Attachment_V-DA_Form_5557.pdf

NAME OF INDIVIDUAL BEING SCREENED/EVALUATED GRADE

NAME AND GRADE OF OFFICIAL CONDUCTING

SCREENING

SIGNATURE DATE

NAME, GRADE AND ORGANIZATION OF CERTIFY-

ING OFFICIAL

SIGNATURE DATE

NAME AND GRADE OF PHYSICIAN SIGNATURE DATE

Reason or reasons for disqualification

PREVIOUS EDITIONS ARE OBSOLETE.

(Continue on reverse side or attach additional explanation, if necessary)

INDIVIDUAL RELIABILITY SCREENING AND EVALUATION RECORD

For use of this form, see AR 190-56; the proponent agency is PMG.

PART I - PERSONNEL RECORDS SCREENING

Personnel records (including personnel security/suitability records) have been reviewed in accordance with AR 190-56.

Information is is not attached which may preclude assignment. The individual possesses a security clearance of Confidential Secret Top Secret based upon a

Exception (NACI requested on (date) BI granted on (date).

NAC

PART II - MEDICAL RECORDS SCREENING

Medial records (including medical examination) have been reviewed in accordance with AR 190-56.

Information is is not attached which may preclude assignment.

PART III - CERTIFYING OFFICIAL'S EVALUATION

Individual has been evaluated in accordance with AR 190-56. Information reflecting possible unsuitability has been thoroughly reviewed. Individual was was not interviewed. I find the individual to be if unsuitable or temporarily suspended.

suitable unsuitable for assignment. Temporarily suspended (if applicable) (date). See Part V

PART IV - BRIEFING CERTIFICATE (If found suitable)

I have briefed this individual on the reliability standards and objectives contained in AR 190-56. Briefing is acknowledged by the individual.

DATE ORGANIZATION SIGNATURE OF INDIVIDUAL

SIGNATURE OF CERTIFYING

OFFICIAL

PART V - DISQUALIFICATION

Individual's status at time of disqualification

Being screened for employment according to AR 190-56. Employed in a position under AR 190-56.

PART VI - RECORDS IDENTIFICATION

NACI

DA FORM 5557, SEP 2009 APD PE v1.00ES

This form is filed in personnel and medical records to identify an individual whose current duty, position requires a high degree of reliability, trustworthiness, physical fitness, and emotional stability. Any information received for entry into personnel or medical records which reflects adversely on the individual must be reported to the certifying official or commander concerned.

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