Blank Da 7652 PDF Template

1. What is the DA Form 7652?
   The DA Form 7652 is a Disability Evaluation System (DES) Commander's Performance and Functional Statement. It's used to provide information about a Soldier's ability to perform duties due to medical impairments. This form gives the Physical Evaluation Board (PEB) data on how a Soldier's medical condition affects their job and the decision-making process regarding their fitness for duty, potential benefits, and disability adjudication.

2. Why is it important to accurately complete the DA Form 7652?
   Accurately completing the DA Form 7652 is crucial because it directly impacts the proper adjudication of a Soldier's case. It helps ensure that decisions made regarding the Soldier’s career and benefits are in the Soldier’s best interest, taking into account their ability to perform military duties in light of any medical conditions.

3. What happens if I do not provide the information requested on the DA Form 7652?
   The information provided on the DA Form 7652 is voluntary. However, failure to provide the requested information may interfere with the accurate adjudication of the Soldier's case and could adversely affect the outcome in terms of disability benefits and career considerations.

4. Who is responsible for filling out Section III of the DA Form 7652?
   Section III of the DA Form 7652, the Commander's Performance and Functional Statement, must be completed by the Soldier's commander or leadership team. This section requires an assessment of how the Soldier's medical condition(s) impact their ability to perform tasks, make decisions, and maintain work relationships, which is essential for the PEB's considerations.

5. Can the DA Form 7652 affect a Soldier’s eligibility for retirement or separation?
   Yes, the information provided in the DA Form 7652 can affect a Soldier's eligibility for retirement or separation for physical disability. The form’s contents are used to evaluate a Soldier’s fitness for continued service, which can determine whether they are retired, separated, or continue serving with limitations or accommodations.

6. How does the DA Form 7652 impact the decision of the Physical Evaluation Board (PEB)?
   The PEB uses the information provided in the DA Form 7652 to understand the extent of a Soldier's medical conditions and how they affect their performance of duties. This comprehensive assessment is critical for the PEB to make informed decisions regarding the Soldier's fitness for duty, potential retirement, separation, or continuation in the service with certain limitations.

7. Where can I find guidance on completing the DA Form 7652?
   Guidance on completing the DA Form 7652 can be found in AR 635-40, which details the procedures for Disability Evaluation for Retention, Retirement, or Separation. It's important to review this regulation to understand the requirements and implications of the information provided on the form.

1. Not confirming the accuracy of administrative information with appropriate personnel activity or directly with the Soldier can lead to incomplete or incorrect data being provided. This oversight might impact the Soldier's case adversely.

2. Overlooking the requirement to attach additional documentation, such as the commander's memorandum for Soldiers assigned to Warrior Transition Units or other medical hold type units, can result in processing delays. The form specifically instructs to attach this if applicable.

3. Failing to specify the type of service when indicating a Soldier's qualification for retirement under a specific chapter/paragraph can cause confusion in the evaluation process. This specificity is crucial for accurate interpretation of the Soldier's status.

4. Omitting the highest rank previously held and not listing the reason the Soldier is not serving at that rank anymore can obscure the Soldier’s complete service record, which might be significant in certain contexts of the evaluation.

5. Ignoring to list mandatory retirement or removal dates for officers and enlisted Soldiers, respectively, can misrepresent the individual’s eligibility for certain retirement or separation benefits.

6. Skipping the section that requires indication of the Soldier's promotable status or inclusion on a promotion list neglects an essential aspect of the Soldier’s current military standing and future career prospects.

7. Not providing detailed observation on how the Soldier's medical condition(s) affect their performance and functional abilities may result in an incomplete understanding by the Physical Evaluation Board (PEB), affecting the outcome of the disability evaluation. The form calls for comprehensive feedback, and missing details could significantly impact the decision-making process.

These mistakes emphasize the importance of thoroughness and attention to detail when completing the DA 7652 form. Each section of the form is designed to capture specific information that is critical for evaluating a Soldier's suitability for continued service or for retirement due to physical disability. Omissions or inaccuracies not only delay the process but can also potentially affect the Soldier's career and benefits.

When managing the complexities of military medical evaluations and potential separations due to disability, the DA Form 7652 serves as a critical piece, but it often works in conjunction with several other documents. Each of these forms plays a vital role in maintaining the integrity and fairness of the evaluation process, ensuring that all relevant aspects of a service member's condition and service are accurately considered.

• Medical Evaluation Board (MEB) Proceedings: This document summarizes the findings and recommendations of the Medical Evaluation Board. It includes detailed information on the service member's medical condition, the extent of their physical and mental impairments, and recommendations for their continuation in service, reclassification, or medical retirement.
• Physical Evaluation Board (PEB) Findings: After the MEB phase, the PEB reviews the case to make a final determination on the service member's fitness for duty and eligibility for disability benefits. This document outlines the PEB’s conclusions, including the level of disability, recommended retirement or separation, and benefits entitlement.
• Line of Duty (LOD) Investigation: If a service member's condition is a result of an injury or illness incurred in or aggravated by military service, an LOD investigation is initiated. This document is crucial for determining the circumstances under which the condition developed and whether it is service-connected, affecting entitlements and benefits.
• NCO Evaluation Reports (NCOERs) or Officer Evaluation Reports (OERs): These evaluations provide insight into the service member’s performance and capabilities over time. They are essential for assessing how the medical condition has impacted the service member's ability to perform their duties and can play a significant role in the disability evaluation process.

The interplay between these documents and the DA Form 7652 ensures a comprehensive assessment of a service member's situation—balancing medical findings with performance records and duty impacts. Together, they form the foundation of a process designed to respect and honor the service of those facing medical challenges, ensuring that decisions are made with a full understanding of their circumstances and contributions.

• The DA Form 4187, Personnel Action, is similar to the DA 7652 in that both forms are used for various administrative purposes within the Army. The DA 4187 is utilized for requests such as reassignments, extra rations, name changes, and other personnel actions that affect a soldier's career. Both forms require detailed soldier information and are processed by military personnel offices, impacting the soldier’s service record.

• The DD Form 2807-1, Report of Medical History, shares similarities with the DA 7652, especially in the context of documenting health-related information that might affect a soldier's duty status. While the DA 7652 focuses more on the soldier’s ability to perform duties and provides information for the Disability Evaluation System, the DD 2807-1 collects a comprehensive medical history that could identify conditions affecting the soldier's fitness for duty or deployment.

• The DD Form 2648, Pre-separation Counseling Checklist, is akin to the DA 7652 as both are pivotal at specific transition points in a service member's career. While the DA 7652 is part of the disability evaluation process, potentially leading to a medical retirement, the DD 2648 is used to ensure that service members are informed about benefits and services as they transition out of the military, including those medically separating.

• The DA Form 3349, Physical Profile, resembles the DA 7652 because both document medical conditions and their impact on a soldier's military duties. The DA 3349 provides a profile of the soldier’s medical fitness for duty by outlining specific physical limitations. Similarly, the DA 7652 involves assessing a soldier’s capabilities in relation to their medical conditions for the Disability Evaluation System, making both critical in determining the future of a soldier’s military career.

Filling out the DA 7652 form properly is crucial for ensuring the appropriate handling and consideration of a Soldier's case within the Disability Evaluation System (DES). Given the significance of this form in assessing the impact of medical impairments on a Soldier's ability to perform duties, as well as its role in disability adjudication and/or benefits determination, it's important to approach this task with care and accuracy. Here's a list of dos and don'ts aimed at guiding individuals through the completion of the DA 7652 form:

• Do review the entire form before starting to ensure you understand what information is required.
• Do gather all necessary documentation and information pertinent to the Soldier's medical condition, duty performance, and administrative information ahead of time.
• Do ensure that all information provided is accurate and truthful. Accuracy is critical for the fair evaluation of the Soldier's condition and capabilities.
• Do use clear, concise, and specific language when describing the impact of the Soldier's medical condition on duty performance and functional capabilities.
• Do consult with medical professionals, if necessary, to accurately convey the Soldier's medical situation and its impact on their duty performance.
• Don't leave any required sections incomplete. If a question does not apply, indicate with "N/A" (Not Applicable) instead of leaving it blank.
• Don't provide vague or generic descriptions. Specificity is key when explaining how a condition affects a Soldier's duties or when providing examples of limitations or capabilities.
• Don't forget to attach any required documentation, such as medical records or commander's memorandum, to the form before submission.
• Don't hesitate to seek clarification on any part of the form you find confusing. It is better to ask for help than to submit incorrect or incomplete information.

Approaching the DA 7652 form with diligence and attention to detail will contribute to a thorough and fair assessment of the Soldier's situation, thus facilitating an appropriate determination regarding their future within the Army. Providing complete and accurate information is not just about filling out a form—it's about ensuring our service members receive the consideration and support they deserve.

When dealing with the intricacies of military paperwork, confusion often arises, particularly with forms like DA Form 7652. Here, we unravel some common misconceptions surrounding this critical document, enhancing understanding and easing the procedural pathway for our soldiers and their leadership.

• Misconception 1: DA Form 7652 is only relevant for soldiers facing medical discharge.

  While it does play a critical role in the Disability Evaluation System (DES), DA Form 7652 also serves broader purposes, providing a comprehensive look at a soldier's ability to perform duties amid medical issues.

• Misconception 2: The form is straightforward and requires minimal input from command.

  Contrary to this belief, the form demands detailed commander insight on the soldier's performance, functional limitations, and the impact on unit readiness, making it far from a simple tick-box exercise.

• Misconception 3: Privacy concerns should prevent full disclosure on DA Form 7652.

  While privacy is always a concern, the form is designed with confidentiality in mind, aiming to protect the soldier's information while still providing necessary details for a fair evaluation.

• Misconception 4: Only medical professionals can provide input for the form.

  This misunderstanding overlooks the importance of commander and leadership contributions. Their unique insights into a soldier's everyday performance and functional abilities are invaluable.

• Misconception 5: The form is only applicable to soldiers in the Active Component.

  Reserve Component soldiers are also subject to the processes outlined in DA Form 7652, especially regarding retirement, retention, and separation considerations.

• Misconception 6: The Soldier's medical data is the only focus.

  While medical information is crucial, the form equally prioritizes the soldier's potential for future service, encompassing broader administrative and performance-related information.

• Misconception 7: Filling out the form guarantees a specific outcome.

  Submission of DA Form 7652 starts a process; it does not assure a predetermined result. Outcomes depend on comprehensive evaluations beyond just this document.

• Misconception 8: Only physical conditions are relevant for the form.

  Mental health conditions and their impact on a soldier’s ability to serve are equally critical, underscoring the form’s comprehensive approach to fitness-for-duty assessments.

• Misconception 9: The form's completion and submission are the end of a commander's involvement.

  In reality, leaders may need to provide additional information or clarification as the soldier moves through the DES process, requiring ongoing engagement.

Understanding DA Form 7652 in full light dispels misconceptions and prepares both leadership and soldiers for the proceedings ahead. It's not merely a form but a crucial step in evaluating and deciding a soldier's future in the face of medical challenges, emphasizing the need for accurate, thorough, and compassionate completion.

When filling out and using the DA 7652 form, it's vital to understand its purpose and how to properly complete it. Here are key takeaways to guide you:

• Ensure all personal and demographic information is accurate to prevent delays or issues in processing the form.
• The DA 7652 form is used within the Disability Evaluation System (DES) to assess a Soldier's ability to perform duties due to medical impairments.
• Commanders play a crucial role in providing detailed information on the Soldier's performance and functional limitations.
• Accurate completion of the form impacts disability adjudication and benefits, making honesty and thoroughness essential.
• Sections of the form require details about the Soldier's medical conditions and how they affect physical tasks, decision-making, and work relationships.
• The form evaluates both the presence of a medical condition and its impact on the Soldier's ability to serve in their primary MOS/AOC.
• It's mandatory to report any work missed and duty schedule modifications due to the Soldier's medical condition.
• The ability of the Soldier to deploy is a critical consideration, requiring the commander's evaluation and comments.
• Failure to provide required information or providing inaccurate information may hinder the adjudication of the Soldier's case and potentially affect their benefits.
• Completion and validation by the commander, including signature and contact information, are required for the form to be processed.

Understanding these key points ensures that the form is filled out accurately and completely, facilitating a smooth process within the Disability Evaluation System.