DA Form 285-w-r Accident Report Summary of Witness Interview

DA Form 285-w-r - also known as the "Accident Report Summary Of Witness Interview" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 285-w-r - was last revised on July 1, 1994. Download an up-to-date PDF version of the DA 285-w-r below or request a copy through the chain of command.

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U.S. ARMY ACCIDENT REPORT
REQUIREMENTS CONTROL SYMBOL
SUMMARY OF WITNESS INTERVIEW
CSOCS-308
For use of this form, see AR 385-40 and DA Pamphlet 385-40; the proponent agency is OCSA
1. NAME OF WITNESS (LAST, FIRST, MI)
2. OCCUPATION/TITLE
3. GRADE
4. SSN
5. AGE
6. ADDRESS (Include ZIP Code) (If military, include organization)
7. TELEPHONE NUMBER
8. DATE OF INTERVIEW
9. EXPERIENCE AND BACKGROUND
10. LOCATION AT TIME OF ACDT
11. INTERVIEWER
12. Was a promise of confidentiality offered to the witness?
Yes
No (If yes, read blk 15a to the witness and complete
blk 16. If no, read blk 15b to the witness.) Confidentiality was requested by the witness.
Yes
No (If Yes, interviewer
sign and date statement below.)
THE WITNESS MADE THIS STATEMENT UNDER A PROMISE OF CONFIDENTIALITY.
Signature of Interviewer
Date
13. SUMMARY OF INTERVIEW
14. DATE OF ACCIDENT (YYMMDD)
DA FORM 285-W-R, JUL 94
USAPPC V1.00
U.S. ARMY ACCIDENT REPORT
REQUIREMENTS CONTROL SYMBOL
SUMMARY OF WITNESS INTERVIEW
CSOCS-308
For use of this form, see AR 385-40 and DA Pamphlet 385-40; the proponent agency is OCSA
1. NAME OF WITNESS (LAST, FIRST, MI)
2. OCCUPATION/TITLE
3. GRADE
4. SSN
5. AGE
6. ADDRESS (Include ZIP Code) (If military, include organization)
7. TELEPHONE NUMBER
8. DATE OF INTERVIEW
9. EXPERIENCE AND BACKGROUND
10. LOCATION AT TIME OF ACDT
11. INTERVIEWER
12. Was a promise of confidentiality offered to the witness?
Yes
No (If yes, read blk 15a to the witness and complete
blk 16. If no, read blk 15b to the witness.) Confidentiality was requested by the witness.
Yes
No (If Yes, interviewer
sign and date statement below.)
THE WITNESS MADE THIS STATEMENT UNDER A PROMISE OF CONFIDENTIALITY.
Signature of Interviewer
Date
13. SUMMARY OF INTERVIEW
14. DATE OF ACCIDENT (YYMMDD)
DA FORM 285-W-R, JUL 94
USAPPC V1.00
15. GENERAL WITNESS INFORMATION BRIEFING (Interviewer must read appropriate instructions to the witness)
a. Promise of confidentiality offered.
b. No promise of confidentiality offered.
(1) This accident investigation board has been convened under the provisions
(1) This accident investigation board has been convened
of AR 385-40 for the purpose of conducting a safety investigation.
under the provisions of AR 385-40 for the purpose of
conducting a safety investigation.
(2) This may be just one of a number of investigations being conducted
regarding this accident; collateral or legal investigations may be ongoing as
(2) This may be just one of a number of investigations being
well. Those investigations are entirely separate from a safety investigation
conducted regarding this accident; collateral or legal
and are also required to inform you of their purpose and of your legal rights.
investigations may be ongoing as well. Those
investigations are entirely separate from a safety
investigation and are also required to inform you of their
(3) This safety investigation is being conducted for accident prevention
purpose and of your legal rights.
purposes only. Within the military, pursuant to Army Regulation 385-40, it
cannot be used for any other purpose, to include any future disciplinary
(3) This safety investigation is being conducted for accident
actions against any individuals. Therefore, the interview you are being asked
prevention purposes only. Within the military, pursuant to
to provide will be used by the Army in the interest of safety and accident
Army Regulation 385-40, it cannot be used for any other
prevention only.
purpose, to include any future disciplinary actions against
any individuals. Therefore, the interview you are being
(4) Nonconfidential witness interviews may be released to the public pursuant
asked to provide will be used by the Army in the interest of
to a Freedom of Information Act request. If you wish to protect your
safety and accident prevention only.
interview from public release outside the military, then your interview must
be pursuant to a promise of confidentiality. Confidentiality means that your
(4) The chain of command will review the final accident
interview will not be released to the public or outside DOD safety channels.
report, which may include a summary of your interview, but
the chain of command may only use the investigation report
(5) Whether your interview is confidential or not, the chain of command will
and the interviews for safety and accident prevention
review the final accident report, which may include a summary of your
purposes. The interview summary may be released to the
interview, but the chain of command may only use the investigation report
public pursuant to a Freedom of Information Act request.
and the interviews for safety and accident prevention purposes.
(5) If you ever have knowledge that your witness interview
(6) If you ever have knowledge that your witness interview was used by the
was used by the Army for anything other than accident
Army for anything other than accident prevention purposes (for example,
prevention purposes (for example, disciplinary action
disciplinary action against an individual), you should consult with your local
against an individual), you should consult with your local
Judge Advocate Defense Counsel Office and request that the Command
Judge Advocate Defense Counsel Office and request that
Judge Advocate, U.S. Army Safety Center, be notified at DSN 558-3960 or
the Command Judge Advocate, U.S. Army Safety Center,
commercial (205) 255-3960.
be notified at DSN 558-3960 or commercial (205)
255-3960.
(7) The promise of confidentiality is available to you if you desire it. Do you
desire it?
16. AVAILABILITY OF PROMISE OF CONFIDENTIALITY FOR "LIMITED USE" REPORT OF INVESTIGATION
a. Pursuant to AR 385-40, witness interviews may only be used within the military for purposes of accident
prevention, and may not be used as evidence in connection with any administrative or disciplinary proceeding.
This protection alone does not prevent release of the interview outside of the military (to the public,
newspapers, attorneys, etc.) under the Freedom of Information Act. If you wish to protect your interview from
release outside of the military, then your interview must be pursuant to a promise of confidentiality.
b. If you do not wish a promise of confidentiality, you may decline such below. In that case, your interview
will still be used in the military only for purposes of accident prevention, but it may be released outside of the
military in response to a Freedom of Information Act request. Please indicate which option you desire by
initialing one of the choices below:
I request a promise of confidentiality. I understand that the results of my interview will be used within the
military only for the purposes of accident prevention, and will also be protected from public release outside of
the military under the Freedom of Information Act.
I decline a promise of confidentiality. I understand that the results of my interview will be used within the
military only for purposes of accident prevention. I also understand that the results may be publicly released
outside of the military under the Freedom of Information Act.
Name of witness (Print)
REVERSE OF DA FORM 285-W-R, JUL 94
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