Form Navpers 5350/3 - Dapa Admin Screening Form - Navpers Form Page 3
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10DAPA ADMIN SCREENING FORM
Servicemember Name
3. Was a urinalysis test conducted?
If yes, date conducted
Yes
No
(DAPA must maintain copy of positive urinalysis results while forwarding copy of results to
MTF). Describe, in detail, incident or facts of referral. (Attach additional paper if needed).
4. Is member currently under orders?
Yes
No
What Command is member going to?
5. Active duty service date
Delayed entry program
Time in service
EAOS
Date reported this command
PRD
Yes
No
Pre-service waiver?
If yes, provide details of waiver.
6. Single
Married
Separated
Divorced
Next of kin listed in service record
Additional comments:
7. Highest grade completed:
Dates of high school:
GED:
If yes, date awarded:
Yes
No
Evidence of college?
Completion of degree:
Yes
No
Yes
No
Date completed
Date of most recent advancement/promotion:
r
DAPA Name
Phone Numbe
NAVPERS 5350/3 (Revised 08-09)
FOR OFFICIAL USE ONLY
PAGE 3 OF 10
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