B08.09 - Attachment 09 - DA Form 3180-2.pdf

CHEMICAL AND BIOLOGICAL PERSONNEL SCREENING AND EVALUATION RECORD

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

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 or biological personnel reliability program (PRP) per AR 50-6 or 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 personnel reliability program.

PRIVACY ACT STATEMENT OF 1974

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE:

PART I - INITIAL INTERVIEW

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DA FORM 3180-2, APR 2018

I have been briefed on the PRP screening requirements and I do not object to the PRP screening, or

I object to the PRP screening requirements

A.

B. NAME OF INDIVIDUAL (Last, First, MI) C. SIGNATURE D. DATE (YYYYMMDD)

USAMRIID

E. ORGANIZATION F. JOB TITLE

Biological Science Laboratory Technician

G. NAME OF INTERVIEWER H. INTERVIEWER SIGNATURE I. DATE (YYYYMMDD)

PART II - REVIEW OF PERSONNEL SECURITY INVESTIGATION (PSI) REPORT

Individual eligible for escorted access based on opened investigation

Escorted access not authorized or not applicable

A.

B. PSI COMPLETED ON (YYYYMMDD) C. TYPE OF PSI (NACLC, ANACI, SSBI, etc.):

D. Security Clearance: None Confidential Secret Top Secret

G. DATE (YYYYMMDD) F. SIGNATURE E. NAME OF OFFICIAL REVIEWING PSI REPORT

PART III - REVIEW OF PERSONNEL RECORDS

A. NAME OF OFFICIAL REVIEWING PERSONNEL RECORDS B. SIGNATURE C. DATE (YYYYMMDD)

Medical record information was forwarded to the certifying official for review, or

Medical record information did not require certifying official review

A.

PART IV - MEDICAL RECORDS SCREENING

B. NAME OF SCREENING OFFICIAL C. SIGNATURE D. DATE (YYYYMMDD)

PART V - DRUG TESTING

A. SPECIMEN COLLECTED ON (YYYYMMDD) Test results were forwarded to certifying official, or

Test results were certified negative by the medical review official.

B.

C. NAME OF OFFICIAL D. SIGNATURE E. DATE (YYYYMMDD)

A. I have conducted a thorough review of the information provided, and

PART VI - CERTIFYING OFFICIAL'S EVALUATION/ASSIGNMENT BRIEFING

____ I find this individual suitable for the PRP, or

____ I find this individual unsuitable for the PRP (Complete Part IX, A to I)

____ I find this individual suitable for interim certification or escorted access, or

B. NAME OF OFFICIAL C. SIGNATURE D. DATE (YYYYMMDD)

Individual's acknowledgment: I have received and understood the briefing on the standards and objectives of the personnel reliability program.

F. DATE (YYYYMMDD) E. SIGNATURE

Individual eligible for unescorted access america.ceralde Sticky Note HR Specialist will fill out Part V from the information on the drug test result.

america.ceralde Rectangle

Document changes in individual's status and/or administrative data per local procedures. Use continuation sheets as needed.

PART VII - CONTINUING EVALUATION

PART VIII - ADMINISTRATIVE TERMINATION

PART IX - DENIAL/TERMINATION

A. Status at time of denial/termination

____ 1. Being screened for the chemical PRP ____ 2. Being screened for the biological PRP ____ 3. Enrolled in the chemical PRP

B. Employment Status

____ 1. Military

____ 2. Civilian

____ 3. Contractor

D. Rationale

Individual was notified of denial/termination:

E. DATE OF NOTIFICATION (YYYYMMDD)

I. DATE (YYYYMMDD) H. SIGNATURE G. NAME OF CERTIFYING OFFICIAL

L. DATE (YYYYMMDD) K. SIGNATURE J. NAME OF REVIEWING OFFICIAL

A. CERTIFYING

OFFICIAL'S

INITIALS

C. REASON FOR UPDATE D. DATE (YYYYMMDD) B. INDIVIDUAL'S

INITIALS

DA FORM 3180-2, APR 2018

B. NAME OF OFFICIAL C. SIGNATURE D. DATE (YYYYMMDD)

CPRP: The individual is no longer required to perform PRP duties and has been administratively terminated from the chemical PRP.

BPRP: The individual is no longer required to perform PRP duties and has been administratively terminated from the biological PRP.

A.

C. Reason for denial/termination ____ 1. Alcohol-related ____ 2. Drug-related ____ 3. Suicide attempt or threat and jeopardizing human life or safety ____ 4. Medical, mental, physical conditions incompatible with PRP ____ 5. Negligence or delinquency in performance of duty

____ 6. Poor attitude or untrustworthiness with respect to PRP responsibilities ____ 7. Personal conduct involving questionable judgment, untrustworthiness, unreliability, lack of candor, or dishonesty ____ 8. Lack or revocation of security clearance eligibility

____ 4. Enrolled in the biological PRP

F. METHOD OF NOTIFICATION

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A. CERTIFYING

OFFICIAL'S

INITIALS

C. REASON FOR UPDATE D. DATE (YYYYMMDD)

PART VII - CONTINUING EVALUATION CONTINUATION SHEET

Document changes in individual's status and/or administrative data. Use continuation sheets as needed.

B. INDIVIDUAL'S

INITIALS

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