DA Form 7767 Army Disaster Personnel Accountability and Assessment System, Needs Assessment Survey

DA Form 7767 or the "Army Disaster Personnel Accountability Assessment System, Needs Assessment Survey" is a Department of the Army-issued form used by and within the United States Military.

The form - often incorrectly referred to as the DD form 7767 - was last revised on February 1, 2017. Download an up-to-date fillable DA Form 7767 down below in PDF-format or look it up on the Army Publishing Directorate website.

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ARMY DISASTER PERSONNEL ACCOUNTABILITY AND ASSESSMENT SYSTEM, NEEDS ASSESSMENT SURVEY
For use of this form, see AR 600-86; the proponent agency is DCS G-1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
10 USC 136, Under Secretary of Defense for Personnel and Readiness; 10 USC 3013, Secretary of the Army; 10 USC
AUTHORITY:
5013, Secretary of the Navy; 10 USC 8013, Secretary of the Air Force; DoD Instruction 3001.02, Personnel Accountability
in Conjunction with Natural or Manmade Disasters; Air Force Instruction 10-218, Personnel Accountability in conjunction
with Natural Disasters or National Emergencies; Army Regulation 500-3, US Army Continuity of Operations Program
Policy and Planning.
To accomplish personnel accountability for DoD affiliated personnel in a natural or manmade disaster or when directed by
PRINCIPAL PURPOSE:
the Secretary of Defense. This system will document the individuals check-in data. The Military Departments may also
collect information about Service members and their dependents for needs assessment as a result of the natural or
manmade disaster. The DoD Components may also use accountability data for accountability and assessment reporting
exercises.
In addition to those disclosures generally permitted under 5 USC 552a(b) of the Privacy Act of 1974, these records may
ROUTINE USES:
specifically be disclosed outside DoD as a routine use pursuant to 5 USC 552a(b)(3) as follows:
To Federal, state, or local governments during actual emergencies, exercises or continuity of operations tests for the
purpose of responding to emergency situations or to allow emergency service personnel to locate the individual(s).
To Federal Emergency Management Agency to facilitate recovery efforts when natural or manmade disasters occur.
The DoD Blanket Routine Uses also apply to this system of records.
DISCLOSURE:
Voluntary; however, failure to provide identifying information may impede processing of this application.
PART I - PERSONAL INFORMATION
1. SURVEY DATE: 2. NAME (Last, First, Middle):
3. EDIPI:
4. DATE OF BIRTH: 5. UIC:
6. COMMAND NAME:
PART II - CURRENT CONTACT INFORMATION
7. ADDRESS/HOTEL:
8. PHONE:
9. CITY, STATE:
10. EMAIL:
FILL IN THE BOXES THAT APPLY TO YOU AND CHECK ALL APPLICABLE BOXES (Please choose Not Affected if none apply)
MEDICAL (Do you or your family need medical help?)
NEED IMMEDIATE CARE FROM A DOCTOR OR HOSPITAL
NOT AFFECTED
NEED MEDICAL HELP OR PRESCRIPTION DRUGS FOR A CHRONIC ILLNESS
NOT SURE
NEED HELP MAKING AN APPOINTMENT FOR ROUTINE NEEDS
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
MISSING FAMILY LOCATOR (Do you need help finding missing family members?)
NEED URGENT HELP FINDING IMMEDIATE FAMILY MEMBER(S)
MY FAMILY HAS BEEN IN CONTACT WITH ME, BUT I NEED HELP FINDING THEIR LOCATION
NOT AFFECTED
MY FAMILY MEMBER(S) HAS/HAVE BEEN IN CONTACT WITH ME, BUT I NEED HELP REACHING THEIR
NOT SURE
LOCATION
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
TRANSPORTATION TO ONWARD DESTINATION (Do you or your family need help getting to Safe Haven or
Permanent Duty Station (PDS)?)
NEED EVACUATION TRANSPORTATION TO SAFE HAVEN, OUT OF THE DISASTER AREA
NOT AFFECTED
NEED TRANSPORTATION TO SAFE HAVEN OR ALTERNATE DUTY LOCATION
NOT SURE
NEED TRANSPORTATION TO RETURN TO MY DUTY STATION
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
Page 1 of 4
DA FORM 7767, FEB 2017
APD LC v1.00ES
ARMY DISASTER PERSONNEL ACCOUNTABILITY AND ASSESSMENT SYSTEM, NEEDS ASSESSMENT SURVEY
For use of this form, see AR 600-86; the proponent agency is DCS G-1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
10 USC 136, Under Secretary of Defense for Personnel and Readiness; 10 USC 3013, Secretary of the Army; 10 USC
AUTHORITY:
5013, Secretary of the Navy; 10 USC 8013, Secretary of the Air Force; DoD Instruction 3001.02, Personnel Accountability
in Conjunction with Natural or Manmade Disasters; Air Force Instruction 10-218, Personnel Accountability in conjunction
with Natural Disasters or National Emergencies; Army Regulation 500-3, US Army Continuity of Operations Program
Policy and Planning.
To accomplish personnel accountability for DoD affiliated personnel in a natural or manmade disaster or when directed by
PRINCIPAL PURPOSE:
the Secretary of Defense. This system will document the individuals check-in data. The Military Departments may also
collect information about Service members and their dependents for needs assessment as a result of the natural or
manmade disaster. The DoD Components may also use accountability data for accountability and assessment reporting
exercises.
In addition to those disclosures generally permitted under 5 USC 552a(b) of the Privacy Act of 1974, these records may
ROUTINE USES:
specifically be disclosed outside DoD as a routine use pursuant to 5 USC 552a(b)(3) as follows:
To Federal, state, or local governments during actual emergencies, exercises or continuity of operations tests for the
purpose of responding to emergency situations or to allow emergency service personnel to locate the individual(s).
To Federal Emergency Management Agency to facilitate recovery efforts when natural or manmade disasters occur.
The DoD Blanket Routine Uses also apply to this system of records.
DISCLOSURE:
Voluntary; however, failure to provide identifying information may impede processing of this application.
PART I - PERSONAL INFORMATION
1. SURVEY DATE: 2. NAME (Last, First, Middle):
3. EDIPI:
4. DATE OF BIRTH: 5. UIC:
6. COMMAND NAME:
PART II - CURRENT CONTACT INFORMATION
7. ADDRESS/HOTEL:
8. PHONE:
9. CITY, STATE:
10. EMAIL:
FILL IN THE BOXES THAT APPLY TO YOU AND CHECK ALL APPLICABLE BOXES (Please choose Not Affected if none apply)
MEDICAL (Do you or your family need medical help?)
NEED IMMEDIATE CARE FROM A DOCTOR OR HOSPITAL
NOT AFFECTED
NEED MEDICAL HELP OR PRESCRIPTION DRUGS FOR A CHRONIC ILLNESS
NOT SURE
NEED HELP MAKING AN APPOINTMENT FOR ROUTINE NEEDS
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
MISSING FAMILY LOCATOR (Do you need help finding missing family members?)
NEED URGENT HELP FINDING IMMEDIATE FAMILY MEMBER(S)
MY FAMILY HAS BEEN IN CONTACT WITH ME, BUT I NEED HELP FINDING THEIR LOCATION
NOT AFFECTED
MY FAMILY MEMBER(S) HAS/HAVE BEEN IN CONTACT WITH ME, BUT I NEED HELP REACHING THEIR
NOT SURE
LOCATION
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
TRANSPORTATION TO ONWARD DESTINATION (Do you or your family need help getting to Safe Haven or
Permanent Duty Station (PDS)?)
NEED EVACUATION TRANSPORTATION TO SAFE HAVEN, OUT OF THE DISASTER AREA
NOT AFFECTED
NEED TRANSPORTATION TO SAFE HAVEN OR ALTERNATE DUTY LOCATION
NOT SURE
NEED TRANSPORTATION TO RETURN TO MY DUTY STATION
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
Page 1 of 4
DA FORM 7767, FEB 2017
APD LC v1.00ES
LOCAL TRANSPORTATION (Do you need transportation to meet personal/family needs?)
NEED URGENT TRANSPORTATION TO HANDLE CRITICAL NEEDS
NOT AFFECTED
NEED TRANSPORTATION FOR NORMAL ACTIVITIES
NOT SURE
HAVE TEMPORARY LOCAL TRANSPORTATION, BUT NEED TO FIND LONG-TERM TRANSPORTATION
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
TEMPORARY HOUSING (Do you need help with temporary housing?)
NEED URGENT HELP FINDING TEMPORARY HOUSING
NEED HELP FINDING MORE ADEQUATE TEMPORARY HOUSING
NOT AFFECTED
HAVE ADEQUATE SHORT-TERM TEMPORARY HOUSING, BUT NEED HELP FINDING LONG-TERM
NOT SURE
TEMPORARY HOUSING UNTIL MY HOME CAN BE REBUILT OR REPAIRED
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
PERMANENT HOUSING (Do you need help with permanent housing?)
MY HOME WAS DESTROYED; NEED HELP FINDING NEW PERMANENT HOUSING
MY HOME IS UNINHABITABLE DUE TO MAJOR DAMAGE; NEED HELP ASSESS DAMAGE/SAFETY OR FIND
NOT AFFECTED
NEW PERMANENT HOUSING
NOT SURE
MY HOME WAS DAMAGED BUT IS HABITABLE; NEED HELP ARRANGING REPAIRS
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
PERSONAL PROPERTY (Do you need help shipping and/or storing personal property?)
NEED URGENT HELP NOW WITH MOVING/STORING PROPERTY
NOT AFFECTED
NEED HELP MOVING/STORING PROPERTY
NOT SURE
NEED HELP WITH MOVING/STORAGE CLAIMS
NEED ASSISTANCE
ONLY NEED INFORMATION ON SHIPPING OR STORING PERSONAL PROPERTY
COMMENTS: (For additional comments use the bottom of the form.)
FINANCIAL ASSISTANCE (Do you need help with personal finances?)
NEED URGENT FINANCIAL AID/MONEY TO HANDLE SURVIVAL NEEDS
NEED ADVICE AND COUNSELING TO MEET SHORT-TERM EMERGENCY FINANCIAL NEEDS
NOT AFFECTED
NEED ADVICE AND COUNSELING ABOUT HOW TO HANDLE DISASTER EXPENSES AND BILLS IN THE
NOT SURE
LONG-TERM
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
PAY AND BENEFITS (Do you need help with your pay, benefits, evacuation allowances, or travel orders?)
NEED HELP BECAUSE I HAVE NOT RECEIVED ANY PAY
NEED A PAY ADVANCE TO MEET EMERGENCY NEEDS
NOT AFFECTED
NOT SURE
NEED HELP GETTING THE RIGHT PAY, BENEFITS, OR ALLOWANCES
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
DA CIVILIAN EMPLOYEES (Are you an Army civilian in need with a work-related issue?)
NEED URGENT HUMAN RESOURCES ASSISTANCE
NOT AFFECTED
NEED IMMEDIATE HUMAN RESOURCES ASSISTANCE
NOT SURE
NEED ROUTINE HUMAN RESOURCES SERVICES
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
DA FORM 7767, FEB 2017
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APD LC v1.00ES
FAMILY EMPLOYMENT (Do you or your family need help finding a job?)
NEED URGENT HELP FINDING A NEW, PERMANENT JOB
NOT AFFECTED
NEED HELP FINDING A TEMPORARY JOB
NOT SURE
NEED HELP DETERMINING JOB STATUS AFTER THE DISASTER OR EVACUATION
NEED ASSISTANCE
ONLY NEED JOB INFORMATION
COMMENTS: (For additional comments use the bottom of the form.)
CHILD CARE (Do you need help with child care?)
NEED URGENT HELP MAKING NEW PERMANENT CHILD CARE ARRANGEMENTS
NEED IMMEDIATE HELP FINDING TEMPORARY CHILD CARE UNTIL MY NORMAL ARRANGEMENTS ARE
NOT AFFECTED
RESTORED
NOT SURE
NEED ADEQUATE TEMPORARY CHILD CARE, BUT NEED TO FIND A PERMANENT ARRANGEMENT
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
SCHOOL (Do you need information on schools?)
NEED URGENT HELP FINDING A NEW SCHOOL FOR MY CHILD
NOT AFFECTED
NEED HELP FINDING OR REGISTERING FOR A SCHOOL IN A TEMPORARY LOCATION
NOT SURE
NEED HELP GETTING MY CHILDREN INTO A SCHOOL OR CHOICE
NEED ASSISTANCE
ONLY NEED INFORMATION ABOUT SCHOOLS
COMMENTS: (For additional comments use the bottom of the form.)
LEGAL SERVICES (Do you need legal help?)
NEED URGENT HELP WITH LEGAL MATTERS AND ASSISTANCE IS UNAVAILABLE
NOT AFFECTED
NEED IMMEDIATE HELP WITH LEGAL MATTERS AND AVAILABLE SERVICES ARE LIMITED
NOT SURE
NEED ASSISTANCE WITH NON-URGENT LEGAL MATTERS RELATED TO THE DISASTER
NEED ASSISTANCE
NEED LEGAL HELP OR INFORMATION, OR ROUTINE LEGAL SERVICES NOT RELATED TO DISASTER
COMMENTS: (For additional comments use the bottom of the form.)
CHAPLAIN (Do you or your family need help from a chaplain?)
NEED URGENT HELP FROM A CHAPLAIN FOR A CRISIS
NOT AFFECTED
NEED HELP FROM A CHAPLIN TO HANDLE GRIEF OR LOSS
NOT SURE
NEED TO SPEAK WITH A CHAPLAIN
NEED ASSISTANCE
NEED ACCESS TO CHAPEL SERVICES OR RELIGIOUS EDUCATION
COMMENTS: (For additional comments use the bottom of the form.)
COUNSELING (Do you or your family need to talk to a counselor?)
NEED URGENT CRISIS COUNSELING
NOT AFFECTED
NEED COUNSELING SUPPORT FOR CHRONIC ISSUES
NOT SURE
NEED ROUTINE COUNSELING SERVICES
NEED ASSISTANCE
ONLY NEED INFORMATION OR REFERRAL FOR COUNSELING
COMMENTS: (For additional comments use the bottom of the form.)
MORTUARY ASSISTANCE (Do you need help with the loss of a family member due to the disaster?)
NEED URGENT AND IMMEDIATE ASSISTANCE IN THE IDENTIFICATION AND RETURN OF FAMILY
MEMBERS REMAINS
NOT AFFECTED
NEED HELP IN THE IDENTIFICATOIN OR RETURN OF FAMILY MEMBERS REMAINS
NOT SURE
NEED HELP IN THE RETURN OF FAMILY MEMBERS PERSONAL EFFECTS
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
DA FORM 7767, FEB 2017
Page 3 of 4
APD LC v1.00ES
FUNERAL ARRAGEMENTS (Do you need help with funeral arrangements or return of personal effects?)
NEED URGENT HELP MAKING FUNERAL ARRANGEMENTS
NOT AFFECTED
NEED SOME ASSISTANCE COMPLETING ALL FUNERAL ARRANGEMENTS
NOT SURE
NEED HELP FINALIZING FUNERAL ARRANGEMENTS
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
CASUALTY/DEATH BENEFITS ASSISTANCE (Do you need help with benefits related to the death of a family member?)
NEED URGENT ASSISTANCE IN SUBMITTING FOR DEATH BENEFITS/CLAIMS
NOT AFFECTED
NEED GUIDANCE ON SUBMITTING CLAIMS FOR DEATH BENEFITS
NOT SURE
NEED FOLLOW-UP ASSISTANCE ON THE STATUS OF DEATH BENEFITS CLAIMS
NEED ASSISTANCE
NEED INFORMATION ONLY
COMMENTS: (For additional comments use the bottom of the form.)
ADDITIONAL COMMENTS
DA FORM 7767, FEB 2017
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APD LC v1.00ES

Download DA Form 7767 Army Disaster Personnel Accountability and Assessment System, Needs Assessment Survey

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