DA Form 5160 at a glance
What it is: DA Form 5160 is the Test Administration Statement for in-service examinees only, for use under AR 611-5.
Who signs: The examinee signs 11. SIGNATURE OF EXAMINEE, the examiner signs 12. SIGNATURE OF EXAMINER, and 13. DATE (YYYYMMDD) is entered.
To be completed by all Examinees prior to testing to ensure the Examinee is mentally and physically fit to test. See the System of Records Notice DoD 0005, Defense Training Records, Federal Register - Privacy Act of 1974; System of Records.
A filled-in DA Form 5160 example: a DLPT examinee fit to test
How to fill out DA Form 5160, box by box
Examinee, rank, date, unit and test
Enter 1. NAME OF EXAMINEE, 2. RANK and 3. DATE (YYYYMMDD).
Enter 4. UNIT OF ASSIGNMENT and 5. NAME OF TEST OR BATTERY.
Examiner, test site and test account
Enter 6. NAME OF TEST EXAMINER, 7. TEST SITE LOCATION and 8. TEST ACCOUNT ID.
Box 9: able to be tested this date
In 9., you are not required to take the named test, this date, provided that there are extenuating circumstances such as fatigue, illness, emotional distress, family, or financial problems, etc., which may interfere with your performance in the test; the test will be administered at another time acceptable to you, the Test Control Officer concerned, and your unit commander.
Check I AM PHYSICALLY AND MENTALLY ABLE TO BE TESTED THIS DATE.
Check I AM NOT PHYSICALLY AND OR MENTALLY ABLE TO BE TESTED THIS DATE. I WILL BE ADMINISTERED THIS TEST AT ANOTHER TIME. The examinee places a checkmark on the DA Form 5160 in that block and signs the test administration statement.[2]
Box 10: eligible to take this test because
In 10., certify you are eligible to take this test because: check I have not taken a DLPT in this language within the last 9 months, per AR 11-6 and AR 611-5.
Check I have not taken the DLAB within the last 6 months, nor achieved a score of 95 or higher on a previous DLAB test, nor have I taken more than two DLAB tests.
Check I have not taken the SIFT within the last 45 days, nor achieved a passing score on a previous SIFT, nor have I failed more than one SIFT test.
Check I have not taken the ASVAB or the AFCT within the last 6 months.
Check I have not taken this Army personnel test within the last 6 months, per AR 611-5.
Or, check I have been granted an exception to policy to retest within the established time limitation and have provided a copy of the exception to the Test Control Officer.
Signature and false statement
Further, I understand that making a false statement on this form may subject me to criminal prosecution under the provisions of Article 107, Uniform Code of Military Justice, or section 1001, Title 18, U.S. Code.
More rules for DA Form 5160
Voluntary; however, failure to complete this form, may disqualify examinees from testing.
Sources
[1] DA Form 5160 (SEP 2023), Test Administration Statement, Department of the Army (the Official source link on this page).
[2] armypubs.army.mil, line_9_not_able_block_doc. Accessed October 21, 2026.