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Form 3180- Personnel Screening And Evaluation Record

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PERSONNEL SCREENING AND EVALUATION RECORD

For use of this form, see AR 50-1; the proponent agency is DCS, G-3/5/7.

PRIVACY ACT STATEMENT OF 1974

Internal Security Act of 1950 (Pub L. 81-831), 5 U.S.C., 301, 10 U.S.C., 3013, E.O. 9397 and records will be

AUTHORITY:

maintained under file #640-10b and 690-200a.

To evaluate the qualifications and suitability of an individual for assignment to certain sensitive duties under the

PRINCIPAL PURPOSE:

nuclear/chemical/biological personnel reliability program.

The "Blanket Routine Uses" set forth at the beginning of the Army compilation of systems of records notices also

ROUTINE USES:

apply to this system.

Voluntary. However, failure to provide all or part of the requested information may result in non-selection for duties

DISCLOSURE:

under the personnel reliability program.

PART I - INITIAL INTERVIEW

A. NAME OF INDIVIDUAL

B. ORGANIZATION

C. JOB TITLE

D. SSN

(Last, First, MI)

E. I

do not object to PRP screening requirements.

(Individual's initials)

F. SCREEN FOR

Biological PRP

Chemical PRP

Nuclear PRP

G. NAME OF INTERVIEWER

H. SIGNATURE

I. DATE

(YYYYMMDD)

PART IIa - PERSONNEL RECORDS SCREENING

Potentially Disqualifying Information

(PDI)

was

found and forwarded to certifying official

not found

B. NAME OF SCREENING OFFICIAL

C. SIGNATURE

D. DATE (YYYYMMDD)

PART IIb - PERSONNEL SECURITY RECORDS SCREENING

(PDI)

Local records Potentially Disqualifying Information

was

found and forwarded to certifying official

not found

Personnel Security Investigation

(PSI):

completed on

Type

(NACLC, ANACI, SSBI, etc.)

DATE (YYYYMMDD)

Favorably adjudicated

Dossier review required

C. PSI request or reinvestigation

submitted on

Type (NACLC, ANACI, SSBI, etc.)

(If required):

DATE

(YYYYMMDD)

D. SECURITY CLEARANCE:

None

Confidential

Secret

Top Secret

E. NAME OF SCREENING OFFICIAL

F. SIGNATURE

G. DATE (YYYYMMDD)

PART III - MEDICAL RECORDS SCREENING

A. Potentially Disqualifying Information

(PDI) was

found and forwarded to certifying official

not found

B. NAME OF SCREENING OFFICIAL

C. SIGNATURE

D. DATE (YYYYMMDD)

E. RESCREENING

- PDI was

found and forwarded to certifying official

not found

(if required)

F. NAME OF SCREENING OFFICIAL

G. SIGNATURE

H. DATE (YYYYMMDD)

PART IV - DRUG TESTING/SCREENING

A. SPECIMEN COLLECTED ON

Test results were

forwarded to certifying official or

certified negative

(YYYYMMDD)

DATE

(YYYYMMDD)

B. NAME OF OFFICIAL

C. SIGNATURE

D. DATE

E. ADDITIONAL SCREENING

(If required):

Specimen collected on

Test results were

forwarded to certifying official or

certified negative

(YYYYMMDD)

DATE

F. NAME OF OFFICIAL

G. SIGNATURE

H. DATE (YYYYMMDD)

Page 1 of 2

PREVIOUS EDITIONS ARE OBSOLETE.

DA FORM 3180, MAY 2008

APD LC v1.00ES

Form 3180- Personnel Screening And Evaluation Record

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