B08.08 - Attachment 08 - DA Form 3180-1.pdf

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APD AEM v1.01ES

DA FORM 3180-1, APR 2018

10) As an applicant tentatively selected for this position, I understand I will not be appointed to the position if I decline to sign the condition of employment. If I sign this statement and cannot meet the conditions of employment as specified in the paragraphs above, I may not be appointed to the position or I may be proposing for removal in accordance with applicable Federal and/or agency regulations. If I sign this statement and later decline to participate in the initial screening process, my refusal may be used as a basis for withdrawal of conditional job offer and/or removal from Federal service in accordance with applicable Federal and/or agency regulations.

For use of this form, see AR 50-6; the proponent agency is DCS, G-3/5/7.

CHEMICAL AND BIOLOGICAL PERSONNEL RELIABILITY PROGRAM STATEMENT OF UNDERSTANDING

Internal Security Act of 1950 (Pub L. 81-831), 5 U.S.C., 301, 10 U.S.C., 3013, E.O. 9397 and records will be maintained under file #640-10b and 690-200a.

To evaluate the qualifications and suitability of an individual for assignment to certain sensitive duties under the chemical personnel reliability program (CPRP)(AR 50-6) or biological personnel reliability program (BPRP) (AR 190-17).

The "Blanket Routine Uses" set forth at the beginning of the Army compilation of systems of records notices also apply to this system.

Voluntary. However, failure to provide all or part of the requested information may result in non-selection for duties under the CPRP or BPRP.

PRIVACY ACT STATEMENT OF 1974

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE:

PART I - INITIAL INTERVIEW

A. NAME OF INDIVIDUAL (Last, First, MI)

B. JOB TITLE

B. DATE (YYYYMMDD)

A. SIGNATURE

PART II - AGREEMENT

I understand the contents of the policy above and I agree to adhere to the terms of the policy as a continuing condition of my employment.

C. Applicant will initial each condition of employment:

1) I understand that all applicants are required to sign a condition of employment statement as part of the application process.

2) In accordance with AR 50-6 or AR 190-17, as a prospective employee, I understand that the CPRP or BPRP requires the selection and retention of only those personnel who demonstrate emotional and mental stability, trustworthiness, physical competence, and adequate training to perform the assigned duties. I understand that if I do not meet or maintain program standards I will not be selected for or retained in the PRP.

3) I understand that I must undergo initial evaluation of my reliability before being assigned to a CPRP or BPRP position.

4) I understand that if I meet any of the following mandatorily denial or termination criteria, I will not be selected for or retained in a CPRP or BPRP position:

b. Illegal trafficking, cultivating, processing, manufacture, or sale of illegal or controlled drugs or substances within the last 15 years.

c. Abuse of drugs or substances in the 5 years before the initial PRP interview.*

d. Abuse of drugs or substances while enrolled or certified in any personnel reliability program.*

e. Being ineligible for a security clearance.

*Note: Isolated abused of another individual's prescribed drugs is not a mandatory denial criteria, however, it must be evaluated by a CMA.

a. Diagnosed with a moderate, or severe alcohol use disorder without sustained remission as defined in the current American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.

5) I understand that the following criteria require a competent medical authority (CMA) review and recommendation, and certifying official (CO) decision based on the "whole-person" concept, which may result in my denial or termination from the PRP:

a. Alcohol-related incidents during the previous 5 years.

b. Any diagnosis of alcohol abuse, dependence or use disorder (not otherwise addressed above).

c. Alcohol-related incidents when certified in the CPRP or BPRP.

d. Abuse of drugs more than 5 years before initial CPRP/BPRP screening or isolated abuse of another person's prescribed drugs within 15 years of initial CPRP/BPRP screening.

e. Exceeding the recommended safe dosage of over-the-counter substances or my own prescribed medications.

f. Suicide attempt or threat and jeopardizing human life or safety.

g. Medical, physical, or mental condition not compatible with CPRP or BPRP duties.

6) I understand that I will be evaluated by the CO on a whole-person concept for the following criteria. If the CO determines that I am not suited for the PRP, I will be denied or terminated from the CPRP/BPRP.

a. Negligence or delinquency in performance of duty.

b. Poor attitude or untrustworthiness with respect to my CPRP/BPRP responsibilities.

c. Personal conduct involving questionable judgment, untrustworthiness, unreliability, lack or candor, or dishonesty.

7) I understand that I must notify the certifying official if I was previously removed from a CPRP, BPRP, or nuclear PRP for cause (including denial, decertification, or disqualification) and I must request and be approved for recertification per AR 50-6 or AR 190-17 before I am considered for CPRP or BPRP certification.

8) I understand that the certifying official will judge my reliability based on an initial interview, a personnel security investigation, a personnel records review, a medical evaluation, a negative drug test, and my qualifications for the position. I understand that the certifying official will determine from the interview, including the suitability guidelines listed in AR 50-6 or AR 190-17 if I am acceptable for further screening. I understand that should the certifying official determine from the interview that I am unsuitable for the CPRP/BPRP, the certifying official will terminate the screening process and I will be disqualified from assignment to the CPRP/BPRP position.

9) As a prospective employee, I understand I must undergo continuing evaluation of my reliability if assigned to a CPRP or BPRP position. This includes self-reporting, peer and supervisor observation and reporting, evaluation of medical treatment by a competent medical authority, periodic reinvestigations, random drug testing, and certifying official observation and evaluation.

1.01ES

DA Form 3180-1, APR 2018 Chemical and Biological Personnel Reliability Program Statement of Understanding