DA Form 7652: Commander's Performance and Functional Statement

Enter Box 1, DATE, as YYYYMMDD, and Box 5, DATE OF BIRTH.

Enter the SOLDIER'S NAME (Last, First, MI) in Box 2, then the GRADE, PMOS, COMPONENT, ETS/MRD and DOD E-MAIL in Boxes 3, 4, 6, 7 and 8.

Enter the ORGANIZATION NAME, ADDRESS, PHONE NUMBER, the HOME/CELL PHONE, the DOD NUMBER and the UNIT IDENTIFICATION CODE (UIC).

Confirm the information in Section II, ADMINISTRATIVE INFORMATION, with the appropriate personnel activity and with the Soldier.

Box 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?

Box 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)? If YES, specify Chapter/paragraph.

Box 3: Does Soldier have an approved voluntary retirement? If YES, list date retirement was approved.

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

Box 5, ACTIVE COMPONENT SOLDIERS ONLY: Does Soldier have prior service in the Selected or Individual Ready Reserve? If YES, specify type of service.

Box 6, RESERVE COMPONENT OFFICERS ONLY: Is officer within 12 months of mandatory removal date? If YES, list mandatory removal date.

Box 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?

Box 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?

Box 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)? If YES, list date Soldier due next automatic advancement.

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

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

Box 12: Has Soldier previously held higher rank? If Yes, list highest rank held and the reason Soldier is not serving in highest rank previously held.

Box 13: Was Soldier's current referral to MEB/PEB the result of a MOS Administrative Retention Review (MAR2)? If YES, list date completed and attach MAR2 results.

Box 14: Is the Soldier flagged IAW any provision of AR 600-8-2? If YES, specify the reason and date of the flag.

Box 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.

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

The Soldier's commander and leadership team are in a unique position to provide this information.

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.

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.

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.

All sections must be completed.

In 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.

Box 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: the Soldier performs tasks and/or duties to standards, has difficulties completing tasks and/or duties to standards, or is unable to complete task and or duties to standards.

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

Is 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)?

Box 2, Decision Making, based on your knowledge and/or understanding of the Soldier, he/she makes reasonable decisions, including complex or unfamiliar ones. Or he/she makes reasonable decisions, occasionally makes (or avoids making) unreasonable complex or unfamiliar decisions, and makes occasional decision making mistakes. Or he/she makes simple decisions but usually not complex or unfamiliar decisions, and does not make frequent decision-making mistakes when making simple decisions.

Box 3, Work Relationships, based on your knowledge and/or understanding of this Soldier's interactions with supervisors and co-workers: he/she has effective work relationships with both supervisors and co-workers, has difficulty with work relationships, or is unable to maintain effective work relationships.

Box 4, Performance: considering Section III A, questions 1-3, choose the most accurate description of the Soldier's medical condition(s) affect(s) on their performance. Soldier performs well and the medical condition(s) do not appear to have any negative affects; medical conditions do not affect the unit's mission. Soldier's performance is adequate but it appears that the medical condition(s) may have negative affects; medical conditions do not affect the unit's mission. Soldier's performance is inadequate and it appears that the medical condition(s) have negative affects; medical conditions negatively affect the unit's mission. Soldier is unable to perform any significant military tasks or duties because of their medical condition(s).

In 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.

Choose Yes or No: Can the service member be assigned against a deployable billet? Do you believe the service member could perform his/her duties in an OCONUS deployed environment without restrictions, limitations, or work-arounds?

In Section III C, after reviewing Sections II and III A, further clarify an item and/or the selections you have made and add any additional comments, and 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).

In Section IV, BATTALION COMMANDER'S CONTACT INFORMATION, enter the NAME (Last, First, MI), UNIT, PHONE, DOD E-MAIL, GRADE and COMPONENT.

In Section V, COMMANDER'S VALIDATION AND SIGNATURE, enter the NAME (Last, First, MI), the SIGNATURE and the DATE.

In Section V, COMMANDER'S VALIDATION AND SIGNATURE, also enter the PHONE, DOD E-MAIL, COMPONENT and GRADE.