Attachment 0009- DA FORM 7708.pdf

19. SECURITY CLEARANCE:

NOT FOUND

20. NAME

4. SSN

14. SIGNATURE13. NAME

24. NAME 26. DATE (YYYYMMDD)25. SIGNATURE

2. ORGANIZATION

21. SIGNATURE 22. DATE (YYYYMMDD)

15. DATE (YYYYMMDD)

PERSONNEL RELIABILITY SCREENING AND EVALUATION

For use of this form, see AR 190-13; the proponent agency is OPMG.

CONFIDENTIAL

TYPE (NACLC, ANACI, SSBI, etc.)

16. POTENTIALLY DISQUALIFYING INFORMATION WAS

12. POTENTIALLY DISQUALIFYING INFORMATION WAS

23. POTENTIALLY DISQUALIFYING INFORMATION WAS

27. POTENTIALLY DISQUALIFYING INFORMATION WAS

PART II - CHECK OF PERSONNEL RECORDS

PART I - IMMEDIATE SUPERVISOR/COMMANDER INTERVIEW

NOT FOUNDFOUND AND FORWARDED TO THE CERTIFYING OFFICIAL

PART III - CHECK OF SECURITY RECORDS

NOT FOUNDFOUND AND FORWARDED TO THE CERTIFYING OFFICIAL

DA FORM 7708, JUN 2019

APD AEM v1.00ES

PART VI - RESULTS OF RANDOM/DIRECTED DRUG TESTING

Authority:

Principal Purpose:

Routine Uses:

Note:

Disclosure:

10 USC 3013 Secretary of the Army; DOD 5200.08, Security of DODI Installations and Resources and the DOD Physical Security Review Board; AR 190-13, The Army Physical Security Program; and E.O. 9397 (SSN) as amended.

FAVORABLY ADJUDICATED

SECRET TOP SECRET NONE

DOSSIER REVIEW REQUIRED

17. PERSONNEL SECURITY INVESTIGATION (PSI): COMPLETED ON DATE (YYYYMMDD)

To evaluate the qualification and suitability of a person for assignment to sensitive duties or unaccompanied access to certain resources.

In addition to those disclosures generally permitted under 5 U.S.C. 552 a(B) of the Privacy Act, this information can be shared with local law enforcement agencies for criminal background checks.

This system of records may contain personally identifiable health information (PHI). The DoD Health Information Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability Act of 1996, applies to most such health information.

DoD 6025.18-R may place additional procedural requirements on the uses and disclosures of such information beyond those found in the Privacy Act of 1974, as amended, or mentioned in this system of records notice.

Voluntary, however failure to provide all or part of the requested information may result in a non-selection for the stated duties.

A0690-200 DAPE Department of the Army Civilian Personnel Systems (January 06 2004, 69 FR 790); and A0600-8-104 AHRC, Army Personnel System (APS) (July 30 2013, 78 FR 45914).

Citation:

3. POSITION TITLE

DO NOT OBJECT TO PERSONNEL SCREEN REQUIREMENTS.5. I DO

7. SIGNATURE

Unaccompanied access to control medical substances

Issuance of Physical Security Inspector Credentials

6. SCREEN FOR

Unaccompanied access to arms, ammunition and explosives

PART IV - CHECK OF MEDICAL RECORDS

FOUND AND FORWARDED TO THE CERTIFYING OFFICIAL

18. PSI REQUEST OR REINVESTIGATION (IF REQUIRED): SUBMITTED ON DATE (YYYYMMDD)

TYPE (NACLC, ANACI, SSBI, etc.)

32. NAME 34. DATE (YYYYMMDD)33. SIGNATURE

NOT FOUNDFOUND AND FORWARDED TO THE CERTIFYING OFFICIAL

31. TESTS RESULTS WERE:

CERTIFIED NEGATIVE FORWARDED TO THE CERTIFYING OFFICIAL

28. NAME 30. DATE (YYYYMMDD)29. SIGNATURE

FOUO

Employment/Retention as DA Civilian Police or Security Guard Other (specify)

11. DATE (YYYYMMDD)9. INTERVIEWER 10. SIGNATURE(Last, First, MI)

(Last, First, MI)

NOT REQUIRED

(Last, First, MI)

(Last, First, MI)

NOT A TESTING-DESIGNATED POSITION

(Last, First, MI)

PART V - CHECK OF LAW ENFORCEMENT RECORDS

(Last, First, MI)

PRIVACY ACT STATEMENT

1. NAME (Last, First, MI)

8. DATE (YYYYMMDD)

50. RATIONALE

56. SIGNATURE55. NAME OF REVIEWING OFFICIAL (Last, First, MI)

45. EFFECTIVE 46. EFFECTIVE

PART VIII - CONTINUING PERIODIC EVALUATION

REASON FOR DISQUALIFICATION

1. Alcohol abuse

2. Drug abuse

3. Negligence/delinquency in duty performance

4. Court-martial/civilian convictions

5. Physical/mental condition

6. Poor attitude/lack of motivation

7. Other (Explain in Block 50)

1. Being screened for

2. Assigned to/as:

Document changes in the individual's status and/or administrative data. Attach a continuation sheet if additional room is required to document an update.

Follow guidance in the pertinent regulation for documentation requirements for restriction, suspension, administrative termination, or disqualification.

(ATTACH BLANK SHEET FOR CONTINUATION OF PART VIII)

DA FORM 7708, JUN 2019

APD AEM v1.00ES

PART XI - DISQUALIFICATION

a. Unaccompanied access to AA&E

b. Unaccompanied access to controlled medical substances

c. DA Civilian Police or Security Guard

PART IX - SUSPENSION OR TEMPORARY DISQUALIFICATION PENCIL ENTRY)

DATE (YYYYMMDD)

43. CERTIFYING OFFICIAL'S

SIGNATURE/DATE

42. PERSON'S SIGNATURE/

DATE

47. STATUS AT TIME OF DISQUALIFICATION

44. REASON FOR UPDATE

PART X - ADMINISTRATIVE TERMINATION

48.

37. SIGNATURE

39. NAME OF CERTIFYING OFFICIAL

36. I HAVE BEEN BRIEFED ON MY DUTIES AND

35. AFTER A THOROUGH REVIEW OF INFORMATION PROVIDED, I FIND THE PERSON:

SUITABLE FOR THE POSITION/DUTY

PART VII - IMMEDIATE SUPERVISOR/COMMANDER EVALUATION/ BRIEFING

UNSUITABLE FOR THE POSITION/DUTY

41. DATE (YYYYMMDD)40. SIGNATURE

DATE (YYYYMMDD)

d. Other

49. PERSON IS DISQUALIFIED FROM THE SUBJECT POSITION/DUTIES

51. PERSON WAS NOTIFIED OF DISQUALIFICATION ON

DATE (YYYYMMDD)

by

METHOD OF NOTIFICATION

54. DATE (YYYYMMDD)53. SIGNATURE52. NAME OF CERTIFYING OFFICIAL (Last, First, MI)

FOUO

(Last, First, MI)

UNDERSTAND THE STANDARDS.

38. DATE (YYYYMMDD)

57. DATE (YYYYMMDD)

19. SECURITY CLEARANCE:

NOT FOUND

20. NAME

4. SSN

14. SIGNATURE

13. NAME

24. NAME

26. DATE (YYYYMMDD)

25. SIGNATURE

2. ORGANIZATION

21. SIGNATURE

22. DATE (YYYYMMDD)

15. DATE (YYYYMMDD)

PERSONNEL RELIABILITY SCREENING AND EVALUATION

For use of this form, see AR 190-13; the proponent agency is OPMG.

CONFIDENTIAL

TYPE (NACLC, ANACI, SSBI, etc.)

16. POTENTIALLY DISQUALIFYING INFORMATION WAS

12. POTENTIALLY DISQUALIFYING INFORMATION WAS

23. POTENTIALLY DISQUALIFYING INFORMATION WAS

27. POTENTIALLY DISQUALIFYING INFORMATION WAS

PART II - CHECK OF PERSONNEL RECORDS

PART I - IMMEDIATE SUPERVISOR/COMMANDER INTERVIEW

NOT FOUND

FOUND AND FORWARDED TO THE CERTIFYING OFFICIAL

PART III - CHECK OF SECURITY RECORDS

NOT FOUND

FOUND AND FORWARDED TO THE CERTIFYING OFFICIAL

DA FORM 7708, JUN 2019

APD AEM v1.00ES

PART VI - RESULTS OF RANDOM/DIRECTED DRUG TESTING

Authority:

Principal Purpose:

Routine Uses:

Note:

Disclosure:

10 USC 3013 Secretary of the Army; DOD 5200.08, Security of DODI Installations and Resources and the DOD Physical Security Review Board; AR 190-13, The Army Physical Security Program; and E.O. 9397 (SSN) as amended.

FAVORABLY ADJUDICATED

SECRET

TOP SECRET

NONE

DOSSIER REVIEW REQUIRED

17. PERSONNEL SECURITY INVESTIGATION (PSI): COMPLETED ON DATE (YYYYMMDD)

To evaluate the qualification and suitability of a person for assignment to sensitive duties or unaccompanied access to certain resources.

In addition to those disclosures generally permitted under 5 U.S.C. 552 a(B) of the Privacy Act, this information can be shared with local law enforcement agencies for criminal background checks.

This system of records may contain personally identifiable health information (PHI). The DoD Health Information Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability Act of 1996, applies to most such health information.

DoD 6025.18-R may place additional procedural requirements on the uses and disclosures of such information beyond those found in the Privacy Act of 1974, as amended, or mentioned in this system of records notice.

Voluntary, however failure to provide all or part of the requested information may result in a non-selection for the stated duties.

A0690-200 DAPE Department of the Army Civilian Personnel Systems (January 06 2004, 69 FR 790); and A0600-8-104 AHRC, Army Personnel System (APS) (July 30 2013, 78 FR 45914).

Citation:

3. POSITION TITLE

DO NOT OBJECT TO PERSONNEL SCREEN REQUIREMENTS.

5. I

DO

7. SIGNATURE

Unaccompanied access to control medical substances Issuance of Physical Security Inspector Credentials

6. SCREEN FOR

Unaccompanied access to arms, ammunition and explosives

PART IV - CHECK OF MEDICAL RECORDS

FOUND AND FORWARDED TO THE CERTIFYING OFFICIAL

18. PSI REQUEST OR REINVESTIGATION (IF REQUIRED): SUBMITTED ON DATE (YYYYMMDD)

TYPE (NACLC, ANACI, SSBI, etc.)

32. NAME

34. DATE (YYYYMMDD)

33. SIGNATURE

NOT FOUND

FOUND AND FORWARDED TO THE CERTIFYING OFFICIAL

31. TESTS RESULTS WERE:

CERTIFIED NEGATIVE

FORWARDED TO THE CERTIFYING OFFICIAL

28. NAME

30. DATE (YYYYMMDD)

29. SIGNATURE

FOUO

Employment/Retention as DA Civilian Police or Security Guard Other (specify)

11. DATE (YYYYMMDD)

9. INTERVIEWER

10. SIGNATURE

(Last, First, MI) (Last, First, MI)

NOT REQUIRED

(Last, First, MI) (Last, First, MI)

NOT A TESTING-DESIGNATED POSITION

(Last, First, MI)

PART V - CHECK OF LAW ENFORCEMENT RECORDS

(Last, First, MI)

PRIVACY ACT STATEMENT

1. NAME

(Last, First, MI)

8. DATE (YYYYMMDD)

50. RATIONALE

56. SIGNATURE

55. NAME OF REVIEWING OFFICIAL (Last, First, MI)

45. EFFECTIVE

46. EFFECTIVE

PART VIII - CONTINUING PERIODIC EVALUATION

REASON FOR DISQUALIFICATION

1. Alcohol abuse

2. Drug abuse

3. Negligence/delinquency in duty performance

4. Court-martial/civilian convictions

5. Physical/mental condition

6. Poor attitude/lack of motivation

7. Other (Explain in Block 50)

1. Being screened for

2. Assigned to/as:

Document changes in the individual's status and/or administrative data. Attach a continuation sheet if additional room is required to document an update.

Follow guidance in the pertinent regulation for documentation requirements for restriction, suspension, administrative termination, or disqualification.

(ATTACH BLANK SHEET FOR CONTINUATION OF PART VIII)

DA FORM 7708, JUN 2019

APD AEM v1.00ES

PART XI - DISQUALIFICATION

a. Unaccompanied access to AA&E

b. Unaccompanied access to controlled medical substances

c. DA Civilian Police or Security Guard

PART IX - SUSPENSION OR TEMPORARY DISQUALIFICATION PENCIL ENTRY)

DATE (YYYYMMDD)

43. CERTIFYING OFFICIAL'S

SIGNATURE/DATE

42. PERSON'S SIGNATURE/

DATE

47. STATUS AT TIME OF DISQUALIFICATION

44. REASON FOR UPDATE

PART X - ADMINISTRATIVE TERMINATION

48.

37. SIGNATURE

39. NAME OF CERTIFYING OFFICIAL

36. I HAVE BEEN BRIEFED ON MY DUTIES AND

35. AFTER A THOROUGH REVIEW OF INFORMATION PROVIDED, I FIND THE PERSON:

SUITABLE FOR THE POSITION/DUTY

PART VII - IMMEDIATE SUPERVISOR/COMMANDER EVALUATION/ BRIEFING

UNSUITABLE FOR THE POSITION/DUTY

41. DATE (YYYYMMDD)

40. SIGNATURE

DATE (YYYYMMDD)

d. Other

49. PERSON IS DISQUALIFIED FROM THE SUBJECT POSITION/DUTIES

51. PERSON WAS NOTIFIED OF DISQUALIFICATION ON

DATE (YYYYMMDD)

by

METHOD OF NOTIFICATION

54. DATE (YYYYMMDD)

53. SIGNATURE

52. NAME OF CERTIFYING OFFICIAL (Last, First, MI)

FOUO

(Last, First, MI)

UNDERSTAND THE STANDARDS.

38. DATE (YYYYMMDD)

57. DATE (YYYYMMDD)

1.00

DA FORM 7708, JUN 2019

PERSONNEL RELIABILITY SCREENING AND EVALUATION

APD