Form Navpers 5350/3 - Dapa Admin Screening Form - Navpers Form Page 2
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10DAPA ADMIN SCREENING FORM
Servicemember Name
1. Drug and Alcohol Program Advisor Administrative Screening Form
NAVPERS 5350/3 (4/00)
Information provided below will assist the DAPA, commanding officer, and medical
treatment facility (MTF) staff in determining the servicemember's need for intervention/
treatment. A copy of this form must be forwarded to the MTF based on local MTF
regulations. Attach additional sheets of paper, if needed.
Date administrative screening form completed:
Servicemember Name (Last, First, MI)
Rate/Rank:
F
M
Sex:
Birth date:
Age:
Command/UIC:
Command Address:
Division/work center:
Phone number:
Supervisor name:
Phone number:
2.
How was the DAPA made aware of the servicemember's possible problem?
Self-referral
date member self-referred
Command-referral
date command referral received
Incident referral
date incident occurred
What substance is involved?
Alcohol
Illicit drug
Yes
No
Yes
No
If yes for illicit drug, what drug(s) is/are involved?
Was the member arrested for DUI/DWI?
How many DUI/DWIs has the member incurred during career?
Yes
No
Was a Blood Alcohol Content (BAC) test conducted?
Results
DAPA Name
r
Phone Numbe
NAVPERS 5350/3 (Revised 08-09)
FOR OFFICIAL USE ONLY
PAGE 2 OF 10
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