Form Navpers 5350/3 - Dapa Admin Screening Form - Navpers Form Page 9

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DAPA ADMIN SCREENING FORM
Servicemember Name
Supervisor Input Form
To:
(Supervisor name/work center/division)
Subj: ADMINISTRATIVE SCREENING IRT
(Servicemember rate/rank, name, work center/division)
1. Subject servicemember is being administratively screened. Your input is
extremely important in helping the commanding officer and medical treatment
facility staff in making the appropriate recommendation and diagnosis of a
possible alcohol or drug problem. Please be as honest and complete in the
answers as possible.
2. How long have you supervised this member?
3. Please place a check next to the word in each category that best describes
the servicemember in the past 12 months:
a. Military performance:
Superior
Adequate
Improving
Excellent
Substandard
Declining
b. Work performance:
Superior
Adequate
Improving
Excellent
Substandard
Declining
c. Uniform/military appearance:
Superior
Adequate
Improving
Excellent
Substandard
Declining
d. Relationships with peers and superiors:
Superior
Adequate
Improving
Excellent
Substandard
Declining
Please provide additional comments about the above markings:
r
Phone Numbe
DAPA Name
NAVPERS 5350/3 (Revised 08-09)
FOR OFFICIAL USE ONLY
PAGE 9 OF 10
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