Blank Da 7652 Template

What is the purpose of the DA 7652 form?

The DA 7652 form is designed to provide essential information to the Physical Evaluation Board (PEB) regarding how a Soldier's medical impairment affects their ability to perform military duties. This information is crucial for determining disability adjudication and any potential benefits if the Soldier is found unfit for service.

Who needs to fill out the DA 7652 form?

The form must be completed by the Soldier, along with input from their commander or leadership team. It is important that the information reflects the Soldier's current medical condition and its impact on their performance and readiness.

What information is required in Section I of the DA 7652 form?

Section I collects demographic information about the Soldier. This includes the Soldier's name, grade, date of birth, component, and contact details. Additionally, it asks for specific dates related to retirement and any prior service, ensuring that all relevant information is available for the evaluation process.

What types of questions are asked in Section II of the DA 7652 form?

Section II contains a series of yes/no questions regarding the Soldier's administrative status. This includes inquiries about any charges under the Uniform Code of Military Justice, pending separations, and retirement status. These questions help assess the Soldier's eligibility for continued service and any necessary actions that may need to be taken.

How does the Commander’s Performance and Functional Statement impact the evaluation?

The Commander's Performance and Functional Statement is vital for illustrating how the Soldier's medical condition affects their daily duties and overall performance. This section requires detailed observations and assessments from the Soldier's leadership, which can significantly influence the outcome of the evaluation.

What happens if the information on the DA 7652 form is incomplete?

Providing incomplete information can hinder the proper adjudication of the Soldier's case. It is essential to complete the form as thoroughly as possible to ensure that the Soldier receives fair consideration regarding their medical condition and potential disability benefits.

1. Incomplete Information: Failing to fill out all required sections can lead to delays in processing. Each section must be completed thoroughly.

2. Incorrect Dates: Entering the wrong dates, such as the Soldier's date of birth or retirement date, can cause significant issues. Always double-check these entries.

3. Missing Signatures: Not obtaining the necessary signatures from commanders or other relevant personnel can invalidate the form. Ensure all required signatures are present.

4. Inaccurate Demographic Information: Providing incorrect demographic details, such as the Soldier's name or grade, can lead to confusion. Verify all personal information before submission.

5. Neglecting to Attach Required Documents: Failing to include necessary attachments, like the commander's memorandum or MAR2 results, can hinder the review process.

6. Misunderstanding Yes/No Questions: Misinterpreting questions can lead to incorrect answers. Review each question carefully to ensure accurate responses.

7. Omitting Relevant Medical Information: Not providing a complete picture of the Soldier's medical condition can affect the evaluation. Include all pertinent details about the Soldier's health.

8. Ignoring Privacy Regulations: Not adhering to privacy guidelines can result in unauthorized disclosures. Be cautious when handling sensitive information.

9. Failing to Review Before Submission: Submitting the form without a final review can lead to overlooked errors. Always conduct a thorough check before sending it off.

10. Using Outdated Versions: Filling out an old version of the form can cause complications. Always ensure you are using the most current version of DA Form 7652.

The DA Form 7652 is used primarily in the context of the Disability Evaluation System (DES). It collects information about a service member's medical condition and its impact on their military performance. Several other forms and documents are often required alongside the DA Form 7652 to ensure a comprehensive evaluation. Below are five commonly used documents.

• DA Form 3349: This form is used to document a Soldier's physical profile. It outlines any medical conditions that may affect their ability to perform military duties and helps determine fitness for service.
• DA Form 2823: Known as the Sworn Statement, this document allows service members to provide a written account of events or circumstances related to their medical condition or performance issues. It serves as a formal record for consideration during evaluations.
• DA Form 2173: This is the Statement of Medical Examination and Duty Status. It is used to report injuries and illnesses that occur in the line of duty, detailing the nature of the injury and its impact on the Soldier's service.
• DA Form 7500: This form is the Medical Evaluation Board (MEB) Proceedings. It summarizes the findings and recommendations of the MEB regarding a service member's medical fitness for duty.
• DD Form 214: This is the Certificate of Release or Discharge from Active Duty. It provides a summary of a service member's military service, including the nature of their discharge and any disability ratings received.

These forms play a crucial role in the evaluation process, ensuring that all necessary information is available to assess a service member's fitness for duty and eligibility for benefits. Proper completion and submission of these documents can significantly influence the outcome of a Soldier's case.

The DA Form 2-1, also known as the Personnel Qualification Record, is similar to the DA 7652 form in that it collects essential information about a soldier's service record. This document includes details such as assignments, training, and qualifications. Like the DA 7652, it serves as a critical resource for evaluating a soldier's capabilities and readiness for various roles within the military. Both forms aim to ensure that accurate and comprehensive data is available for administrative and evaluative purposes.

The DA Form 4856, or Developmental Counseling Form, is another document that shares similarities with the DA 7652. This form is used to document counseling sessions between soldiers and their leaders. It helps track a soldier's performance and development over time. While the DA 7652 focuses on medical and administrative information, both forms are essential for maintaining a soldier's record and ensuring they receive the support needed for their career progression.

The DA Form 3349, known as the Physical Profile, also parallels the DA 7652 in its focus on a soldier's medical conditions. This form outlines any physical limitations or medical issues that may affect a soldier's ability to perform their duties. Like the DA 7652, the DA Form 3349 is used to inform decision-making regarding a soldier's fitness for duty and potential accommodations needed for their service.

The DD Form 214, Certificate of Release or Discharge from Active Duty, is another important document that relates to the DA 7652. It provides a summary of a service member's military career, including their discharge status and reason for separation. While the DA 7652 is used during a soldier's service, the DD Form 214 is crucial for their transition to civilian life, ensuring that all relevant information about their service is accurately captured.

The DA Form 600-9, or Body Composition Program, is similar to the DA 7652 in that it addresses aspects of a soldier's physical readiness. This form is used to assess and document a soldier's body composition and compliance with Army standards. Both forms play a role in evaluating a soldier's overall fitness and readiness for duty, with the DA Form 600-9 focusing specifically on physical standards.

The DA Form 1059, or Academic Evaluation Report, is another document that complements the DA 7652 by providing insights into a soldier's educational achievements and performance. This form is used to evaluate soldiers who have completed training courses. Like the DA 7652, it helps assess a soldier's qualifications and readiness for future assignments based on their performance in educational settings.

The DA Form 67-9, or Officer Evaluation Report, is similar in purpose to the DA 7652, as both documents evaluate a soldier's performance. The DA Form 67-9 focuses specifically on officers, providing a comprehensive assessment of their leadership abilities and contributions to their units. Both forms are vital for ensuring that soldiers receive appropriate evaluations that inform their career progression.

The DA Form 7500, or Soldier's Record Brief, serves as a summary of a soldier's career and qualifications, much like the DA 7652. This document captures key information about a soldier's assignments, training, and awards. Both forms are used to provide a clear picture of a soldier's capabilities and history, which is essential for administrative decisions and evaluations.

The DA Form 2823, or Sworn Statement, is another document that shares similarities with the DA 7652. This form is used to collect statements from soldiers regarding incidents or issues that may impact their service. Like the DA 7652, it serves to gather critical information that can influence a soldier's administrative status or medical evaluation.

Lastly, the DA Form 1506, or Statement of Service, is related to the DA 7652 as it documents a soldier's service history. This form provides a concise overview of a soldier's time in service, including periods of active duty and reserve status. Both forms are important for maintaining accurate records and ensuring that all relevant information is available for administrative purposes.

When filling out the DA 7652 form, it's important to follow certain guidelines to ensure accuracy and compliance. Here are four key do's and don'ts:

• Do provide accurate and complete information in all sections. Ensure that all dates and names are correct.
• Do verify information with the Soldier and relevant personnel before submission. This helps avoid errors.
• Don't leave any sections blank unless specifically instructed. Missing information can delay the process.
• Don't submit the form without reviewing it thoroughly. Double-check for any inconsistencies or mistakes.

Here are seven common misconceptions about the DA 7652 form, along with explanations to clarify them:

• Misconception 1: The DA 7652 form is only for Soldiers with physical disabilities.

This form is used for both physical and mental conditions. It assesses how any medical impairment affects a Soldier's ability to perform their duties.

• Misconception 2: Filling out the DA 7652 is optional.

While some parts of the form may seem voluntary, providing accurate information is crucial. Not completing it can hinder the Soldier's case and benefits.

• Misconception 3: The form only needs to be filled out by the Soldier.

Input from commanders and leadership is essential. They provide valuable insights into the Soldier's performance and limitations.

• Misconception 4: The DA 7652 form is only relevant for retirement cases.

This form is used in various situations, including evaluations for medical separations and disability benefits, not just retirement.

• Misconception 5: Once submitted, the information on the DA 7652 cannot be changed.

Updates can be made if new information arises or if there are changes in the Soldier's condition. It's important to keep the form current.

• Misconception 6: The DA 7652 is a quick and easy form to complete.

While it may seem straightforward, gathering the necessary information and ensuring accuracy can take time. Thoroughness is key.

• Misconception 7: The DA 7652 form is not confidential.

The information provided is protected under privacy regulations. It is used solely for the purpose of evaluating the Soldier's medical condition and its impact on service.

Key Takeaways for Filling Out and Using the DA 7652 Form:

• The DA 7652 form is essential for documenting a Soldier's medical condition and its impact on their military duties.
• Accurate completion of the form is critical for the Physical Evaluation Board (PEB) to assess a Soldier's fitness for duty.
• All sections of the form must be filled out completely, including demographic and administrative information.
• Commanders should provide detailed performance information to reflect how medical conditions affect a Soldier's duties.
• It is important to indicate any prior service or pending administrative actions that may affect the Soldier's retirement eligibility.
• Disclosures on the form are voluntary, but failing to provide accurate information can hinder the adjudication process.
• Soldiers should ensure their commanders are aware of their medical conditions to facilitate accurate reporting.
• Specific comments and examples should be included to clarify the Soldier's limitations and performance issues.
• Review the form carefully before submission to ensure all required attachments, such as MAR2 results, are included.