Get DA 3887 2010-2024

NURSING EDUCATION AND EXPERIENCE POST GRADUATE AND UNIVERSITY COURSES COURSE INSTITUTION LOCATION INCLUSIVE DATES CIVILIAN NURSING EXPERIENCE POSITION MILITARY COURSES CLINICAL FIELD MILITARY NURSING EXPERIENCE REMARKS FORM COMPLETED Date REVERSE OF DA FORM 3887 APR 2010 APD PE v1. NAME Last First Middle Initial TEMP GRADE DATE Check one RA USAR DATE OF BIRTH RELIGION MARITAL STATUS Check one SINGLE MARRIED LOCAL ADDRESS SERVICE AGREEMENT EXPIRATION DATE DATE CURRENT TOUR AD MAIDEN NAME PMOS SMOS DMOS WIFE OR HUSBAND S NAME OTHER Include Zip Code TELEPHONE NUMBER SECURITY CLEARANCE NEXT OF KIN INFORMATION NAME AND RELATIONSHIP ADDRESS Include Area Code SCHOOL OF NURSING INFORMATION STATE YEAR NAME OF SCHOOL DIPLOMA DEGREE-YEAR MAJOR FIELD CURRENT REGISTRATION REGISTRATION NUMBER DATE RETURNED FROM OVERSEAS PROFESSIONAL ORGANIZATION MEMBERSHIPS Check applicable box es AMERICAN NURSES ASSOCIATION NATIONAL LEAGUE FOR NURSING Specify NURSING ASSIGNMENT PREFERENCE FIRST SECOND DA FORM 3887 APR 2010 THIRD PREVIOUS EDITIONS ARE OBSOLETE ASSIGNED DATE NURSING DEPARTMENT - ARMY NURSE CORPS DATA For use of this form see AR 40-3 the proponent agency is Office of The Surgeon General DATA REQUIRED BY THE PRIVACY ACT OF 1974 5 U.S.C. 552a 1. AUTHORITY 5 US Code 301 Departmental Regulations. 10 US Code 1071 Medical Dental Care Purposes. 552a 1. AUTHORITY 5 US Code 301 Departmental Regulations. 10 US Code 1071 Medical Dental Care Purposes. 42 US Code Social Security. 44 US Code 3101 Record Management by Agencies General Duties. 2. PRINCIPAL PURPOSE S This form is to provide a ready source of professional and personal information on each Army Nurse Corps officer in the Office of the Chief Department of Nursing* During inprocessing to a medical treatment facility individual officers complete this data card and report necessary changes as these occur. 3. ROUTINE USES The DoD Blanket Routine Uses set forth at the beginning of the Army s compilation of systems of records notices also apply to this system* 4. MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION Voluntary however failure to provide the requested information may result in the improper utilization/assignment of Army Nurse Corps officer and safe effective nursing care to patients. 552a 1. AUTHORITY 5 US Code 301 Departmental Regulations. 10 US Code 1071 Medical Dental Care Purposes. 42 US Code Social Security. 44 US Code 3101 Record Management by Agencies General Duties. 2. PRINCIPAL PURPOSE S This form is to provide a ready source of professional and personal information on each Army Nurse Corps officer in the Office of the Chief Department of Nursing* During inprocessing to a medical treatment facility individual officers complete this data card and report necessary changes as these occur. 42 US Code Social Security. 44 US Code 3101 Record Management by Agencies General Duties. 2. PRINCIPAL PURPOSE S This form is to provide a ready source of professional and personal information on each Army Nurse Corps officer in the Office of the Chief Department of Nursing* During inprocessing to a medical treatment facility individual officers complete this data card and report necessary changes as these occur. 3. ROUTINE USES The DoD Blanket Routine Uses set forth at the beginning of the Army s compilation of systems of records notices also apply to this system* 4. .