA PAM 385-40) No a.

b.

Male Female

On Duty

Off Duty

PREVIOUS EDITION IS OBSOLETE. PAGE 1 OF 5

For injured Army Civilians or Contractors, enter home address

Hando.

No Injury.h.

a.

b.

c.

g.

e.

f.

d.

h.

j.

k.

l.

m.

n.

o.

p.

q.

r.

s.

t.

u.

Noise Injury/ Illness

Other (Specify)

Heat Exhaustion

Concussion

Sprain/Strain

Cuts/Lacerations

Contusion

Puncture Wound

Hernia, Rupture

Frostbite

Heat Stroke

Fractures

Dislocation

Burns (Chemical)

Burns (Thermal)

Amputation

Asphyxiation (Suffocation)

Abrasions

Army Direct Contractor

NG Activated

USAR AGR

USAR Activated x.

y.

z.

aa.

Leave

Pass

Date From:

Date To:

20. FLIGHT STATUS (Check one) a. Yes b. No

22. HRS. SLEEP IN LAST 24:

a. Yes

b. No

a. Hospitalized: Days

b. Not Hospitalized: Days

c. Restricted Activity:

Days

25b. Name of Physician/Health Care Provider:

25c. If treatment was given away from worksite, where was it given?

Facility:

Street:

City: State:

12. NAME (Last, First, MI)

MOS OR JOB

SERIES

Foreign Mil. Attached to the U.S. Army

Caught In/ Under/ Between

Decompression Sickness

Loss of Consciousness

Needle Stick or Sharp

EMERGENCY

ROOM

APD AEM v1.00ES

32. SPECIFIC DESCRIPTION OF ACTIVITY/TASK

35. Type of training facility being used (Check one)

34. ACTIVITY PART OF TACTICAL

TRAINING?

z. Sports

DA FORM 285, FEB 2009 PAGE 2 OF 5

31. Person's action(s) at time of accident (Check one and explain in Block 32.)

SECTION B - PERSONNEL INFORMATION (Continued)

gg. Parachuting (See Instructions DA Pamphlet 385-40)

aa. Hobbies

bb. Passenger

cc. Human movement

dd. Horseplay

ee. Bystanding/spectating

s. Fabricating

t. Handling Material/Passengers

w. Supervisory

v. Food/Drink Preparations

x. Office

y. Counseling/Advisory

g. Security/Law Enforcement

a. Soldiering

b. Combat Soldiering

c. Physical Training

d. Weapons Firing/Handling

e. Engineering or Construction

f. Communications

h. Fire Fighting

i. Patient Care (People/Animals)

p. Operating Vehicle or Vessel

j. Test/Study/Experiments

k. Educational

l. Information and Arts

m. Food and Drug Inspection

n. Laundry/Dry Cleaning Services

o. Pest/Plant Control

q. Handling Animal

r. Maintenance/Repair/Servicing

(1) Jumper Height (7) Wind Direction/Speed At (15) Date graduated basic airborne training

(YYYYMMDD)

(16) Type of Aircraft

(2) Jumper Weight

(3) Type of Jump

(5) Equipment

(6) Wt. of Equipment

Jump Height Drop Zone

(8) Jump Altitude

(9) Position in Stick

(10) Door Exited

(11) Time pre-jump conducted

(12) Date of Last Jump

(4) Parachute Type/Model

(13) Type of Last Jump

(14) Number of previous jumps

(17) Accident factors (parachute):

(Explain as necessary)

33. ON FIELD EXERCISE/NAMED OPERATION

a. Yes

b. No

a. Yes

b. No

g. Std. range facility/live fire a. Garrison

b. Local training area

c. Major training area

d. NTC

e. JRTC

f. CMTC

h. Other (Specify):

36. Type of training participating in at the time of accident (Check/specify)

c. On-the-job training

(1) Platoon (2) Crew (3) Individual

a. School (Specify):

b. UNIT

d. Other (Specify):

37. Last time individual received training prior to accident on activity specified in Block 31? (Check one)

a. 0 - 3 months

b. 3 - 6 months

c. 6 - 9 months

d. 9 - 12 months

e. 1 - 2 years

f. More than 2 years

g. Never

h. Not applicable

CHECK APPROPRIATE BLOCK(S)

38. REQUIRED PROTECTIVE EQUIPMENT AVAILABLE?

YES

USED?

NO

N/A a.

c.

Seat belt

Helmet

Goggles/Glasses/Visor

Gloves

Ear plugs

YES NO

DOT Approved (If Motorcycle)?

IBA

c. N/A

a. Yes

b. No

a. Yes

b. No

39c. MSF CERTIFIED

a. Yes

b. No

(Check one)

a. Yes BAC %: b. No c. Unknown

Other (Specify):

u. Janitorial/Housekeeping/ Grounds Keeping

ff. Personal Hygiene/Food/Drink Consumption/Sleeping

(If YES, specify name of exercise/operation.)

If Yes, Date

If Yes, Date

40.DID ALCOHOL USE BY THIS INDIVIDUAL CAUSE/CONTRIBUTE TO THIS ACCIDENT?

39a. INDIVIDUAL LICENSED

TO OPERATE

VEHICLE/EQUIPMENT?

39b. MANDATORY 4 hr

TRAFFIC SAFETY

TRAINING

d.

e.

f.

g.

h.

Yes No

b. Restraint System

c. TYPE: d. MODEL:

46. What was the mistake? How was the activity/task performed incorrectly? (Explain below.)

DA FORM 285, FEB 2009 PAGE 3 OF 5

43. Standard/Reference covering activity/task

47. Why was mistake made/activity performed incorrectly? (Check all that apply.)

a. Soldier's Manual (Task No.)

b. CTT (Task No.)

c. AR/TM/FM (Specify)

d. SOP

e. Federal/State Law

44. WAS ACTIVITY/TASK PERFORMED IAW STANDARD/REFERENCE? (Check one) 45. DID INDIVIDUAL MAKE A MISTAKE? (Check one)

41. If drug use by this individual caused/contributed to this accident, check appropriate block.

SECTION B - PERSONNEL INFORMATION (Continued)

a. Yes b. No (If NO, complete blocks 45-47.) a. Yes (If YES, complete blocks 46-47.) b. No

a. Prescription b. Illegal c. Over-the-counter d. Supplements e. None

42. Were vision enhancement devices being used? (Check appropriate block.)

a. Yes (Specify type/model in c and d.) b. No

f. Other (Specify):

g. None (Go to Block 45.)

m. Inadequate written procedures (AR, TM, SOP)

n. Improper supervision

o. Other (Specify in narrative)

a. Inadequate school training (content/amount)

b. Inadequate unit training (content/amount)

c. Inadequate on-the-job training

d. Fear/excitement/anger

e. Overconfident in own/others abilities/complacent

f. In a hurry

g. Poor/bad attitude/indiscipline

h. Lack of rest/sleep

i. Effects of alcohol/drugs/illness

j. Inadequate facilities

k. Inadequate services

l. Improper equipment design

48. Time licensed on this vehicle (Check one) 49. Total AMV driving mileage (Check one) 50a. Total time in unit (Check one)

a. Less than one year

b. One to two years

c. Over two years

d. Unlicensed

a. Less than 1,000 miles

b. 1,000 - 5,000 miles

c. 5,000 - 10,000 miles

d. Over 10,000 miles

Less than 6 months

6 months - 1 year

Over one year

51. WHICH ITEM FROM SECTION C APPLIES TO THE INDIVIDUAL NAMED IN BLOCK 12?

(This is needed in order to relate the person in Block 12 to the equipment/vehicle below.)

Item A Item B Item C Other (Specify)

50b. Date Assigned/Hired

(YYYYMMDD)

(YYYYMMDD)

56. Rollover protection system installed?

SECTION C - PROPERTY/MATERIEL INVOLVED (Whether Damaged or Not)

52. Type of item

57. Was this item being towed?

58. If towed, enter letter for item doing towing.

59. Types of collision codes (Pick up to three from list below and enter in blocks.) (In sequence)

ITEM CITEM A ITEM B

Types of Collisions

Yes No NA Yes No NAYes No NA

b. Serial number

53a. Model number

54. Ownership (DoD, DA, POV, Unit Person)

55. Dollar cost of damage.

Yes No NA Yes No NAYes No NA

50c. Date of redeployment from combat zone, if applicable

7- Ran off the road 8- Jackknifed 9- Going forward and rear-ended moving vehicle 10- Going forward and rear-ended parked vehicle

12- Other (Specify) 11- Collision while turning

6- Overturned 5- Collision with object (other than vehicle/pedestrian) 4- Collision with pedestrian 3- Collision while backing 2- Going forward and collided with parked vehicle 1- Going forward and collided with moving vehicle

b. Part Number

c. Describe Part

d. Manufacturer's Identification Code

e. EIR/QDR Number

64a. PRINTED/TYPED NAME OF PERSON COMPLETING THIS REPORT 64b. RANK 64c. TITLE

64d. SIGNATURE

(YYYYMMDD)

64f. TELEPHONE NO.

64g. EMAIL ADDRESS

9 - Twisted/torqued 10 - Compressed/hit/punctured 11 - Bent/warped 12 - Sheared/cut 13 - Decayed/decomposed 14 - Electric current action 15 - Unknown/Other Blank - Not Reported

60. Component/Part that Failed/Malfunctioned (Complete this section if a materiel failure/malfunction caused/contributed to the accident.)

ITEM A ITEM B ITEM C

61. How/Why Part Malfunctioned (Select code from "How" list below and enter in first block; select

HOW WHY HOW WHY HOW WHY

1 - Improper equipment design 2 - Inadequate maintenance 3 - Inadequate manufacture of equipment 4 - Inadequate written procedures (AR, TM, SOP) 5 - Improper supervision 6 - Unknown 7 - Other (Specify in narrative)

1 - Overheated/burned/melted 2 - Froze (temperature) 3 - Obstructed/pinched/clogged 4 - Vibrated 5 - Rubbed/worn/frayed 6 - Corroded/rusted/pitted 7 - Overpressured/burst 8 - Pulled/stretched

a. National Stock Number

How Part Failed/Malfunctioned Codes: Why Part Failed/Malfunctioned Codes:

DA FORM 285, FEB 2009 PAGE 4 OF 5

SECTION C - PROPERTY/MATERIEL INVOLVED (Whether Damaged or Not) (Continued)

SECTION D - ENVIRONMENTAL CONDITIONS INVOLVED

62. Environmental Conditions. (Check environmental conditions present and indicate if conditions caused/contributed to the accident.)

CONDITIONPRESENT CAUSED/

CONTRIBUTED CONDITIONPRESENT CAUSED/

CONTRIBUTED

SECTION E - ACCIDENT DESCRIPTION/NARRATIVE (From Blocks 10, 46, 47, 61 and 62)

a. Clear/dry; visibility unlimited k. Wind gust/turbulence

b. Bright, glare l. Vibrate, shimmy, sway, shake

c. Dark, dim m. Radiation, laser, sunlight

d. Fog, condensation, frost n. Holes, rocky, rough, rutted, uneven

e. Mist, rain, sleet, hail o. Inclined/steep

f. Snow, ice p. Slippery (not due to precipitation)

g. Dust, fumes, gazes, smoke, vapors q. Air pressure (bends, decompression, altitude, hypoxial)

h. Noise, bang, static r. Lightning, static electricity, ground

i. Temperature/humidity (cold, heat) s. Other (Specify)

j. Storm, hurricane, tornado code from "Why" list and enter in second block.)

63. The investigation board will report, in narrative form on letter size paper, the facts, conditions, and circumstances as established during the investigation and present this information in accordance with DA PAM 385-40, paragraph 4-4.

64e. DATE OF

SIGNATURE

66a. PRINTED/TYPED NAME OF COMMANDER 66b. RANK

66c. SIGNATURE

(YYYYMMDD)

66e. TELEPHONE NO.

66f. EMAIL ADDRESS

70. LOCAL REPORT NO. 71. ARMY HEADQUARTERS

73. NAME OF SAFETY POINT OF CONTACT (POC)

(YYYYMMDD)

74a. PHONE NO. OF SAFETY OFFICER POC (DSN, Commercial, etc.)

74b. EMAIL ADDRESS

77. SPECIAL INTEREST

78. SUPPLEMENTAL INFORMATION

DA FORM 285, FEB 2009

APD AEM v1.00ES

SECTION F - CORRECTIVE ACTION AND COMMAND REVIEW

SECTION G - SAFETY OFFICE USE ONLY

67.

68.

69.

a. TYPED NAME/EMAIL ADDRESS b. SIGNATURE c. TITLE d. RANK/DATE

72. ACCIDENT TYPE (Check choice)

a. Army Motor Vehicle h. Other Army Vehicle o. Personal Injury - Other

b. Army Combat Vehicle i. Fire p. Property Damage - Other

c. Army Operated Vehicle j. Chemical Agent q. POV - On Official Business

d. POV - Not on Official Business k. Explosive r. Space

e. Marine Diving l. Missile s. Commercial Carrier/Transportation

f. Marine Underway m. Radiation

g. Marine Not Underway n. Nuclear

SECTION H - EXPLOSIVES/AMMUNITION

ITEM 1 ITEM 2 ITEM 4ITEM 3 76. EXPLOSIVE/AMMUNITION INFORMATION:

a. LOT #

b. QUANTITY

c. NET EXPLOSIVE WEIGHT (NEW)

d. DoDIC/DoDAC

66d. DATE OF

SIGNATURE

75. DATE REPORT

COMPLETED BY

SAFETY OFFICER

65. The investigation board will formulate the findings and recommendations on letter sized paper in accordance with the examples contained in DA PAM 385-40, paragraph 4-3.