Complete Da Form 1380

Complete Da Form 1380
I J AHRC-DZB DEPARTMENT OF THE ARMY UNITED STATES ARMY PHYSICAL DISABILITY AGENCY 6900 GEORGIA AVENUE, NW BUILDING 7 WRAMC 1 4 2010 MEMORANDUM FOR Presidents, U.S.Army Physical Evaluation Boards (PEBs) SUBJECT: Instructions for Completing DA Form 7652, Physical Disability Evaluation Commander's Performance and Functional Statement 1.Purpose.To provide guidance to the PEBs on continued use of HQDA Ltr 635-08-1 to complete the DA Form 7652.The HQDA Ltr 635-08-1 expired on 8 Decymber 2010.

This letter authorized the DA Form 7652 and provided instmctions for completing Section U.S.Army Publishing Website forms link, though the HQDA Ltr 635-08-1 does not.b.The PEBs "first line medical supervisor," that means, "first line, clinical medical supervisor." c.USAPDA will request to distribute this memorandum to the PEBLOs Point of contact for this action is Ms.Frances Dennis, Policy Officer, (202) 782-3064.FOR THE COMMANDER: Encl as Daniel Cassidy COL,IN Deputy Commander ..,/ ", DAPE-MPE DEPARTMENT OF THE ARMY WASHINGON, D.C.20310 Expires 8 December 2010 HQOA Ltr 635-08-1 8 December 20D8 SUBJECT: DA Form 7652, Physical Disability Evaluation System (PDES) Commander's Performance and Functional Statement SEE DISTRIBUTION 1.

Purpose.This letter prescribes use of electronic DA Form 7652, Physical Disability Evaluation System (PDES) Commander's Performa!,,\oe and Functional Statement, to obtain command and personnel information of Soldiers referred Into the PDES under the dutyrelated process.This form will be incorporated into the next complete revision of AB 635-40.of the controlling law and regulations.The proponent may delegate this approval authority, In writing, to a division chief within the proponent agency or Its direct reporting unit or field operating agency, in the grade of colonel or the civilian equivalent.

Activities may request a waiver to this letier by providing justification that includes a full.analysts of 1he expected benefits and must include formal review by the activity's senior legal officer.All waiver requests will be endorsed by the commander or senior leader of the requesting activity and forwarded through their higher headquarters to the policy proponent.Refer to AR 25-30 for specifio guidance.


References.Required and related publications and prescribed and referenced forms are listed in appendix A.4.

Explanation of abbreviations and terms.Abbreviations and speoial terms used In this HQDA Letter are listed in the glossary.

5.Applicability.This policy applies to Soldiers of the Active Army, the Army National Guard/Army National Guard of the United States, and the U.S.Army Reserve who are referred into the Physical Disability Evaluation System under the process.This ----I policy is effective for two years from date of publication unless superseded by the publication of a complete revIsion (not a rapid action revision) of AR 635-40.() P,inl.ed on * Recyded Paper I, ! '"1 !, .

i '-, / } .,/,.) 6.Background.To properly adjudicate cases.

the Physical Evaluation Board (PEB) requires both performance and personnel information.This Information is also needed to make certain administrative determinations that Impact disability compensation and other benefits accorded to Soldiers who are separated or retired due to physical disability.Previously.this information was provided to the PEB by separate memorandum and eertificate from the Soldier's unit commander and servicing personnel activity.Subsequent law and policy changes necessitated additional personnel information.To consolidate this Information and reduoe the number of separate documents, Fragmentary Order (FRAGO) 29 to Operation Order -7-55 (MEDCOM Implementation of the Army Medical Action Plan (AMAP) USAMEDCOM) directed reformatting and presentation of this information as a HQDA form.7.Policy.

a.The DA Form 7652 is required for all cases of Soldiers referred to the PEB under the duty-related process.

Except as provided in subparagraphs band c below.the Soldier's current unit oommander Is responsible for completion of the form.The unit commander should coordinate with the servicing personnel aotivity and the Soldier to oomplete Section \I of the form.b.

When the case involves a Medical Corps (Me) officer with a clinical specialty area of concentration (AOC) and assigned to a clinical position, the officer's first line medical supervisor will complete $ection III and Seotion IV.In Section IV, the first line medical supervisor will describe any additional duty limitations not otherwise addressed in Section III.

The PES must have a clear and specific description of how the MC officer's medical condition affects performanoe as a Soldier and more speoiflcally as a physioian.The Physical Evaluation Board Liaison Officer (PE8l0) will coordinate with the servicing personnel activity and the officer to complete Section \J of the form, C.When the case Involves a Judge Advocate General Corps officer, Section III and Section IV will be completed by the officer's Staff Judge Advocate (SJA), Command Judge Advocate (CJA) , or legal agency/section supervisor.The PEBLO will coordinate with the servicing activity and the officer to complete Section \I of the form.

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; t J' \'l ' DAPE-MPE SUBJECT: DA Form 7652, Physical Disability Evaluation System (POES) Commander's Performance and Functional Statement Appendix A References Section I Required Publications AR 635-40 Physical Evaluation for Retention, Retirement, or Separation (Cited in paras 1 and 5.) Section II Related Publications This section contains no entries.

Section III Prescribed Forms DA Form 7652 Physical Disability Evaluation System (PDES) Commander's Performance and Functional Statement (Available at Section IV Referenced Forms This section contains no entries.3 ---------------------I" t ".j' III Glossary Section I Abbreviations AMAP Army Medical Action Plan AOC area of concentra1ion ARNG Army National Guard ARNGUS Army National Guard of the United States CJA Command Judge Advocate Me Medical Corps MEB Medical Evaluation Board POES / \ Physical Disability Evaluation System ) PES Physical Evaluation Board PEBLO Physical Evaluation Board Liaison Officer .SJA Staff Judge Advocate USAR U.S.Army Reserve \ .--) ..-------_._----..---.._-----_ ..-----4 \ I DAPE-MPE SUBJECT: DA Form 7652, Physical Disability EValuation System Commander's Performance and Functional Statement -Section II Terms Duty related process The process of referral for physical disability evaluation that consists of a Medical Evaluation Board (MEB) to document the Soldier's medical status and a Physical Evaluation Board (PES) 10 determine the Soldier's fitness.

If determined unfit, the PES further determines the Soldier's eligibility for disability benefits and type of disability disposition according t.o the provisions of Title 10, United States Code, Chapter 61.Section III Special Abbreviations and Terms This section oontains no entries.By Order of the Seoretary of the Army: GEORGE W.


General, United States Army Chief of Staff Official: Administrative Assistant to the Searetsry of the Army 5 -------------------------------' ..: -This publication is available in eleotronic media only and is intended for the following addresses: HQDA (AASA) HQDA (DAIM-ZXA) HQDA (SAAL-IMO) HQDA (SAFM-SACO) HQDA (SAlE) HQDA (SAMR-ZA) HQDA (SASA-RF) HQDA (DACH-IMB) HQDA (SAIS-GKP) HODA (NGB) HQDA (DAPN-ZA) HQDA (SAPA-ZDA) HQDA (SAPA-ZDA) HQDA (DAPE-ZXM) HODA (DAMI) HODA (DAMO-ZXA-M) HQDA (DALO-ZXA-A) HQDA (SAGC-ZA) HQDA (DAPM-OPS) HQDA (SAAG) HQDA (SASA-RF) HQDA (SAIGOP) HQDA (OT JAG) HQDA (DASG-AO) HQDA (DAPR-ZXS) HQDA (DAPE-ZXM) COMMANDERS U.S.Army Materiel Command U.S.Army Forces Command U.S.

Army Training and Doctrine Command U.S.Army Central U.S.Army, Europe and Seventh Army U.S.Army North U.S.

Army South U.S.Army Pacific U.S.Army Special Operations Command Military Surface Deployment and Distribution Command U.S.Army Space Defense Command/Army Strategic Command Eighth Army U.S.

Army Test and Evaluation Command U.S.Army Criminal Investigation Command U.S.Army Installation Management Command U.S.Army Intelligence and Seourity Command U.S.

Army Military District of Washington U.S.

Army Medical Command U.S.Army Network Enterprise Technology Command/9th Signal Command (Army) U.S.Army Acquisition Support Center U.S.Army Corps of Engineers 6 ------------------------------------.------------------------------.1 i ) 1_.-_-DAPE-MPE SUBJECT: DA Form 7652, Physical Disability Evaluation System (PDES) Commander's Performance and Functional Statement U.S.Army Reserve Command U.S.Army Space and Missile Defense Command Superintendent, U.S.Military Academy, West Point U.S.

Army Records Management and Declassifioatlon Agency 7 , ' C PHYSICAL DISABILITY EVALUATION SYSTEM (PDES) COMMANDER'S PERFORMANCE AND FUNCTIONAL STATEMENT For use of this from see HQDA Letter 635-08-1 ; The proponent agency is DCS, G-1.) PRIVACY ACT STATEMENT .-__ ....IrHORITY: 10 USC chapter 61 and 5 USC 301 PUBPOSE: To provide information to the PEB on the impact of a medical impairment on a Soldier's ability to perform duties and to provide administrative information that impacts disability adjudication and/or benefits if the Soldier is determined unfit.ROUTINE USES: See Purpose DISCLOSURE: Information is required in order to properly adjudicate the Soldier's case in the best interests of the Soldier and the Army.

complete da form 1380
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.BIRTHDATE 6b, AGE 7, UNIT OF ASSIGNMENT (yYYYMMOD) SECTION II: ADMINISTRATIVE INFORMATION Instructions: The information in this section should be confirmed by the appropriate personnel activity and with the Soldier.DATA ITEM Yes No 1.Is Soldier charged or investigation for an offense chargeable under the UCMJ, which could result in D D dismissal or discharge? 2.Is Soldier pending voluntary or involuntary administrative separation under AR 635-200 (enlisted) or If answer is YES, specify AR 600-8-24 (officer)? D D the chapter and paragraph.Chapter , Para 3, D,:es Soldier have an approved voluntary retirement? D D If answer is YES, list date Date retirement approved: retirement was approved.4.Is officer within 12 months of mandatory retirement for age or years of service or approved for Selective If answer is YES, list .• ' -"'5etirement? D D i ....mandatory retirement date.f officer's mandatory retirement: .

S-:-'REGULAR COMPONENT SOLDIERS ONLY: Does Soldier have prior service in the Selected or Individual If answer is YES, specify Ready Reserve? D D type of service, Ex: Served as a member of the ARNG or a USAR Troop Program Unit.6.RESERVE COMPONENT SOLDIERS ONLY: Is Soldier within 12 months of his or her mandatory If answer is YES, list removal date? D D mandatory removal date.

Mandatory Removal Date: 7.

RESERVE COMPONENT SOLDIERS ONLY.If the answer to question to 6 is yes, will Soldier have 20 qualifying years of service at time of his or her D D mandatory removal date for purposes of eligibility for non regular retirement? 8.ACTIVE COMPONENT ONLY.Is Soldier within 12 months of his or her Retention Control Point (RCP) If answer is YES, list RCP and will Soldier be eligible for length of service retirement at the RCP? D D date, RCP date: ..

9.Was Soldier's retirement for length of service delayed by Stop Loss? If answer is YES, list the MILPER MESSAGE D D applicable MILPER Stop Loss message.

10.If an enlisted Soldier, is the Soldier due an automatic advancement? (See AR 600-8-19 concerning If answer is YES, list date promotable status of enlisted Soldiers in the PDES,) D D Soldier due next automatic Date due automatic promotion: advancement.

11.If an enlisted Soldier, is the Soldier on a semi,centralized or centralized promotion list? D D 12, If an officer, is the Soldier on an approved promotion list? D D 13.Has Soldier previously held higher rank? If answer is YES, list rank rank held: D D and explain the reason I Soldier is not serving in (\ _.J } highest rank previously L DA FORM 7652, DEC 2008 .

held, Page 1 of 5 APD PE v2.00ES , ' -"--, " DATA ITEM (Con.nued) Yes No 14-.Was Soldier on 24 September 0 0 _ cc-mponents, the National Oceanic and Atmospheric Administration (NOAA and formerly the Coast and rdetic Survey), the U.S.Public Health Service, or under a binding written agreement to become such a mber? (NOTE: A Soldier who was a contracted cadet of a U.S.Service Academy or a contracted __ /,OTC cadet or a member of an Armed Force of another country on that date is included in the meaning of Armed Forces.) 15.Was Soldier's current referral to MEB/PEB the result of evaluation by an MaS/Medical 0 0 If answer is YES, attach (MMRB)? MMRB results.

SECTION III.PERFORMANCE INFORMATION You your comments PEB must understand the impact of your Soldier's conditions on his/her ability to perform duties in the primary MOS.Severe, acute physical conditions generally need little performance discussion bE,cause the PEB members easily understand the limitations.mlOuld the PEB determine the Soldier is not fit for either a mental disorder or residuals of a Traumatic Brain Injury (TBI), the PEB must gauge the Soldier's ca.pacity to perform in the civilian sector.

For these conditions, the PEB looks at the Soldier's current functioning in the military, without regard to whether the Soldier is performing in his/her PMOS.In all cases of Medical Corps officers with a clinical specialty area of concentration and assigned to a clinical position, the officer's first line medical supervisor will complete Sections III and complete and sign in IV.In all cases of officers of the Judge Advocate General Corps (JAG), Sections III and IV will be completed by the officer's Staff Judge Advocate, Command Judge Advocate, or agency/section supervisor.SECTION 111 A.

For each Soldier, regardless of condltlon(s).For each item, mark Yes, No, or N/Obs (not observed).

In Section III D: fully explain every 'No.' # ITEM Yes No N/Obs 1.Soldier performs duties in MOS (to include assigned MOS 0 0 0 --, '\ Soldier in appropriate TO&E or TDA position for grade and MOS.n 0 [] -j Soldier's medical conditions/limitations affect unit accomplishing mission.

If Yes, fully 0 0 0 I recommend retaining this Soldier.0 0 0 SECTION III B.For each Soldier with a mental disorder (Including Post Traumatic Stress Disorder (PTSD), major depressive disorder, anxiety disorder, bipolar disorder, etc.).Consider Soldier's performance over the past several months.Indicate whether performance seems to be improving, worsening, or static.For example, where Soldier demonstrated periods of not completing tasks to time and quality standards, but is now completing tasks to standards indicate Soldier had iSBues but is now performing normally.

[ DA FORM 7652, DEC 2008 Page 2 of 5 APD PE v2.00ES t ' SECTION III S (Continued) Use Section III D if additional space required and to provide additional discussion.Describe/list discrete, specific duties/tasks Soldier can complete to standard (time and quality).A B 0 No difficulties.C 0 Not observed.2 Describe types of duties Soldier does not complete to standard (time and quality).A B 0 No difficulties.

C 0 Not observed.3 Indicate whether performance issues are due to (choose all that apply): A 0 Soldier needs mom time for each task; B 0 Soldier performs duties/tasks with errors or incompletely.C 0 Soldier does not complete the duties/tasks.

D 0 Soldier duty day.F " 0 Not observed.-) Considering 1-3 above, and Soldier's work performance during the time you have observed Soldier, choose most accurate description of Soldier's performance: A 0 Periods of diminished attention or performance only when significantly stressed.If known, indicate type of stress eliciting performance issues.

Indicate frequency (for example: once two months ago for two days before court appearance).Describe performance during this time.

B 0 Occasional decrease in work efficiency (performs more slowly and/or with more errors).

C 0 Intermittent periods where Soldier unable to perform occupational tasks.D 0 Occasional difficulties with reduced reliability and productivity.E 0 Not observed.5 Effective work relationships with supervisors and/or co-workers.A 0 Has effective work relationships with both supervisors and co-workers.

B 0 Difficulty establishing and/or maintaining effective work relationships with supervisors and/or co-workers.Discuss.C 0 Does not establish and/or does not maintain effective relationships with supervisors and/or co-workers.


D 0 N'ot observed.SECTION III C.If Soldier has a diagnOSis of Traumatic Brain Injury (TSI), assess Soldier's performance.Use Section III D to provide additional discussion.1.Task/duty completion (functional capacity).Completing tasks/duties to standard.A D Performs tasks/duties to standards.

B III Mild difficulties completing tasks/duties to standards.Discuss.C o Moderate difficulties completing tasks/duties to standards.

Discuss.D o Severe difficulties completing tasks/duties to standards.Discuss.\ ) E o Not observed.-"" " D/J.J'=-ORM 7652, DEC 2008 Page 3 of 5 APD PE v2.00ES \ \ V' Maki09.

I Sased on your observations of Soldier's performance, can you gauge the quality of Soldier's decisions? If so, indicate whether Soldier: / A 0 Makes reasonable decisions, including complex or unfamiliar ones.Discuss and include examples of Soldier's reasonable decisions.S 0 Makes reasonable decisions; occasionally makes (or avoids making) unreasonable complex or unfamiliar decisions.Discuss and include examples.

C 0 Makes simple decisions but usually not complex or unfamiliar decisions.

Discuss and include examples.D 0 Not observed.3.

Social Interactions.Social interaction.

Describe whether Soldier displays inappropriate social interactions.Discuss.A 0 Describe behaviors and indicate frequency (occasionally, frequently, most of the time; or you can indicate in %s.) Discuss.S 0 Not observed.4.

Performance issues due to Soldier's complaints of TSI residuals.

Where you have observed negative performance issues and Soldier attributes these performance issues to physical symptoms (e.g., headache; dizziness; insomnia, hypersensitive to sound or light) indicate the impact on Soldier's performance.A 0 Mild interference, e.g., able to complete with more time or completes work with more than the normal frequency of errors.S 0 Moderate interference, e.g., the result is the equivalent to missing work several hours a day.An example of the impact on performance and the frequency of this impact is: "headaches requiring rest period during most days." C 0 Not observed.

'5.Workplace Interactions.

Does Soldier appear: irritable; impulsive; unpredictable; unmotivated; verbally aggressive; physically aggressive; belligerent; apathetic; moody; uncooperative; inflexible; unfeeling; or unaware of condition? If so, indicate how these characteristics appear to impact Soldier's workplace interactions: A 0 Do not interfere with workplace interaction.Discuss.S 0 Occasionally interfere with workplace interaction.Discuss.C 0 Frequently interfere with workplace interaction.Discuss.

D 0 Interfere or preclude workplace interaction on most days.Discuss.E 0 Occasionally requires supervision (for safety of self or others.) Discuss.

F 0 Not observed.<
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