Free Da 7652 Form in PDF

Instructions on Writing Da 7652

Filling out the DA 7652 form is a process that requires careful attention to detail. This form is used within the Disability Evaluation System (DES) to assess the impact a medical impairment has on a Soldier's ability to perform duties. It's essential for the Physical Evaluation Board (PEB) to receive comprehensive information for disability adjudication and/or benefits determination. The following steps should be followed meticulously to ensure the information provided is accurate and complete, helping to secure the best interest of both the Soldier and the Army.

1. Begin by entering the Soldier’s demographic information in Section I. This includes the date in the specified format (YYYYMMDD), Soldier's name, grade, primary MOS (PMOS), date of birth, component, ETS/MRD, DoD email, home/cell phone number, DoD number, and unit identification code (UIC), followed by the organization name, address, and phone number.
2. In Section II, address the administrative information. Carefully review each item, confirming the information with the appropriate personnel activity and the Soldier. For each item, mark ‘Yes’ or ‘No’ and provide remarks when necessary. This includes inquiries about charges or investigations under UCMJ, pending separations, approved retirements, mandatory retirement dates, previous higher rank held, and if the Soldier is flagged according to AR 600-8-2, among others.
3. Proceed to Section III, the Commander's Performance and Functional Statement. Choose the options that best describe the impact of the Soldier’s medical condition on completing physical tasks/duties, decision making, and work relationships. This should be done carefully, as it directly influences the PEB’s understanding of the Soldier's condition.
4. In Section III A, detail the Soldier’s ability in terms of physical task completion, decision making, and work relationships, selecting from the provided options (A, B, C, etc.).
5. In Section III B, indicate whether the Soldier is able to be assigned against a deployable billet and if they could perform duties in an OCONUS deployed environment without restrictions. Elaborate on your selection in Section III C if "No" is chosen.
6. Use Section III C to provide further clarification on the selections made above. Include any additional comments or examples that illustrate the Soldier's limitations due to their medical condition(s), specifying how these impact their MOS/AOC specific tasks.
7. Fill in the Battalion Commander's contact information in Section IV, including name, DoD email, grade, unit, component, and phone.
8. Complete Section V, the Commander's Validation and Signature. Enter the Commander's name, sign, and date the form, and include the DoD email, phone, component, and grade.
9. Before submission, review the form thoroughly to ensure all information is correct and complete. Attach any necessary documentation, such as the commander's memorandum or completed Line of Duty (LOD), as indicated in the instructions.

Upon completion, the form should be submitted to the designated authority for the DES process to continue. This will facilitate a thorough review by the Physical Evaluation Board, ultimately leading to a determination that best supports the Soldier's health and career in the Army.

What is the DA Form 7652 used for?

DA Form 7652, also known as the Disability Evaluation System (DES) Commander's Performance and Functional Statement, is used to provide detailed information about a Soldier's ability to perform duties due to medical impairments. This information helps the Physical Evaluation Board (PEB) assess the impact of the medical condition on the Soldier's duties and determine appropriate disability adjudication or benefits.

Who needs to complete the DA Form 7652?

This form is primarily completed by a Soldier's commander or leadership team. They are in the best position to describe how the Soldier's medical condition(s) affect performance, ability to complete physical tasks, make decisions, maintain work relationships, and overall impact on the unit's mission readiness. In certain cases, this may involve input from a higher-level supervisor or specialist.

What information is included in Section I of the DA Form 7652?

Section I collects Soldier demographic information such as date, name, grade, Primary Military Occupational Specialty (PMOS), date of birth, component, expected term of service/mandatory removal date, DOD email, home/cell phone number, DOD number, and unit identification code (UIC).

What does Section II of the DA Form 7652 cover?

Section II requires administrative information to be confirmed with both personnel activity and the Soldier. It includes questions related to whether the Soldier is charged or under investigation, pending voluntary or involuntary administrative separation, has an approved voluntary retirement, and other considerations affecting their status and eligibility within the military structure.

How does Section III of the DA Form 7652 assess a Soldier's performance?

Section III is the Commander's Performance Information section, which is critical for determining the effects of the Soldier's medical conditions on their military performance. It assesses the Soldier's ability to complete physical tasks, decision making, work relationships, and how these factors affect the unit's ability to fulfill its mission. It also addresses the Soldier's ability to deploy.

Is there any part of the form that addresses the Soldier's ability to deploy?

Yes, Section III B specifically addresses the Soldier's ability to deploy. It asks whether the service member can be assigned a deployable billet and if they could perform their duties in an overseas deployed environment without restrictions, limitations, or work-arounds.

What is the purpose of Section IV and V on the DA Form 7652?

Section IV collects the battalion commander's contact information, ensuring a point of contact for further communication or clarification regarding the information provided in the form. Section V is for the commander's validation and signature, confirming the accuracy and completeness of the information submitted on the form.

How is this form part of the Disability Evaluation System (DES)?

The DA Form 7652 provides a structured format for commanders to convey the necessary information on a Soldier's performance and functional limitations due to medical conditions. This input is essential for the Physical Evaluation Board (PEB) to make informed decisions regarding a Soldier's fitness for continued service or the need for retirement or separation due to physical disability within the DES Process.

What happens if the information on the DA Form 7652 is not accurately provided?

Failure to provide accurate and complete information on the DA Form 7652 can interfere with the proper adjudication of the Soldier's case. It may lead to delays in the process or incorrect determinations about the Soldier's fitness for duty, benefits, and entitlements. Therefore, it's crucial that the data is meticulously reviewed and validated before submission.

When completing the DA Form 7652, it's crucial that individuals avoid common mistakes to ensure their submission accurately reflects the situation and facilitates the desired outcomes. One common error involves not fully reading and understanding the Privacy Act Statement and the form's purpose. This statement outlines why and how personal information will be used, which is essential for understanding the implications of the data provided.

Another frequent oversight is inaccurately filling out the soldier's demographic information. Every detail from the date to the soldier’s grade, MOS (Military Occupational Specialty), and DOD number must be meticulously reviewed for accuracy. Mistakes here can lead to unnecessary delays or confusion in processing the form.

Responding incorrectly or incompletely to the administrative information can severely impact the evaluation process. For example, neglecting to specify whether the soldier is charged under the Uniform Code of Military Justice or incorrectly stating the soldier's retirement eligibility or mandatory removal dates could misrepresent the soldier's situation, affecting the outcomes.

Failing to attach required documentation, such as the MAR2 results or the commander's memorandum for soldiers assigned to a Warrior Transition Unit, is another common mistake. This oversight can result in an incomplete assessment of the soldier's case, delaying or affecting the decision-making process.

A significant number of errors stem from the Commander's Performance and Functional Statement section. Providing vague or non-specific descriptions of how a medical condition affects the soldier’s ability to perform duties can hinder the Physical Evaluation Board's ability to understand the full impact. It is essential that this section provides a clear and detailed account of the limitations and performance impacts.

When it comes to performance information, oversimplifying or exaggerating the impact of medical conditions can mislead the evaluation process. The accuracy of this section is vital for assembling a comprehensive picture of the soldier's ability to fulfill their duties.

Misunderstanding the deployment ability section (Section III B) can also lead to complications. Incorrectly indicating a soldier’s ability to deploy without fully considering all medical and functional limitations presents an incomplete assessment, potentially leading to unfit personnel being designated deployable.

Moreover, neglecting to further clarify or provide examples in Section III C of the DA Form 7652, where asked, can result in an understated evaluation. Specific examples of limitations or tasks the soldier cannot perform are crucial for a thorough understanding and appropriate consideration by the board.

Lastly, an equally critical mistake is the incorrect or incomplete filling of the battalion commander's contact information and the final commander's validation and signature. This section is paramount for verification and validity purposes. Any errors or omissions here can nullify the entire submission or delay its processing, as it directly affects the form's credibility and authority.

When dealing with the DA Form 7652, it's essential to understand that it's part of a broader administrative and evaluative process within the U.S. Army, especially concerning the Disability Evaluation System (DES). Various forms and documents often accompany it to build a comprehensive profile of the soldier's service, medical condition, and administrative status. These supporting documents are as crucial as the DA Form 7652 itself, ensuring the Department of the Army thoroughly reviews and fairly evaluates each case.

• Medical Evaluation Board (MEB) Report: This document outlines a soldier's medical diagnosis and the impact of their condition on military service. It is crucial for the Physical Evaluation Board (PEB) to understand medical limitations.
• Line of Duty (LOD) Investigation: If a soldier's medical condition is the result of an incident that occurred while on duty, a LOD investigation report is necessary to establish the circumstances and whether the condition was service-connected.
• DA Form 3349: This form provides physical profile information, detailing any physical limitations a soldier has and how these impact their duties. It complements the DES commander's performance and functional statement.
• NCO Evaluation Report (NCOER) or Officer Evaluation Report (OER): These evaluation reports give insight into a soldier's performance and potential, which is essential when determining how a medical condition affects their duties.
• DA Form 31 (Request and Authority for Leave): While not directly related to the disability evaluation, leave records can help establish timelines and show periods of recovery or treatment.
• DA Form 137-2 (Installation Clearance Record): This form ensures that a soldier has settled all responsibilities on an installation before transferring, separating, or retiring, which is essential for processing disability separations.
• Commander’s Statement: Additional to DA Form 7652, a detailed narrative from the soldier’s commander can provide further insight into how a soldier's condition affects their performance and ability to fulfill their duties.

Each document plays its role in painting a full picture of a soldier's situation. Collectively, they assist in ensuring that decisions regarding a soldier's career and health are made with a comprehensive understanding of their performance, medical condition, and overall wellbeing. It’s a meticulous process that demands attention to detail and thorough documentation to support each soldier’s case effectively.

The DA Form 638, Recommendation for Award, shares similarities with the DA 7652 in its structured layout designed to capture specific, detailed information about an individual. Just like the DA 7652 requires comprehensive data on a soldier's condition and performance, the DA 638 meticulously gathers information on the achievements and meritorious actions of military personnel to determine their eligibility for awards. Both forms serve crucial roles in administrative processes, emphasizing the importance of accurately and thoroughly completing each section to ensure proper consideration and evaluation.

Similarly, the NGB Form 22, Report of Separation and Record of Service, parallels the DA 7652 in purpose for documenting key aspects of a service member’s career, particularly at the time of separation from the National Guard. The DA 7652 focuses on the impact of medical conditions on a soldier's ability to perform duties, while the NGB Form 22 documents service history and entitlements. Both forms are critical for the administrative processing of military personnel, aiding in the transition to civilian life or in the evaluation of retirement and medical benefits.

The VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, also aligns with the DA 7652 regarding the focus on how a soldier’s ability to perform their duties is affected by medical conditions. The VA Form 21-526EZ is used by veterans to claim disability benefits, requiring detailed information on military service, medical conditions, and how these impairments affect daily living. Both forms are integral for ensuring individuals receive the proper benefits and considerations due to medical constraints.

The OPM Form 2809, Health Benefits Election Form, while used in a different context, has a procedural resemblance to the DA 7652 by gathering essential personal and health-related information that impacts benefits eligibility. The DA 7652 assesses a soldier’s medical fitness and its effect on their career, whereas OPM Form 2809 allows government employees to elect health insurance benefits, documenting personal information and family status that determine coverage needs and options. Both forms illustrate the intricate processes within governmental and military systems for managing health and benefit-related decisions.

The DD Form 214, Certificate of Release or Discharge from Active Duty, shares a primary function with the DA 7652 as it plays a critical role in documenting a military service member’s career. While the DA 7652 is primarily concerned with the evaluation related to medical conditions and performance, the DD Form 214 provides a comprehensive record of service, including reasons for discharge, service duration, and rank. Both documents are pivotal for establishing eligibility for veterans’ benefits, employment opportunities, and retirement services.

The SF 86, Questionnaire for National Security Positions, similarly demands thorough and accurate information regarding personal history, but it is utilized for security clearance purposes rather than evaluating physical or functional ability like the DA 7652. Both the DA 7652 and SF 86 are designed to capture detailed personal data, but the SF 86 focuses on assessing an individual’s reliability, trustworthiness, and loyalty to the United States. Although serving different outcomes, they underscore the importance of integrity and accuracy in the completion of governmental forms.

Each of these documents, while unique in their specific purpose, shares the commonality of requiring detailed, personal information critical to the evaluation and decision-making processes within military and civilian personnel systems. They highlight the structured mechanisms in place for administering benefits, recognizing achievements, and assessing individual qualifications and conditions within both the U.S. Armed Forces and federal employment contexts.

Filling out the DA Form 7652, especially in the context of the Disability Evaluation System (DES), is a critical process that directly impacts the adjudication of a Soldier's case, possibly influencing their benefits and future within the Army. To ensure the accuracy and completeness of this essential documentation, here are several recommended dos and don'ts:

Do:

1. Review the Privacy Act Statement thoroughly before proceeding, to understand the implications of providing personal and medical information.
2. Confirm all administrative information with the appropriate personnel activity and the Soldier to ensure its accuracy.
3. Gather and attach all required documentation, including reports and memos related to the Soldier’s medical condition, especially if referred to a Warrior Transition Unit or similar assignment.
4. Ensure that all responses, particularly those related to the Soldier’s performance and functional limitations, are detailed and accurate, offering a clear picture of the impact on duties and the unit's mission readiness.
5. Explicitly note any condition that prevents the Soldier from performing tasks required by their MOS or affecting their decision-making or work relationships.
6. For conditions related to injuries, confirm whether a line of duty determination has been completed or initiated and attach the necessary documentation.
7. Sign and date the form as required in Section V to validate the information provided.

Don't:

• Leave sections incomplete - if a particular question does not apply, mark it accordingly, rather than skipping it.
• Provide vague or general descriptions of the Soldier’s medical condition(s); specificity is critical for a fair evaluation by the Physical Evaluation Board (PEB).
• Omit context or examples that illustrate how the medical condition affects the Soldier’s duty performance or unit readiness.
• Forget to review the form for accuracy and completeness before submission, as missing or incorrect information can delay the evaluation process.
• Overlook the requirement to attach relevant supporting documents, such as Medical Evaluation Board (MEB) results or commander’s memorandum.
• Assume all sections are only applicable to active component members; pay attention to sections specifically designated for Reserve Component Officers and enlisted Soldiers as well.
• Rush through the process without taking the time to accurately detail the impacts of the condition(s), both physically and mentally, on the Soldier’s ability to serve.

By following these guidelines, you can help ensure the form is accurately and thoroughly completed, facilitating a fair and prompt evaluation process for the Soldier in question.

Many misunderstandings surround the DA Form 7652, a pivotal document in the Disability Evaluation System (DES) process for soldiers. Clarifying these misconceptions is crucial to properly navigate this complex process.

• Misconception 1: The form is only for Army personnel. While primarily used within the Army, it’s important in the broader military context for evaluating a soldier’s fitness due to medical conditions across various components, including active duty and reserves.
• Misconception 2: It’s a simple medical form. The DA Form 7652 encompasses much more; it includes assessments of the soldier's ability to perform duties, the impact of medical conditions on their role and mission readiness, and administrative information relevant to disability adjudication.
• Misconception 3: Only medical officers need to understand it. Commanders, administrative staff, and the soldiers themselves should comprehend the form's implications to accurately convey the soldier's medical limitations and their effect on duty performance.
• Misconception 4: The form determines immediate discharge. In fact, it’s part of a broader evaluation to determine if a soldier can be retained, retired, or separated due to physical disability, not an automatic initiation of discharge.
• Misconception 5: Submission guarantees a disability rating. Submitting the form starts the review process, but the Physical Evaluation Board (PEB) makes disability determinations based on comprehensive evaluations beyond this single document.
• Misconception 6: Only physical conditions are considered. The DA Form 7652 also requires input on mental health conditions and their impact on military performance, showcasing a holistic approach to evaluating fitness for duty.
• Misconception 7: It’s a confidential medical record. While the form contains sensitive information, it's used within a system subject to proper routine uses, and failure to provide required information can hinder the soldier’s case.
• Misconception 8: All sections are filled out by the soldier. The form requires inputs from commanders, medical professionals, and administrative personnel to offer a complete picture of the soldier's capacity to serve, not just self-reported information.

Understanding the DA Form 7652’s scope and process is key for soldiers and their leadership to navigate the DES effectively and ensure fair consideration of each case.

The DA Form 7652 serves as the Disability Evaluation System (DES) Commander's Performance and Functional Statement, which is a critical document in the process of evaluating a soldier's medical condition(s) and its impact on their military duties. It aims to provide the Physical Evaluation Board (PEB) with comprehensive data on how a medical impairment affects a soldier’s ability to perform assigned tasks and any possible administrative implications regarding disability adjudication and/or benefits.

• It is essential to complete the form thoroughly and accurately, as it asks for specific information regarding the soldier's medical conditions, both physical and mental, and the effect these conditions have on performing basic soldier skills, primary military occupational specialty (PMOS) tasks, and the overall impact on unit mission readiness.

• Section III of the form is dedicated to the Commander's Performance Information, requiring input from current or former commanders, NCO leadership, immediate supervisors, or peers, to provide a detailed account of the soldier's functional limitations and duty performance.

• The form requests detailed administrative information about the soldier, including any pending charges or investigations, retirement status, previous ranks held, and reasons for not serving at the highest rank previously held. It also covers soldiers' eligibility for retirement or separation based on service time and health conditions.

• Disclosure on the form is voluntary; however, failure to provide the requested information may interfere with the proper adjudication of the soldier's case, potentially affecting the outcomes in their best interest and the interests of the Army.

• The DA Form 7652 requires information on the soldier’s ability to deploy, necessitating a Yes/No response on whether the service member can be assigned against a deployable billet and if they could perform duties in an Overseas Contingency Operation (OCONUS) deployed environment without restrictions. If "No" is selected, the commander must provide further elaboration in Section III C.

Accurate and comprehensive completion of the DA Form 7652 is crucial for the decision-making process regarding a soldier's fitness for continued service, potential retirement, or separation for physical disability, underlining the significance of each item detailed within the form.