For use of this form, see DA PAM 40-11; the proponent agency is OTSG.
10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. Chapter 55; Army Regulation 40-407.
To provide a means for case management and surveillance of Latent Tuberculosis Infection (LTBI).
In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information
contained therein may specifically be disclosed outside the DOD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as
follows: 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. NOTE: This system of records contains individually identifiable health information. The DoD
Health Information Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability and
Accountability Act of 1996, applies to most such health information. DoD 6025.18-R may place additional procedural
requirements on the uses and disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in
this system of records notice.
Mandatory. Mandatory reporting provides the information necessary for public health officials to protect the public's health by
tracking communicable disease and other conditions. Notification allows public health officials to treat persons already ill,
provide preventive therapies for individuals who came into contact with infectious agents, and investigate and halt outbreaks.
It also allows for assessment of broader patterns by historical trends or geographic clustering. Armed with this knowledge,
public health officials can take action by redirecting programs or developing new policies.
(Last, First, MI)
2. DATE OF BIRTH
7. UNIT ADDRESS
8. DUTY PHONE
9. HOME ADDRESS
(Include Zip Code)
10. EMAIL ADDRESS
11. HOME PHONE
12. ACTIVE CASE
DATE CONTACT TERMINATED
SKIN TEST RESULTS
LAST NEGATIVE SKIN TEST
15. DRUG REGIMEN
LENGTH OF THERAPY
16. REPORTED TO STATE/LOCAL HEALTH DEPARTMENT (If yes, list name of State or Local Health Department and date reported.)
17. X-RAY FINDINGS
18. RETURN VISIT ACTIONS (Use pencil).
*American Thoracic Society standard diagnostic and therapeutic code.
DA FORM 3897, MAY 2009
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.00