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The DA Form 7652 serves a vital role in the military disability evaluation process. Designed primarily for the Physical Evaluation Board (PEB), this form collects key information regarding a Soldier's medical impairments and their impact on the ability to perform military duties. It compels service members to provide not only personal and demographic details, such as name, grade, and unit assignment, but also requires an assessment of their medical conditions and how these may affect their job performance and overall readiness for duty. Additionally, it highlights relevant administrative information, including any pending separations or retirement approvals, and inquiries about the Soldier's eligibility for promotions and advancements. Commanders are tasked with making informed evaluations based on their interactions with the Soldier, covering how well the Soldier can perform physical tasks, make decisions, and maintain effective work relationships. The seriousness of accurate completion cannot be overstated; inaccuracies or omissions may hinder the proper adjudication of disability cases, potentially impacting both the Soldier’s future and the Army’s mission readiness.

Da 7652 Example

APD LF v1.01ES
If YES, specify Chapter/paragraph.
If YES, list date retirement was approved.
If YES, list mandatory retirement date.
If YES, specify type of service.
If YES, list mandatory removal date.
Indicate whether the Active Component member's qualification for retirement is under.
If YES, list date Soldier due next automatic advancement.
If Yes, list highest rank held. Choose an item.
List reason Soldier is not serving in highest rank previously held.
If YES, list date completed and attach MAR2 results.

DISABILITY EVALUATION SYSTEM (DES)

COMMANDER'S PERFORMANCE AND FUNCTIONAL STATEMENT

For use of this form see AR 635-40; The proponent agency is DCS, G-1.

PRIVACY ACT STATEMENT

AUTHORITY: U.S.C. chapter 61, Retirement or Separation for Physical Disability; and 5;

AR 635-40, Disability Evaluation for Retention, Retirement, or Separation.

PURPOSE: To provide information to the Physical Evaluation Board (PEB) on the impact of a medical impairment on a Soldier's ability to perform duties and to provide Administrative information that impacts disability adjudication and/or benefits if the Soldier is determined unfit. For additional information see the System System of Records Notice A0040-3b DASG Medical Evaluation Files https://dpcld.defense.gov/Privacy/ SORNsIndex/DOD-wide-SORN-Article-View/Article/569965/a0040-3b-dasg.aspx

ROUTINE USES:

There a no specific routine uses anticipated for this form; however it may be subject to a number of proper and

 

necessary routine uses identified in the system of records notice(s) specified in the purpose statement above

DISCLOSURE:

Voluntary, however failure to provide the information will interfere with the proper adjudication of the Soldier's case in the best

 

interest of the Soldier and the Army.

 

 

 

 

 

 

 

SECTION I: SOLDIER DEMOGRAPHIC INFORMATION

 

 

 

1. DATE (YYYYMMDD)

2. SOLDIER'S NAME (Last, First, MI)

 

3. GRADE

 

4. PMOS

 

 

 

 

 

 

 

 

5. DATE OF BIRTH

 

6. COMPONENT

7. ETS/MRD

8. DOD E-MAIL

 

 

 

 

 

 

 

 

 

 

9. HOME/CELL PHONE

10. DOD NUMBER

11. UNIT IDENTIFICATION CODE (UIC)

9. ORGANIZATION NAME,

 

 

 

 

 

ADDRESS, PHONE NUMBER

SECTION II: ADMINISTRATIVE INFORMATION

Instructions: The information in this section should be confirmed by the appropriate personnel activity and with the Soldier.

DATA ITEM

YES NO

REMARK

1.Is Soldier charged or under investigation for an offense chargeable under the Uniform Code of Military Justice, which could result in dismissal or punitive discharge?

2. Is Soldier pending voluntary or involuntary administrative separation under AR 635-200 or AR 135-178 (enlisted) or AR 600-8-24 or AR 135-175 (officer)?

3. Does Soldier have an approved voluntary retirement?

4. ACTIVE COMPONENT OFFICERS: Is officer within 12 months of mandatory retirement for age or years of service or approved for Selective Early Retirement?

5. ACTIVE COMPONENT SOLDIERS ONLY: Does Soldier have prior service in the Selected or Individual Ready Reserve?

6. RESERVE COMPONENT OFFICERS ONLY: Is officer within 12 months of mandatory removal date?

7.RESERVE COMPONENT OFFICERS ONLY: If block 6 is `YES', will officer have 20 qualifying years of service at time of his or her mandatory removal date for purposes of non regular retirement?

8. ACTIVE or RESERVE COMPONENT ENLISTED SOLDIERS ONLY: Is enlisted Soldier within 12 months of his/her Retention Control Point (RCP) and will qualify for a regular retirement at RCP or, if a member of the Reserves will qualify for a 20-year letter at RCP?

9. If an enlisted Soldier, is the Soldier due an automatic advancement? (See AR 600-8-19 concerning promotable status of enlisted Soldiers in the DES.)

10. If an enlisted Soldier, is the Soldier on a semi-centralized or centralized promotion list?

11. If an officer, is the Soldier on an approved promotion list?

12. Has Soldier previously held higher rank?

13. Was Soldier's current referral to MEB/PEB the result of a MOS Administrative Retention Review (MAR2)?

DA FORM 7652, APR 2019

PREVIOUS EDITIONS ARE OBSOLETE.

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14. Is the Soldier flagged IAW any provision of AR 600-8-2?

 

 

 

 

If YES, specify the reason and date of

 

 

 

 

the flag.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. Is the Soldier assigned a Warrior Transition Unit or other medical type hold type unit?

 

 

 

If YES, attach the commander's

 

 

 

 

memorandum used to refer the Soldier

 

 

 

 

to this unit with this form.

 

 

 

16.If a drilling USAR or ARNG Soldier (and not on active duty), did the Soldier accept the Career Status Bonus?

SECTION III: COMMANDER'S PERFORMANCE INFORMATION

This form is a critical document in determining the effects the Soldier's medical condition(s) (both physical and/or mental) have on their military performance. It is essential to provide accurate information, whether it is from the current or former commanders, NCO leadership, immediate supervisor, or peers. The Commander's Performance and Functional Statement must be complete and provide an accurate picture of the Soldier's actual functional limitations and duty performance. The Soldier's commander and leadership team are in a unique position to provide this information. Even if this statement is difficult to obtain, (e.g., the Soldier or Commander is new to the unit, the Soldier's condition prevents drill attendance, etc.) the statement must be completed to the maximum extent possible.

You are entering information into a performance-based system. Describe how the Soldier's medical condition(s) (both physical and/or mental) affects his or her ability to perform basic Soldier skills; the skills and duties of the primary military occupational specialty (PMOS); and how the Soldier's condition impacts or affects unit mission readiness. (Note: Performance information is of greater significance for Soldiers with chronic conditions. Severe, acute physical conditions generally need little performance discussion because the PEB members easily understand the limitations posed by such impairments.) If a condition prevents the Soldier from executing a task(s) that is required by his/her MOS, please specify what MOS task(s) cannot be executed in Section III C.

In all cases of Medical Corps officers with a clinical specialty area of concentration and assigned to a clinical position, Sections III and V will be completed by the officer's first line clinical supervisor. In all cases of officers of the Judge Advocate General Corps (JAG), Sections III and V will be completed by the officer's Staff Judge Advocate, Command Judge Advocate, or agency/section legal supervisor.

All sections must be completed

SECTION III A

Choose the answer that most accurately describes the impact of the Soldier's medical condition in completion of physical tasks/duty completion; decision making; and work relationships.

1.Physical Task/duty completion: Based on your knowledge and/or understanding of this Soldier's performance of physical duties both within and outside their MOS, this Soldier:

A Performs tasks and/or duties to standards.

B Has difficulties completing tasks and/or duties to standards.

C Is unable to complete task and or duties to standards.

D Do you believe the member's condition(s) will prevent him/her from serving in their primary MOS/AOC in future assignments? If so, how?

EHas the member's duty schedule been modified due to his/her medical condition(s) (i.e., limited duty, half days, no shift work, etc.)? If so, how and for how long?

F Other than medical appointments, approximately how many days of work has the member missed over the past 90-360 days due to this condition?

GIs the commander/first line supervisor aware of the Soldier's medical condition? If YES, what job tasks does the medical condition prevent the Soldier from adequately performing? If NO, please explain.

If the medical condition is due to an injury, was the injury due to a vehicle accident or other incident requiring a line of duty? If so, was a line of duty completed (attach the completed LOD or initiate one if not completed)?

DA FORM 7652, APR 2019

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SECTION III A (Continued)

2. Decision Making: Based on your knowledge and/or understanding of the Soldier, he/she:

A Makes reasonable decisions, including complex or unfamiliar ones.

BMakes reasonable decisions; occasionally makes (or avoids making) unreasonable complex or unfamiliar decisions; makes occasional decision making mistakes.

CMakes simple decisions but usually not complex or unfamiliar decisions; does not make frequent decision-making mistakes when making simple decisions.

D Do you believe the member's condition(s) will prevent him/her from serving in their primary MOS/AOC in future assignments? If so, how?

3.Work Relationships: Based on your knowledge and/or understanding of this Soldier's interactions with supervisors and co-workers, he/she:

A Has effective work relationships with both supervisors and co-workers.

BHas difficulty with work relationships, and may be disurptive or cause problems with tasks performance and/or completion.

C Is unable to maintain effective work relationships.

4.Performance: Considering Section III A, questions 1-3 above and based on your knowledge and/or understanding of this Soldier's work performance, choose the most accurate description of the Soldier's medical condition(s) affect(s) on their performance:

ASoldier performs well and the medical condition(s) do not appear to have any negative affects on the performance of his/her duties; medical conditions do not affect the unit's mission.

BSoldier's performance is adequate but it appears that the medical condition(s) may have negative affects on the performance of his/her duties; medical conditions do not affect the unit's mission.

CSoldier's performance is inadequate and it appears that the medical condition(s) have negative affects on the performance of his/her duties; medical conditions negatively affect the unit's mission

D Soldier is unable to perform any significant military tasks or duties because of their medical condition(s); unable to conttibute to the unit's mission.

SECTION III B

Choose the answer that most accurately describes the Soldiers ability to deploy. When "No" is chosen, the commander will elaborate in Section III C.

Yes

 

No

 

Can the service member be assigned against a deployable billet?

 

 

 

 

 

Yes

 

No

 

Do you believe the service member could perform his/her duties in an OCONUS deployed environment without restrictions, limitations,

 

 

 

 

or work-arounds?

 

 

 

 

SECTION III C

After reviewing Sections II and III A, further clarify an item and/or the selections you have made above and add any additional comments. Please include examples of the Soldier's general and/or MOS/AOC specific task limitation(s) due to their medical condition(s) (both physical and/or mental).

SECTION IV: BATTALION COMMANDER'S CONTACT INFORMATION

1.NAME (Last, First, MI)

4.DOD E-MAIL

5. GRADE

2. UNIT

6. COMPONENT

3. PHONE

SECTION V: COMMANDER'S VALIDATION AND SIGNATURE

 

1. NAME (Last, First, MI)

 

2. SIGNATURE

3. DATE

 

 

 

 

 

 

 

 

4. DOD E-MAIL

5. PHONE

6. COMPONENT

7. GRADE

DA FORM 7652, APR 2019

 

 

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APD LF v1.01ES

Get Da 7652 PDF Form

Form Characteristics

Fact Name Fact Description
Form Purpose The DA 7652 form is used to gather information regarding a Soldier's medical condition and its impact on their military duties.
Governing Law This form operates under the authority of U.S.C. chapter 61 and AR 635-40, which pertain to retirement or separation for physical disability.
Privacy Statement The form includes a Privacy Act Statement to ensure that the Soldier's personal information is protected during the evaluation process.
Sponsorship The DCS, G-1 functions as the proponent agency overseeing the use of this form within the military context.
Voluntary Disclosure Providing information on the form is voluntary; however, failure to do so can hinder the adjudication of the Soldier's case.
Sections Breakdown The form consists of several sections, each targeting different types of information including demographic, administrative, and performance insights.
Commander's Role The Soldier's commander plays a significant role by providing a performance and functional statement detailing the Soldier's condition and duties.
Automatic Advancement If an enlisted Soldier is due for an automatic advancement, it must be documented on this form.
Approval for Retention The form assists in determining whether a Soldier's medical condition allows them to continue serving or qualifies them for retirement.
Tracking Performance Details regarding the Soldier's ability to complete tasks, make decisions, and maintain work relationships are thoroughly evaluated.

Guidelines on Utilizing Da 7652

After gathering the required information, you will start filling out the DA 7652 form. Make sure you have all necessary documents and details ready to ensure a smooth process.

  1. Begin with the DATE section. Enter the date in the format YYYYMMDD.
  2. In the SOLDIER'S NAME field, provide the soldier's last name, first name, and middle initial.
  3. Fill in the GRADE of the soldier accurately.
  4. Indicate the PMOS (Primary Military Occupational Specialty) of the soldier.
  5. For the DATE OF BIRTH, enter the soldier’s birth date.
  6. Specify the COMPONENT (e.g., Active, Reserve).
  7. Note the ETS/MRD (Expiration Term of Service/Mandatory Retirement Date).
  8. Enter the DOD E-MAIL address of the soldier.
  9. Fill in the HOME/CELL PHONE number of the soldier.
  10. Provide the DOD NUMBER.
  11. List the UNIT IDENTIFICATION CODE (UIC) of the soldier’s unit.
  12. Complete the ORGANIZATION NAME, ADDRESS, PHONE NUMBER section accurately.

Completing this form involves careful attention to several sections, including Administrative Information and Commander's Performance Information. Ensure all yes/no questions are answered truthfully as they impact the evaluation process significantly.

What You Should Know About This Form

What is the purpose of the DA Form 7652?

The DA Form 7652 serves to provide essential information to the Physical Evaluation Board (PEB). It assesses how a Soldier's medical condition impacts their ability to perform required duties. Additionally, the form gathers administrative details that are significant for decisions related to disability adjudication and benefits if the Soldier is deemed unfit for service.

Who is required to complete the DA Form 7652?

This form should be completed by commanders, leadership teams, or authorized personnel who can accurately assess the Soldier's performance and medical condition. It's essential that the details provided reflect the Soldier's abilities and limitations to ensure a comprehensive evaluation process.

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

Section I requires demographic and contact information about the Soldier. This includes the Soldier’s full name, date of birth, grade, and contact details such as email and phone number. It is critical that this information is accurate as it links the Soldier to their evaluation and subsequent findings.

What type of questions are included in Section II regarding administrative information?

Section II poses a series of yes or no questions to assess the Soldier’s current administrative status. These questions cover topics like pending investigations, approved retirements, and the Soldier’s qualifications for retirement based on their medical condition. This section helps determine how administrative issues might affect the Soldier's evaluation.

How is the Soldier’s performance evaluated in Section III?

Section III is focused on evaluating the Soldier’s performance concerning their medical condition. Evaluators are asked to assess how the condition affects task completion, decision-making, and work relationships. They provide insights into whether the Soldier can perform their military occupational specialty effectively and how their health impacts unit readiness.

What happens if a Soldier does not complete the DA Form 7652?

While completing the DA Form 7652 is voluntary, not providing the requested information can hinder the Soldier’s case. It may lead to delays or complications in the adjudication process and could negatively affect the Soldier's benefits. Therefore, it is in the best interest of the Soldier to ensure that the form is completed thoroughly and accurately.

Common mistakes

Filling out the DA 7652 form can be a tricky process. One common mistake people make is failing to provide correct personal information. The first section asks for details like the soldier's name, grade, and date of birth. If these details are wrong, it can lead to delays or even issues with the processing of the form. Always double-check that the information matches official documents.

Another frequent error involves unclear answers in the administrative information section. When asked about pending separations or whether a soldier holds a higher rank, people sometimes leave comments vague or unchecked. Each answer requires careful thought, as unclear responses can create confusion for those reviewing the form. It’s best to provide specific and straightforward answers whenever possible.

People also sometimes attach documents incorrectly. The form may ask for supporting memos or results, like the MAR2 results. Failing to attach these or providing incorrect documents can hinder the evaluation process. Always ensure that you attach the necessary paperwork in the correct format. It's not just about filling out the form; presenting a complete package is essential.

Finally, signatures are crucial. Some individuals forget to have the appropriate authorities sign the form. This includes the soldier’s commander and the battalion commander. Without these signatures, the form may be rejected. Make it a point to secure all necessary signatures before submitting the document. Each step is significant in creating a comprehensive and accurate submission.

Documents used along the form

The DA 7652 form plays a crucial role in the retirement and separation process for service members, especially regarding the Disability Evaluation System. However, it is often accompanied by several other essential forms and documents that collectively facilitate a smooth transition for servicemen and women. Below is a list of common documents that may be required alongside the DA 7652, providing vital supplementary information and assisting in the administrative process.

  • DA Form 3349: This form, known as the Physical Profile, outlines a Soldier's physical and medical limitations. It is important in determining what duties the Soldier can perform and supports evaluations of medical readiness for service.
  • DA Form 2823: Also called the Sworn Statement form, this document is used to collect testimonials or accounts related to incidents or injuries that may impact a Soldier's qualifications or service record.
  • DA Form 7501: Officially referred to as the Medical Board Report, this form provides a comprehensive summary of a Soldier's medical evaluations and is essential for establishing the Soldier's fitness for duty.
  • MEB Roster: The Medical Evaluation Board (MEB) roster is a listing of Soldiers who are undergoing medical evaluations. This document tracks service members' cases throughout the evaluation process.
  • PEB Findings: The Physical Evaluation Board's findings detail the PEB's decisions concerning a Soldier's medical fitness for duty and any corresponding disability ratings. These findings directly influence the Soldier's retirement status and benefits.
  • VA Service Connection Documents: These documents include records that establish a service member's connection to disabilities incurred during service, which are essential for determining eligibility for Veterans Affairs benefits.
  • Record of Emergency Data (DA Form 93): This form provides information about a Soldier's beneficiaries in case of emergency situations and ensures that necessary parties are informed about the Soldier’s condition.
  • DD Form 214: This is the Certificate of Release or Discharge from Active Duty document. It is crucial for all service members as it contains information on their military service, including duration, type of discharge, and any awards received.
  • Commander's Memorandum: This internal document assists in the referral process for Soldiers to medical treatment facilities or specialized units, detailing why specific medical assistance is required.

In summary, these forms and documents work together with the DA 7652 form to provide a comprehensive picture of a Soldier's medical situation and enable appropriate action for their retirement or separation. It is essential for service members to complete each form accurately and submit any required attachments to ensure a smooth transition process.

Similar forms

The DA Form 7652 serves various essential purposes within military administrative processes. Below is a list of documents that share similarities with the DA Form 7652, highlighting how they are alike.

  • DA Form 4856: This counseling form documents individual performance, behavior, and potential. Like the DA Form 7652, it emphasizes the assessment of military personnel regarding their ability to fulfill duties, along with collecting critical information for reviews.
  • DA Form 3349: This form is utilized to assess a Soldier's physical profile and limitations. It parallels the DA Form 7652 in its focus on medical information and its impact on a Soldier's ability to perform within their military role.
  • DD Form 214: This document serves as the Certificate of Release or Discharge from Active Duty. It provides a comprehensive overview of a service member’s career, similar to how the DA Form 7652 outlines detailed performance and functional capabilities affecting disability evaluations.
  • DD Form 93: Also known as the Record of Emergency Data, this form contains crucial information about a Soldier's emergency contacts and preferences. Both forms collect essential personal details that can influence administrative actions.
  • DA Form 2807-1: This is a Report of Medical History that discloses a service member's medical background. Like the DA Form 7652, it provides valuable insights into how medical conditions affect service capabilities.
  • DA Form 705: This is the Army Physical Fitness Test Scorecard, used to track physical fitness levels. Its purpose aligns with the DA Form 7652 in assessing a Soldier’s abilities in relation to their roles and responsibilities.
  • DA Form 6430-R: Request for a Medical Evaluation Board (MEB). This form is similar in that it initiates the process of evaluating a member's fitness for duty based on medical conditions, similar to evaluating performance in the DA Form 7652.
  • AR 635-40: This Army regulation covers the Disability Evaluation System (DES). It ties closely to the DA Form 7652 by outlining the procedures for evaluating Soldiers’ fitness related to their medical condition, thereby linking it with the documentation process of the DA Form 7652.

Dos and Don'ts

Things to Do When Filling Out the DA 7652 Form:

  • Read all instructions carefully before starting to fill out the form.
  • Provide complete and accurate information in all sections.
  • Confirm details with the Soldier or appropriate personnel to ensure accuracy.
  • Attach any required supplementary documents, like the commander's memorandum.
  • Collect detailed performance information from commanders and supervisors.
  • Check for the Soldier's prior service or any pending investigations.
  • Submit the form by the deadline to avoid unnecessary delays.

Things to Avoid When Filling Out the DA 7652 Form:

  • Do not leave any required fields blank.
  • Avoid providing ambiguous or incomplete information.
  • Do not submit the form without necessary attachments or documentation.
  • Never guess the answers; confirm details before recording them.
  • Avoid submitting the form without reviewing it for errors.
  • Do not provide medical opinions outside your expertise.
  • Refrain from using informal language or jargon in the entries.

Misconceptions

Misconceptions surrounding the DA 7652 form can lead to confusion and errors in the retirement and disability evaluation process. Here are six common misconceptions and clarifications regarding them:

  • 1. The DA 7652 form is only for Soldiers nearing retirement. Many believe this form is only applicable for those close to retirement. In reality, it is also critical for active duty Soldiers undergoing medical evaluation for disabilities, regardless of their retirement timeline.
  • 2. It is not necessary to provide comprehensive details. Some think that filling out minimal information is sufficient. However, comprehensive and accurate information is essential for the Physical Evaluation Board to make well-informed decisions regarding a Soldier’s fitness for duty.
  • 3. The form is optional for Soldiers with medical conditions. There is a misconception that Soldiers can choose whether or not to submit the DA 7652 if they have medical issues. In fact, this form is crucial for the disability evaluation process and should be completed and submitted to ensure proper adjudication.
  • 4. Only the Soldier needs to fill out the form. Many assume that the Soldier is solely responsible for completing the form. In reality, input from commanders and supervisors is required to provide a full picture of the Soldier’s performance and functional capabilities.
  • 5. Filling out the form can harm a Soldier’s career. Some believe submitting the DA 7652 will negatively impact job security. On the contrary, the form helps ensure that appropriate support and evaluations are in place, which can protect a Soldier's rights and benefits.
  • 6. The information on the form is not confidential. There is a belief that details submitted in the DA 7652 can be shared widely. However, the information is protected under privacy laws and is used exclusively for the purposes of disability determination and retirement processes.

Understanding these misconceptions can clarify the importance of the DA 7652 form in a Soldier's career and well-being. Proper completion and submission can aid in securing fair evaluations and benefits.

Key takeaways

Filling out the DA 7652 form properly is essential for accurate processing regarding a Soldier's medical condition and retirement status. Below are critical takeaways regarding the form.

  • Accurate Information is Key: Ensuring all personal and demographic details are correct can prevent delays in processing.
  • Review Administrative Questions: Verify all "YES" or "NO" responses in the administrative section to reflect the Soldier's current status accurately.
  • MOS Impact: Clearly describe how a Soldier's medical condition affects their ability to perform specific tasks related to their military occupational specialty (MOS).
  • Commander’s Statement is Crucial: The Commander’s Performance and Functional Statement must be thorough to provide insight into the Soldier's work performance and medical limitations.
  • Document Attendance: Record any missed days due to medical issues to give context to the Soldier's current condition and reliability.
  • Mandatory Dates Matter: Pay attention to mandatory retirement and removal dates listed on the form as they are important for timely processing.
  • Provide Context in Section III: Utilize Section III to clarify any limitations and provide examples of how medical conditions impact the Soldier's performance.
  • Confirm Supervisor Awareness: Check whether the direct supervisor is aware of the Soldier’s medical condition; this can affect how tasks are assigned.
  • Utilize All Sections: Complete every section as thoroughly as possible to ensure all relevant information is included.
  • Understand the Privacy Aspect: Be aware of the voluntary nature of information disclosure and its potential impact on case adjudication.

Following these guidelines when filling out the DA 7652 form ensures that the information is complete and accurately represents the Soldier's situation. This attention to detail is critical in supporting a fair evaluation process.

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