Navpers Form 5350 3 PDF Details

The NAVPERS 5350/3 form, known as the Drug and Alcohol Program Advisor (DAPA) Administrative Screening Form, plays a crucial role in the administrative screening process within the Navy. It serves as a comprehensive checklist and information recording tool aimed at identifying service members who may require intervention or treatment for substance use. The form covers a wide array of data points, including personal details about the servicemember, such as name, rank, and command, alongside information on how their potential substance use issue came to attention—be it through self-referral, command referral, or an incident. It also asks about the specifics of any substance involved, including alcohol or illicit drugs, DUI/DWI arrests, urinalysis tests, and any history of drug or alcohol treatment. The form further delves into the servicemember's duty status, marital status, educational background, disciplinary history, and performance evaluations, providing a holistic view for DAPAs, commanding officers, and medical treatment facility (MTF) staff. This detailed approach ensures that all necessary information is gathered to assist in determining the need for, and type of, intervention or treatment, crucial for the servicemember’s health and career. Moreover, it highlights the Navy's dedication to the wellness of its personnel, addressing substance use concerns with thoroughness and care.

QuestionAnswer
Form NameNavpers Form 5350 3
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesIRT, DAAR, paygrade, MTF

Form Preview Example

FILLABLE FORM

DAPA ADMIN SCREENING FORM

Servicemember Name:

Supporting Directive OPNAVINST 5350-4C

ADMINISTRATIVE SCREENING CHECKLIST

Action

Date Completed

Comments

Member identified

Notify C.O. (if required)

Collect service record

Page 9 -10 delivered to member's supervisor

Supervisor input returned

Initial DAAR submitted within 30 days (Reservists 90 days)

Member appointmemt scheduled (member and supervisor notified)

Member interview conducted

C.O. notified (if required) of

DAPA recommendations

MTF appointment scheduled

Member/supervisor notified of appointment and MTF requirements (uniform etc.)

Admin screening form/records delivered to MTF

Recommendations/diagnosis received from MTF

C.O. notified of diagnosis

Member notified on treatment program requirements

Final DAAR submitted (upon member's completion of formal treatment)

Continuing Care (Aftercare) Plan received (after member completes treatment)

Initial Aftercare meeting held; member notified of Aftercare requirements

Aftercare Exit interview completed

This checklist is only a guide. DAPAs must liaise with local MTF on

specific requirements for the area.

NAVPERS 5350/3 (Revised 06-09)

FOR OFFICIAL USE ONLY

PRIVACY SENSITIVE

RESET FORM

PAGE 1 OF 10

PRINT FORM

DAPA ADMIN SCREENING FORM

Servicemember Name

1.Drug and Alcohol Program Advisor Administrative Screening Form NAVPERS 5350/3 (4/00)

Information provided below will assist the DAPA, commanding officer, and medical treatment facility (MTF) staff in determining the servicemember's need for intervention/ treatment. A copy of this form must be forwarded to the MTF based on local MTF regulations. Attach additional sheets of paper, if needed.

Date administrative screening form completed:

Servicemember Name (Last, First, MI)

Rate/Rank:Sex:

Birth date:

 

Age:

 

 

 

Command/UIC:

F

M

Command Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Division/work center:

 

 

Phone number:

 

 

Supervisor name:

 

 

 

Phone number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.How was the DAPA made aware of the servicemember's possible problem?

Self-referral

date member self-referred

Command-referral

date command referral received

Incident referral

date incident occurred

What substance is involved? Alcohol Yes No

Illicit drug

Yes

No

If yes for illicit drug, what drug(s) is/are involved?

Was the member arrested for DUI/DWI?

How many DUI/DWIs has the member incurred during career?

Was a Blood Alcohol Content (BAC) test conducted?

Yes

No Results

DAPA Name

Phone Number

NAVPERS 5350/3 (Revised 06-09)

FOR OFFICIAL USE ONLY

PRIVACY SENSITIVE

RESET FORM

PAGE 2 OF 10

PRINT FORM

DAPA ADMIN SCREENING FORM

Servicemember Name

3. Was a urinalysis test conducted? Yes No If yes, date conducted

(DAPA must maintain copy of positive urinalysis results while forwarding copy of results to MTF). Describe, in detail, incident or facts of referral. (Attach additional paper if needed).

4.Is member currently under orders? What Command is member going to?

Yes No

5. Active duty service date

 

 

Delayed entry program

 

 

Time in service

 

EAOS

 

 

 

Date reported this command

 

 

 

 

PRD

 

 

Pre-service waiver?

Yes

No

If yes, provide details of waiver.

 

6.Single Married Separated Next of kin listed in service record Additional comments:

Divorced

7. Highest grade completed:

 

Dates of high school:

GED: Yes No

If yes, date awarded:

Evidence of college? Date completed

Yes

No

Completion of degree:

Yes

No

Date of most recent advancement/promotion:

DAPA Name

 

Phone Number

 

 

 

NAVPERS 5350/3 (Revised 06-09)

FOR OFFICIAL USE ONLY

PAGE 3 OF 10

 

PRIVACY SENSITIVE

 

RESET FORM

PRINT FORM

DAPA ADMIN SCREENING FORM

Servicemember Name

8. Date of reduction in paygrade:

From what paygrade:

 

 

 

Provide details of reduction in paygrade:

 

9. Previous duty station:

 

 

 

 

 

 

 

Location:

 

 

Reported:

 

 

 

Detached:

 

 

Evidence of previous drug or alcohol treatment?

Yes

No

If yes, provide details:

 

 

 

 

 

 

 

10.History of disciplinary action:

Evidence of NJP or Captains Mast? If yes, provide details.

Courts Memoranda: If yes, provide details.

Evidence of civil arrests: If yes, provide details.

Unauthorized absences: If yes, provide details.

Additional comments on disciplinary history:

DAPA Name

Phone Number

NAVPERS 5350/3 (Revised 06-09)

FOR OFFICIAL USE ONLY

PRIVACY SENSITIVE

RESET FORM

PAGE4 OF 10

PRINT FORM

DAPA ADMIN SCREENING FORM

Servicemember Name

11.Enlisted Evaluations (Officer Fitness Reports are not maintained in service record) Past Two (2) Evaluations:

Command:

 

Date:

 

 

 

 

 

 

Type:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Professional Knowledge:

 

 

 

 

 

Professional Expertise:

 

(E1-E6)

 

 

 

 

 

 

 

(01-06)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal Job Accomplishment

 

 

 

 

 

Mission Accomplishment/

 

/Initiative:

 

 

 

 

 

Initiative:

 

(E1-E6)

 

 

 

 

 

 

 

(01-06)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Military Bearing/Character:

 

 

 

 

 

Leadership:

 

(E1-E6)

 

 

 

 

 

(01-06)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Trait Average:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(E1-06)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alcohol or drug related entries?

Yes

No

 

If yes, provide details.

 

Command:

 

 

Date:

 

 

 

 

 

Type:

 

 

Professional Knowledge:

 

 

 

 

Professional Expertise:

 

(E1-E6)

 

 

 

 

 

 

(01-06)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal Job Accomplishment

 

 

 

 

Mission Accomplishment/

 

/Initiative:

 

 

 

 

Initiative:

 

(E1-E6)

 

 

 

 

(01-06)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Military Bearing/Character:

 

 

 

 

Leadership:

 

(E1-E6)

 

 

 

 

(01-06)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Trait Average: (E1-06)

Alcohol or drug related entries?

Yes No If yes, provide details.

DAPA Name

Phone Number

NAVPERS 5350/3 (Revised 06-09)

FOR OFFICIAL USE ONLY

PAGE 5 OF 10

PRIVACY SENSITIVE

RESET FORM

PRINT FORM

DAPA ADMIN SCREENING FORM

Servicemember Name

12.Enlisted Evaluations (Officer Fitness Reports are not maintained in service record) Past Two (2) Evaluations:

Command:

 

Date:

 

Type:

Institutional & Technical Expertise: (E7-E9)

Character:

(E7-E9)

Deck Plate Leadership: (E7-E9)

Individual Trait Average: (E1-06)

Alcohol or drug related entries?

Yes No If yes, provide details.

Command:

 

Date:

 

Type:

Institutional & Technical Expertise: (E7-E9)

Character:

(E7-E9)

Deck Plate Leadership: (E7-E9)

Individual Trait Average: (E1-06)

Alcohol or drug related entries?

Yes No If yes, provide details.

DAPA Name

Phone Number

NAVPERS 5350/3 (Revised 06-09)

FOR OFFICIAL USE ONLY

PAGE 6 OF 10

PRIVACY SENSITIVE

RESET FORM

PRINT FORM

DAPA ADMIN SCREENING FORM

Servicemember Name

13.Drug and Alcohol Education Evidence of attendance at:

NASAP

Yes

No

NADSAP

Yes

No

 

PREVENT

Yes

No

PREVENT 2000

Yes

No

ADAMS (Supervisor)

Yes No

ADAMS (Manager)

Yes

No

AWARE Yes NoOther training (GMT etc) Yes No

If yes to any course, provide details including date, location and if member attended due to alcohol related incident.

14. Security Clearance:

downgraded removed access denied

If any of these, describe circumstances:

special handling

15. Is DD-1966 located in service record? Yes No

List prior civilian employment including dates of employment:

Pre-service arrests/charges/court actions/convictions (provide dates and description of circumstances):

Additional information found on DD-1966:

DAPA Name

Phone Number

NAVPERS 5350/3 (Revised 06-09)

FOR OFFICIAL USE ONLY

PRIVACY SENSITIVE

RESET FORM

PAGE 7 OF 10

PRINT FORM

DAPA ADMIN SCREENING FORM Servicemember Name

16. Summary of review:

Commanding Officer comments (if so desired):

DAPA Name

Phone Number

NAVPERS 5350/3 (Revised 06-09)

FOR OFFICIAL USE ONLY

PRIVACY SENSITIVE

RESET FORM

PAGE 8 OF 10

PRINT FORM

DAPA ADMIN SCREENING FORM

Servicemember Name

Supervisor Input Form

To:

(Supervisor name/work center/division)

Subj: ADMINISTRATIVE SCREENING IRT

(Servicemember rate/rank, name, work center/division)

1.Subject servicemember is being administratively screened. Your input is extremely important in helping the commanding officer and medical treatment facility staff in making the appropriate recommendation and diagnosis of a possible alcohol or drug problem. Please be as honest and complete in the answers as possible.

2.How long have you supervised this member?

3.Please place a check next to the word in each category that best describes the servicemember in the past 12 months:

a. Military performance:

 

Superior

Adequate

Excellent

Substandard

b. Work performance:

 

Superior

Adequate

Excellent

Substandard

c. Uniform/military appearance:

Superior

Adequate

Excellent

Substandard

d. Relationships with peers and superiors:

Superior

Adequate

Excellent

Substandard

Improving

Declining

Improving

Declining

Improving

Declining

Improving Declining

Please provide additional comments about the above markings:

DAPA Name

Phone Number

NAVPERS 5350/3 (Revised 06-09)

FOR OFFICIAL USE ONLY

PRIVACY SENSITIVE

RESET FORM

PAGE 9 OF 10

PRINT FORM

DAPA ADMIN SCREENING FORM Servicemember Name

e. Has remedial counseling been conducted in the past

12 months?

Yes

 

f. Has servicemember received NJP or other disciplinary action

 

during the previous 12 months

Yes

g. Are you aware of any civil actions or referrals for family or financial

 

counseling that have occurred in the previous 12 months?

Yes

h.Are you aware of any previous/additional alcohol or drug problems? Yes

i.Does this member have a history of Monday or Friday absences,

sick call visits or tardiness to work?

Yes

 

j. Is this member the first to arrive or the last to leave?

Yes

k. Does this member take unusually long lunch breaks on a

Yes

routine basis?

 

If you marked yes for e, f, g, h, i or j please explain in detail.

 

4. If you had a choice would you want this servicemember to

 

continue working for you?

Yes

Provide details on why or why not.

 

5. Please complete and return this form no later than

(date required)

No

No

No

No

No

No

No

No

to

, located in

 

(DAPA's name)

 

(Room/bldg/comparetment number)

If using internal mail, please place in sealed envelope. If you have any questions,

I can be reached at

.

 

 

 

 

(Telephone)

 

 

 

 

 

 

 

 

 

(DAPA Signature)

 

 

(Date)

 

 

 

 

 

 

(Supervisor Signature)

 

 

(Date)

DAPA Name

Phone Number

NAVPERS 5350/3 (Revised 06-09)

FOR OFFICIAL USE ONLY

PRIVACY SENSITIVE

RESET FORM

PAGE 10 OF 10

PRINT FORM

Navpers Form 5350 3 isn’t the one you’re looking for?

Related Documents