Form Navpers 1306/97 - Reserve Affiliation Screening Checklist And Contract Information Sheet

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RESERVE AFFILIATION SCREENING CHECKLIST AND CONTACT INFORMATION SHEET
1306/97 (Rev. 12-2013)
NAVPERS
PREVIOUS EDITIONS ARE OBSOLETE
Supporting Directive MILPERSMAN Article 1306-1501
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Department Regulations; 10 U.S.C. 5013, Department Regulations; MILPERSMAN Article 1306-1501.
PURPOSE: To assist officials and employees of the Department of the Navy in determining future duty assignment of personnel.
ROUTINE USES: Department of the Navy officials and employees involved in the assignment and distribution of Navy personnel.
DISCLOSURE: Mandatory. Failure to provide the requested information may result in delay or disapproval of your assignment request.
2. RATE:
3. DESIRED TRANSITION DATE:
1. NAME:
4. EAOS:
5. PROPOSED NAVY RESERVE ACTIVITY:
6. PRISE-R RATE:
*Conversion
7. TRANSITION ASSISTANT (if known):
SECTION A: GENERAL CRITERIA
INTERVIEWER'S INITIALS
YES
NO
1. Is member recommended for retention on most recent evaluation?
YES
NO
2. Does member meet all eligibility requirements for ECTP?
YES
NO
3. Is member eligible for an affiliation bonus per the current NAVADMIN?
YES
NO
4. Does member have 3 or more physical fitness assessment failures within the past 48 months?
5. Is member currently frocked? (Must request permission through Reserve Enlisted Programs and NEAS
YES
NO
Branch (PERS-812) to retain pay grade). Refer to BUPERSINST 1430.16.
6. ADMIN OFFICER'S NAME AND RANK:
7. ADMIN OFFICER'S SIGNATURE:
8. DATE:
SECTION B: MEDICAL/DENTAL SCREENING
INTERVIEWER'S INITIALS
1. Is member physically qualified to be retained on active duty?
YES
NO
Ref: NAVMED P-117 Manual of the Medical Department.
2. Is member worldwide assignable?
YES
NO
Ref: BUMEDINST 1300.2A.
Last PHA completed on
.
3. MEDICAL OFFICER'S NAME AND RANK:
4. MEDICAL OFFICER'S SIGNATURE:
5. DATE:
SECTION C: COMMAND CAREER COUNSELOR INFORMATION
1. NAME:
2. RATE:
3. COMMAND NAME:
5. WORK PHONE
4. PERSONAL EMAIL:
NUMBER:
Page 1 of 2
FOR OFFICIAL USE ONLY - PRIVACY SENSITIVE
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