Form 3180- Personnel Screening And Evaluation Record Page 2
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PART V - CERTIFYING OFFICIAL'S EVALUATION/ ASSIGNMENT BRIEFING
A.
After thorough review of information provided, I find this individual:
suitable for the PRP
(Complete Part V, B & C)
unsuitable for the PRP
(Complete Part V, B and Part IX)
authorized for Interim Certification
(Complete Part V, B & C)
B.
NAME OF CERTIFYING OFFICIAL
C. SIGNATURE
D. DATE (YYYYMMDD)
F. SIGNATURE
G. DATE (YYYYMMDD)
E.
Individual's signature indicates a briefing on standards
and objectives of the PRP was received and understood.
PART VI - CONTINUING EVALUATION/RECORD OF UPDATES
Document changes in individual's status and/or administrative data. If additional room is required to document an update, attach a continuation sheet.
For documentation requirements for restriction, suspension, administrative termination, or disqualification follow guidance in the appropriate regulation.
(ATTACH BLANK SHEET FOR CONTINUATION OF PART VI)
A. INDIVIDUAL'S SIGNATURE
C. REASON FOR UPDATE
D. DATE
(YYYYMMDD)
B. CERTIFYING OFFICIAL'S SIGNATURE
PART VII - SUSPENSION OR TEMPORARY DISQUALIFICATION
PART VIII - ADMINISTRATIVE TERMINATION
(PENCIL ENTRY)
EFFECTIVE
EFFECTIVE
DATE
(YYYYMMDD)
DATE
(YYYYMMDD)
PART IX - DISQUALIFICATION
A.
STATUS AT TIME OF DISQUALIFICATION
B.
REASON FOR DISQUALIFICATION
1.
Being screened for PRP.
1.
Alcohol abuse
2.
Assigned to:
2.
Drug abuse
a. biological duty position
3.
Negligence/delinquency in duty performance
b. chemical duty position
4.
Court-martial/civilian convictions
c. critical nuclear duty position
5.
Physical/mental condition
d. controlled nuclear duty position
6.
Poor attitude/lack of motivation
7.
Other
Biological PRP
Chemical PRP
Nuclear PRP
C. Individual is disqualified from the
D. RATIONALE
E. Individual was notified of disqualification on
by
DATE
(YYYYMMDD)
METHOD OF NOTIFICATION
H. DATE (YYYYMMDD)
F. NAME OF CERTIFYING OFFICIAL
G. SIGNATURE
K. DATE (YYYYMMDD)
I. NAME OF REVIEWING OFFICIAL
J. SIGNATURE
Page 2 of 2
DA FORM 3180, MAY 2008
APD LC v1.00ES
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