Da Form 3666 – Fill Out and Use This PDF

NAME (Last, First, Middle)

DATE OF BIRTH (YYYYMMDD)

ADDRESS (Number, Street, City, State and ZIP Code)

TITLE OF POSITION APPLIED FOR

		SECTION A - PHYSICAL LIMITATIONS
Answer each circled item "YES" or "NO" by placing an "X" in the proper box below. If you answer "YES" to any circled item, give additional details in
Section D.
1.	Do you have any problem:		YES
	(a)	reading small newspaper print (glasses permitted)?
	(b)	reading ordinary newspaper headlines without glasses?
	(c)	seeing distant objects with either eye (glasses permitted)?
2.	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Do you have difficulty in distinguishing basic colors (red, green, blue)?
3.	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Do you have difficulty in distinguishing shades of colors?
4.	. . . . . . . . . . . . . . . . . . . . . . . . .Do you have any hearing problem, including hearing telephone conversations (hearing aid permitted)?
5.	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Do you wear a hearing aid?

6.Do you have any speech impairment which hinders:

(a) person -to -person conversation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(b) telephone conversation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Do you have an amputation or abnormality of a leg, foot, arm, hand, and/or finger? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8. Do you have difficulty in using arms, hands, or fingers for reaching in any direction, grasping, handling, or fingering?. . . . . . . . . . . . . .

9. Do you have any disease or disability which would make your employment in light duty work a hazard to yourself or others? . . . . . . . . . .

NO

SECTION B - PHYSICAL ENDURANCE FACTORS

Answer each circled item "YES" or "NO" by placing an "X" in the proper box to show your physical ability to carry out the listed activities during each work day. If you answer "NO" to any item, give additional details in Section D.

DURING THE WORK DAY ARE YOU PHYSICALLY ABLE TO PERFORM ACTIVITIES INVOLVING:

YES

1. Sitting for long periods of time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Standing for long periods of time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Some walking on flat surfaces, slight inclines, and occasionally climbing stairs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Frequent walking and/or climbing of stairs or steep inclines? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Occasional pushing and pulling motions as needed? (For example, opening and closing doors, drawers, etc.) . . . . . . . . . . . . . . . . . . . .

6. Frequent pushing and pulling motions? (For example, frequent opening and closing file drawers) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Occasional bending, stooping, and crouching? (For example, reaching the bottom shelf of a supply cabinet) . . . . . . . . . . . . . . . . . . . . . .

8. Frequent bending, stooping, and crouching? (For example, frequently opening and closing lower file drawers) . . . . . . . . . . . . . . . . . . .

9. Occasionally lifting objects weighing up to 10-12 lbs. and frequently carrying lightweight items? (For example,

ledgers, dockets, or lightweight equipment) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10. Occasionally lifting objects weighing up to 20-25 lbs. and frequently carrying objects weighing up to 10-12 lbs? . . . . . . . . . . . . . . . . . . .

NO

Can you work under the following conditions:

1. Outside (frequently) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Severe heat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Severe cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Severe humidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Severe dampness or chilling . . . . . . . . . . . . . . . . . . . . . . . .

6. Dry atmospheric conditions . . . . . . . . . . . . . . . . . . . . . . . .

7. Severe noise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8. Constant noise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9 . Dusty atmospheres . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES

NO

10. Some exposure to fumes, smoke, or gases . . . . . . . . . . . . . .

11. Some contact with solvents, greases, and oils . . . . . . . . . . . .

12. Occasional walking over rough terrain . . . . . . . . . . . . . . . .

13. Some climbing of short ladders (For example, to

reach upper supply shelves) . . . . . . . . . . . . . . . . . . . . . . .

14. Working below ground surface . . . . . . . . . . . . . . . . . . . . .

15. Working alone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16. Occasional travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17. Frequent travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES NO

This statement is to be used in lieu of a Certificate of Medical Examination for Department of the Army Nonappropriated Fund positions whose maximum physical requirements do not exceed those identified on the questionnaire and may properly be evaluated by an appointing officer.

If either as a result of replies on the statement, or of personal observation, the appointing officer believes the applicant is physically unable to do the job or would create a hazard to himself/herself or others, the appointing officer may require the applicant to undergo a medical examination as a prerequisite to employment in the position.

(The examination may not be required solely on the basis of the

In addition, for positions having unusual sight or hearing requirements an appropriate specialized examination may be required.

In all cases, the statement should be completed and reviewed prior to employment and before the applicant incurs any expense in traveling a distance to a duty station .

Completed statements may be disposed of as soon as they have served the purpose of the appointing officer.

1.Fill in "Title of Position Applied For" under "IDENTIFICATION OF APPLICANT".

2.Circle in RED the item number of the questions, in each section, which will determine the applicant's physical ability to perform the duties of the position. Circle ONLY those items which pertain to the physical requirements of the job, or in the case of Section C, the environmental factors.

3.After the applicant completes the statement, take appropriate action as indicated by the applicant's replies. A medical officer should be consulted when indicated by detailed replies. Complete item 3, Section F, "FOR DEPARTMENT OF THE ARMY USE ONLY," by entering the appropriate handicap code . The list of handicaps and corresponding codes is on the reverse side of these instructions.