Form Navpers 5350/3 - Dapa Admin Screening Form - Navpers Form Page 10
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10DAPA ADMIN SCREENING FORM
Servicemember Name
e. Has remedial counseling been conducted in the past
Yes
No
12 months?
f. Has servicemember received NJP or other disciplinary action
Yes
No
during the previous 12 months
g. Are you aware of any civil actions or referrals for family or financial
Yes
No
counseling that have occurred in the previous 12 months?
h. Are you aware of any previous/additional alcohol or drug problems? Yes
No
i. Does this member have a history of Monday or Friday absences,
Yes
No
sick call visits or tardiness to work?
Yes
No
j. Is this member the first to arrive or the last to leave?
k. Does this member take unusually long lunch breaks on a
Yes
No
routine basis?
If you marked yes for e, f, g, h, i or j please explain in detail.
4. If you had a choice would you want this servicemember to
Yes
No
continue working for you?
Provide details on why or why not.
5. Please complete and return this form no later than
(date required)
to
, located
in
(DAPA's name)
(Room/bldg/comparetment number)
If using internal mail, please place in sealed envelope. If you have any questions,
.
I can be reached at
(Telephone)
(DAPA Signature)
(Date)
(Supervisor Signature)
(Date)
DAPA Name
r
Phone Numbe
NAVPERS 5350/3 (Revised 08-09)
FOR OFFICIAL USE ONLY
PAGE 10 OF 10
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