Fillable Self Disclosure Worksheet printable pdf download

Iowa National Guard Positions of Significant Trust and Authority

Read Privacy Act Statement on back

SELF DISCLOSURE WORKSHEET

before completing form.

1. APPLICANT NAME (Last, First, Middle Initial)

2. GRADE / RANK

3. SSN

4. DOB (MM/DD/YY)

5. CURRENT UNIT / UIC

6. Position Applying For:

SHARP Program

Rec & Ret

7. Position Status:

8. Position Title:

AGR

TECH

M-DAY

Recruiter

RRB CADRE

SHARP/VA

9. TYPE I REPORTS: For each question write either Yes or No. If Yes, complete block 13.

YES / NO

(If Uncertain, write Yes and explain in block 13)

Have you ever been charged, investigated or found guilty of any activity involving sexual harassment, sexual

_____________________

assault, family member or child abuse, pandering or prostitution?

Have you ever been charged, investigated or found guilty of any activity related to pornography, incest, bestiality,

_____________________

sexual activity with a subordinate or fraternization?

Have you ever been charged, investigated or found guily of multiple instances of drug abuse, (use, possession,

_____________________

distribution, manufacturing), to include prescription medication and synthetic drugs?

10. TYPE IIA REPORTS: For each question write either Yes or No. If Yes, complete block 14.

YES / NO

(If Uncertain, write Yes and explain in block 14)

Have you ever been charged, investigated or convicted in any Court-Martial (to include convictions from other

_____________________

services)?

Have you ever been charged, convicted or investigated for conduct in violation of the Army's policy regarding

_____________________

participation in extremist organizations or activities?

Have you ever received an initial enlistment waiver for any derogatory information related to or listed as a Type I

_____________________

Report?

11. TYPE IIB REPORTS: For each question write either Yes or No. If Yes, complete block 15.

YES / NO

(If Uncertain, write Yes and explain in block 15)

Have you ever been charged, investigated or convicted of any single incident involving drug abuse (use or

_____________________

possession) to include prescription medication and synthetic drugs?

Have you ever received a Relief for Cause NCOER or OER, a No on the Army Values block of your NCOER or OER

_____________________

or been reduced in rank or removed from a promotion list?

Have you ever been seperated from any service due derogatory information related to or listed as a

Type I or Type

_____________________

IIA Report?

Have you ever received an initial enlistment waiver due to derogatory information not related to or listed as a Type I

_____________________

Report?

Have you been charged, investigated or convicted of any offense related to adultery, stalking or assault in the past 5

_____________________

years?

Have you had your security clearance revoked, denied or suspended or failed to attain or maintain a favorable

_____________________

NACLC Investigation in the past 5 years?

Have you been charged, investigated or convicted of any offense involving larceny / theft / fraud / burglary in the

_____________________

past 5 years?

Have you been charged, investigated or convicted of any alcohol related incident to inlcude but not limited to

_____________________

operating a motor vehicle under the influence or while impaired in the last 5 years?

Have you been charged of found guilty of any misdemeanor level traffic offenses (E.G., wreckless driving, speeding,

_____________________

seatbelt violations, etc.) in the past 5 years?

Have you received any Letters of Reprimand, Misconduct Reports or been investigated for any offenses other than

_____________________

those listed above in the past 5 years?

12. APPLICANT VERIFICATION.

(Read Privacy Act Statement on back before signing)

a. SIGNATURE OF APPLICANT

b. DATE SIGNED

IA FORM 7424, OCT 2013

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Self Disclosure Worksheet

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