1.
REPORT DATE
(YYMMDD)
REPORT OF INVESTIGATION
LINE OF DUTY AND MISCONDUCT STATUS
2.
INVESTIGATION
OF
3.
STATUS
(X one)
(X as applicable)
INJURY
DISEASE
ILLNESS
DEATH
a. REGULAR OR EAD
4.
TO
(Major Army or Air Force Commander)
b. CALLED OR ORDERED TO AD FOR
(1) MORE THAN 30 DAYS
(2) 30 DAYS OR LESS
5.
NAME OF INDIVIDUAL
6.
SSN
7.
GRADE
(Last, First, Middle Initial)
c. INACTIVE DUTY TRAINING (Type)
8.
ORGANIZATION
AND STATION
d. SHORT TOUR OF ACTIVE DUTY
FOR TRAINING
9.
OTHER
MILITARY PERSONNEL INVOLVED IN THE SAME INCIDENT
d. LOD INVESTI
e. DURATION (Applies ONLY to 3.c. and d.)
NAME (Last, First, Middle Initial)
SSN
GRADE
GATION MADE (X)
a.
b.
c.
YES
NO
DATE
HOUR
(YYMMDD)
(1) START
(2) FINISH
10. BASIS FOR FINDINGS
(As determined by investigation)
(1) HOUR
(2) DATE (YYMMDD)
(3) PLACE
a. CIRCUMSTANCES
(4) HOW SUSTAINED
b. MEDICAL DIAGNOSIS
d. IF ABSENT: (X)
c. PRESENT FOR
e. WAS INTENTIONAL MISCONDUCT OR
f. WAS INDIVIDUAL
(Do not complete
DUTY? (X)
NEGLECT THE PROXIMATE CAUSE? (X)
MENTALLY SOUND? (X)
WITH AUTHORITY
10.e. and f. in
death cases.)
YES
NO
WITHOUT AUTHORITY
YES
NO
YES
NO
g. REMARKS
11. FINDINGS
(X one. Do not complete in death cases.)
IN LINE OF DUTY
NOT IN LINE OF DUTY - NOT DUE TO OWN MISCONDUCT
NOT IN LINE OF DUTY - DUE TO OWN MISCONDUCT
12. INVESTIGATING OFFICER
a. TYPED NAME (Last, First, Middle Initial)
b. GRADE
c. BRANCH OF SERVICE
d. SSN
e. ORGANIZATION AND STATION
f. SIGNATURE
13.
ACTION
BY APPOINTING AUTHORITY
14.
ACTION
BY REVIEWING AUTHORITY
a. HEADQUARTERS
b. DATE (YYMMDD)
a. HEADQUARTERS
b. DATE (YYMMDD)
c. (X one. Indicate reasons and substituted findings on back.)
c. (X one. Indicate reasons and substituted findings on back.)
APPROVED
DISAPPROVED
APPROVED
DISAPPROVED
d. TYPED NAME (Last, First, Middle Initial)
d. TYPED NAME (Last, First, Middle Initial)
e. GRADE
f. BRANCH OF SERVICE
g. SSN
e. GRADE
f. BRANCH OF SERVICE
g. SSN
h. SIGNATURE
h. SIGNATURE
15.
FINAL APPROVAL
(For action of office indicated in Item 4.)
DD FORM 261, OCT 95
PREVIOUS EDITION WILL BE USED.
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