DA Form 3822 at a glance
What it is: DA Form 3822, JUN 2019, is the Report of Mental Status Evaluation under AR 40-66.
Who signs: Sign Behavioral Health Provider's Signature and Behavioral Health Supervisor Signature (if needed). Enter Date.
A filled-in DA Form 3822 example: an evaluation that finds no impairing condition
How to fill out DA Form 3822, box by box
Section I, Reason for MSE
In SECTION I, select the Reason for MSE, or write Other.
Section II, behavioral health disposition determination
In SECTION II - BEHAVIORAL HEALTH DISPOSITION DETERMINATION, check: SM shows no evidence of an impairing behavioral health (BH) condition. SM is cleared for advanced military training.
Check: No duty limitations due to behavioral health reasons. SM currently meets behavioral health medical retention standards (IAW AR 40-501).
Check: BH condition meets retention standards but may require waiver for deployability within specific areas of operation.
Check: SM is on a Profile which expires. See Profile for details.
Check: SM currently does NOT meet medical retention standards, has reached medical retention determination point, and a Disability Evaluation System referral is indicated or has already occurred.
Check: Further assessment is needed to determine behavioral health medical readiness status.
For Ch. 5-13/17, AR 635-200, check: SM meets criteria for Ch. 5-13/17 administrative. SM currently meets medical retention standards.
Mark Yes or No if SM deployed to an imminent danger pay area IAW MEDCOM Policy 19-001 (YES Requires OTSG-Level approval using BHAR).
Check: There is no evidence of a documented change in diagnosis from a boardable to a non-boardable condition within the past 90 days.
Check: The condition is of sufficient severity to interfere with the SM's ability to function in the military. The SM is not amenable to BH treatment and is unlikely to respond to Command efforts at rehabilitation.
Section III, pertinent findings
In SECTION III - PERTINENT FINDINGS, Screening performed: check Post-Traumatic Stress Disorder, Depression, Substance Misuse or Sexual Trauma.
Screening performed: check Traumatic Brain Injury.
Mark BEHAVIOR: Normal or Abnormal. Mark COGNITION: Not Impaired or Impaired.
Mark PERCEPTIONS: Not Impaired or Impaired. Mark IMPULSIVITY: Normal or Abnormal.
Mark BH RISK FOR HARM TO SELF and BH RISK FOR HARM TO OTHERS: Not Elevated, Low, Intermediate or High.
Enter Positive Screens/Findings/Elevated Risks (Use further Comment section if space is needed).
Section IV, diagnoses
In Section IV, only report diagnoses required for supporting Section II findings. Enter BH diagnoses and other medical diagnoses.
Section V, follow-up recommendations
Check No follow-up needed, Follow-up recommended or Follow-up as already scheduled.
Enter Clinic, Location, Date, Time and Phone.
Other: Recommend Command referral to: Family Advocacy Program, Substance Use Disorder Evaluation.
Patient information
Under PATIENT INFORMATION, enter Patient Name, Rank/Grade, Status, DOB (YYYYMMDD), Sponsor DOD ID, Date, MTF and Prefix.
Section VI, recommendations and comments for commander
In SECTION VI - RECOMMENDATIONS AND COMMENTS FOR COMMANDER, check: No safety precautions are indicated.
Mark Yes or No: SM can understand and participate in administrative proceedings and appreciate the difference between right and wrong.
Mark Yes or No: SM's behavioral health condition was likely a mitigating factor in the alleged behavior leading to administrative separation.
Mark Yes or No for Ch. 10,14 & Officer elimination: The effects of PTSD and TBI likely constitute matters in extenuation that relate to the basis for separation.
Check: Ensure SM attends all follow-up appointments.
Check: Prohibit use of alcohol. Alcohol can interfere with medication, decrease rational judgment, and increases risk for impulsive behavior.
Check: Increase leader/supervisory support with intent of keeping SM engaged with unit members and other sources of support.
Check: Consider placement of Service member in barracks for increased support and potentially reduced access to weapons.
Check: Encourage SM to use gun locks and gun safes or temporarily secure personal weapons with MPs, unit arms room, or other trusted source.
Check: Restrict access to or disarm all military weapons and ammunition. No range duties.
Check: Consider no contact order between Service member and to limit risk of harm to self/others.
If Service member shows concerning changes in mood, behavior, or safety, then Command should call: Name, Phone during duty hours. After hours, Command should escort Service member to the nearest emergency room.
Check: The Service Member has a condition that is likely to impair his/her judgment or reliability to protect classified information. (If checked, Commanders will ensure prompt notification to the Army Central Clearance Facility IAW AR 380-67 DA Personnel Security Program, by providing an incident report via the Joint Personnel Adjudication System (JPAS) or its successor.)
Enter Further Comments.
Signatures and the command representative contacted
Command representative contacted. Enter Name, Duty Position and Phone.
Sign Behavioral Health Provider's Signature and Behavioral Health Supervisor Signature (if needed). Enter Date.
Sources
[1] DA Form 3822 (JUN 2019), Report of Mental Status Evaluation, Department of the Army (the Official source link on this page).