TYPE OF INCIDENT SIR #
BRIGADE & (RSID) COMPANY CENTER/STATION
FULL NAME (Last, First, Middle) DATE OF BIRTH
COMPONENT
RANK & DATE OF RANK
PAY ENTRY BASIC DATE (PEBD)
GENDER
MARITAL STATUS NUMBER OF CHILDREN IN HOUSEHOLD
TOTAL # COMBAT DEPLOYMENTS
MOST RECENT START - END DATE
COUNTRY CODE
# OF MONTHS
Did the Soldier…
If yes, please elaborate below.
… have any physical health issues/concerns?
… receive a Command-Directed Behavioral Health Evaluation (CDBHE)?
… receive mental health counseling or treatment (marital, individual, etc.)?
… previously enroll in any substance abuse program (ASAP or similar)?
… stay at least overnight in a hospital due to mental health issue?
… receive any negative counseling from Command Leadership Team (formal or informal)?
… have any previous SIRs or IRs?
… have a history of disciplinary (UCMJ) actions?
… own or have access to firearms or weapons?
Were alcohol, drugs, or other substance involved?
If Soldier had access to or owns firearms/weapons, who has control NOW?
If hospitalized, provide the name and location of the facility.
Who is providing support to the Soldier?
Who is providing support to the Soldier's Family (if applicable)?
How is the Family reacting to the incident (if applicable)?
NOTE: Not all items are required or feasible. Use Date & Comment fields to track actions to reduce duplicity.
Coordinate with Brigade Behavioral Health Consultant or HQ USAREC OCP:
Substance-related incident, ASAP referral/assessment
CDBHE
Clinical Counseling or Therapy
Warrior Transition Unit (WTU)
Coordinate with Services, Support &/or Resources:
Brigade Family Advocacy Program (FAP) - DV or child abuse
Brigade Judge Advocate - UCMJ or other legal matters
Brigade Soldier & Family Assistance (SFA) - TRICARE, Financial, etc.
Brigade Unit Ministry Team (UMT) - Chaplain support services
Command Actions:
Restrict Soldier's accessibility to firearms or weapons
Suspend GOV privileges
Assign Soldier to another USAREC location
Assign Soldier to non-recruiting job in USAREC
Remove Soldier from recruiting, but retain in the Army
Notes
POST-INCIDENT - WAY AHEAD (PLAN OF ACTION)
Date
Location of Referral
CURRENT INCIDENT - ADDITIONAL INFORMATION
PRE-INCIDENT - BACKGROUND INFORMATION
BATTALION
USAREC SERIOUS INCIDENT REPORT - ADDENDUM
The Addendum is used to help leaders gather pertinent data and to plan courses of action after a Serious Incident occurs. The information on
the Addendum is fluid--if changes need to be made, send updates using the SIR follow-up procedures. The first Addendum will be emailed to
the USAREC COC within
72 hours
of the INITIAL SIR. A Final Addendum will be submitted with the Final SIR.
(For use of this form please refer to UR 190-4)
DEMOGRAPHIC INFORMATION
Yes_____ No_____
USAREC Form 190-4.3, 1 May 2014
V2.00
Notes
Yes
No
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
Yes
No
No
Yes
No
Yes
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