Dd3128

Prescribed by: DoDI 8910.01, DoDM 8910.01

INFORMATION COLLECTION REQUEST
COORDINATION SUMMARY SHEET
1. OMB CONTROL NO.
(or placeholder)

0704-0553

2. TITLE

3. COMPONENT

Naval Hospital Rota Access to Care Survey (OMB Fast Track Generic Clearance)

DHA

4. ACTION OFFICER
a. NAME

b. PHONE NUMBER

LCDR Jason Galk

c. E-MAIL ADDRESS

314.727.3565

jason.s.galka.mil@health.mil

5. PRA LIAISON
a. NAME

b. PHONE NUMBER

Amanda Grifka

571-329-1420

c. E-MAIL ADDRESS

amanda.b.grifka.civ@health.mil

d. SIGNATURE

e. DATE (YYYYMMDD)

GRIFKA.AMANDA.BETH.1525770539

Digitally signed by GRIFKA.AMANDA.BETH.1525770539
Date: 2024.09.05 12:42:13 -04'00'

20240905

6. COORDINATION
a. COORDINATOR

b. COORDINATION
REQUIRED (Yes/No)

PRIVACY OFFICER (SORN, PAS,
PAA, SSN Justification/Plan)

RECORDS MANAGER/
RECORDS ADMINISTRATOR
(Records Schedule/ Disposition)
https://www.archives.gov/records-mgmt/
agency/departments/defense.html

YES

c. COORDINATOR REMARKS

No PAS is required, PII such Name and
Number will be collected however the
information will not be stored in a SOR

d. COORDINATOR SIGNATURE

e. DATE
(YYYYMMDD)

signed by
BROWN.LUCH Digitally
BROWN.LUCHELL.C.126
ELL.C.1266908 6908195
20240905
Date: 2024.09.05 12:37:31
195
-04'00'

YES

CHIEF INFORMATION OFFICER
(PIA/Data Security)

DPAC (Surveys - Methodology &
Scientific Review)
dodhra.mc-alex.dpac.mbx.dod-surveyreview@mail.mil

HRPP OFFICIAL/INSTITUTIONAL
REVIEW BOARD (Research)

FORMS MANAGER (Forms
Assessment)

GENERAL COUNSEL (For
Incentive/Gifts)

RDD (For DD Forms Only)

Air Force Survey Office (complete
before DPAC for surveys to AF
personnel)

afpc.dsys.af.surveyoffice@us.af.mil
7. ADDITIONAL REMARKS

DD FORM 3128, MARCH 2021

Page 1 of 1

Reset