DA Form 5017 Civilian Employee Consent Statement

DA Form 5017 or the "Civilian Employee Consent Statement" is a Department of the Army-issued form used by and within the United States Military.

The form - often incorrectly referred to as the DD form 5017 - was last revised on November 1, 2001. Download an up-to-date fillable DA Form 5017 down below in PDF-format or look it up on the Army Publishing Directorate website.

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CIVILIAN EMPLOYEE CONSENT STATEMENT
For use of this form, see DA PAM 600-85; the proponent agency is ODCSPER
NOTE: Prepare this form in the original only and file in the ASAP client case file folder. Reproduction and distribution
of this form are prohibited.
SECTION I - JUSTIFICATION
Purpose of this statement is to request and enlist the cooperation and assistance of your immediate supervisor in your behalf. His/her involvement in
your treatment plan will greatly assist us in providing U.S. Army Substance Abuse Program (ASAP) services. For this purpose, however, it is
necessary to obtain your consent, pursuant to S 1401.21 of the Public Law cited as follows: Section 408, Public Law 92-255, The Drug Abuse Office
and Treatment Act of 1972 (21 USC 1175), as amended in 1974 by Section 303, Public Law 93-282.
SECTION II - UNDERSTANDING
I understand that I must give my consent before any involvement or participation by my supervisor can take place
concerning my treatment plan. (By "supervisor," it is intended the person who initiates and/or rates all personnel
actions concerning myself.) I further understand that my supervisor will only receive information on progress and
attendance. No personal information of any kind will be disclosed without my specific consent each time information is
either required or given. I also understand that, with or without consent for release of information to my supervisor,
ASAP services will be equally available to me.
SECTION III - CIVILIAN EMPLOYEE CONSENT STATEMENT
I
authorize:
(Name of Employee)
(a) the ASAP in which I am enrolled; (b) the ASAP Employee Assistance Program Coordinator; (c) my supervisors;
and (d) agency officials (personnel officials, equal employment opportunity officials, and attorneys) properly in
receipt of information pursuant to this consent form to disclose facts concerning my enrollment, progress, and
attendance in the ASAP;
TO (a) my supervisors; and (b) other state and federal government officials (e.g., Department of the Army, Department
of Defense, Equal Employment Opportunity Commission, Merit Systems Protection Board) who have an official
need to know this information;
FOR (a) supervisor participation in my treatment plan; (b) administration of the Personal Reliability Program (PRP)
or a DOD Personnel Security Program (PSP) if I am enrolled in the PRP or a PSP by virtue of my employment
position with the Armed Forces; and, (c) administrative processing and consideration of personnel actions, worker's
compensation, or unemployment compensation cases and/or equal employment opportunity complaints in which my
enrollment, progress, or attendance in the ASAP is an issue.
SIGNATURE OF EMPLOYEE
DATE (YYYYMMDD)
NAME AND TITLE OF WITNESS (Type or print)
SIGNATURE OF WITNESS
DATE (YYYYMMDD)
SECTION IV - WITHDRAWAL OF CONSENT
(Sign below if and when you decide to withdraw your consent)
This consent is subject to revocation at any time except to the extent that the program has already taken action in reliance
on it. If not previously revoked, this consent will terminate upon the later event of (a) my successful completion of the
ASAP; (b) my disenrollment from the PRP or a DOD PSP, if I am enrolled in such a program by virtue of my employment
position with the Armed Forces; or (c) the conclusion, to include all appeals, of any personnel action, worker's
compensation cases, or equal employment opportunity complaint in which my enrollment, progress, or attendance in the
ASAP is an issue.
SIGNATURE OF EMPLOYEE
DATE (YYYYMMDD)
APD LC v2.01ES
DA FORM 5017-R, JAN 1999, IS OBSOLETE
DA FORM 5017, NOV 2001
CIVILIAN EMPLOYEE CONSENT STATEMENT
For use of this form, see DA PAM 600-85; the proponent agency is ODCSPER
NOTE: Prepare this form in the original only and file in the ASAP client case file folder. Reproduction and distribution
of this form are prohibited.
SECTION I - JUSTIFICATION
Purpose of this statement is to request and enlist the cooperation and assistance of your immediate supervisor in your behalf. His/her involvement in
your treatment plan will greatly assist us in providing U.S. Army Substance Abuse Program (ASAP) services. For this purpose, however, it is
necessary to obtain your consent, pursuant to S 1401.21 of the Public Law cited as follows: Section 408, Public Law 92-255, The Drug Abuse Office
and Treatment Act of 1972 (21 USC 1175), as amended in 1974 by Section 303, Public Law 93-282.
SECTION II - UNDERSTANDING
I understand that I must give my consent before any involvement or participation by my supervisor can take place
concerning my treatment plan. (By "supervisor," it is intended the person who initiates and/or rates all personnel
actions concerning myself.) I further understand that my supervisor will only receive information on progress and
attendance. No personal information of any kind will be disclosed without my specific consent each time information is
either required or given. I also understand that, with or without consent for release of information to my supervisor,
ASAP services will be equally available to me.
SECTION III - CIVILIAN EMPLOYEE CONSENT STATEMENT
I
authorize:
(Name of Employee)
(a) the ASAP in which I am enrolled; (b) the ASAP Employee Assistance Program Coordinator; (c) my supervisors;
and (d) agency officials (personnel officials, equal employment opportunity officials, and attorneys) properly in
receipt of information pursuant to this consent form to disclose facts concerning my enrollment, progress, and
attendance in the ASAP;
TO (a) my supervisors; and (b) other state and federal government officials (e.g., Department of the Army, Department
of Defense, Equal Employment Opportunity Commission, Merit Systems Protection Board) who have an official
need to know this information;
FOR (a) supervisor participation in my treatment plan; (b) administration of the Personal Reliability Program (PRP)
or a DOD Personnel Security Program (PSP) if I am enrolled in the PRP or a PSP by virtue of my employment
position with the Armed Forces; and, (c) administrative processing and consideration of personnel actions, worker's
compensation, or unemployment compensation cases and/or equal employment opportunity complaints in which my
enrollment, progress, or attendance in the ASAP is an issue.
SIGNATURE OF EMPLOYEE
DATE (YYYYMMDD)
NAME AND TITLE OF WITNESS (Type or print)
SIGNATURE OF WITNESS
DATE (YYYYMMDD)
SECTION IV - WITHDRAWAL OF CONSENT
(Sign below if and when you decide to withdraw your consent)
This consent is subject to revocation at any time except to the extent that the program has already taken action in reliance
on it. If not previously revoked, this consent will terminate upon the later event of (a) my successful completion of the
ASAP; (b) my disenrollment from the PRP or a DOD PSP, if I am enrolled in such a program by virtue of my employment
position with the Armed Forces; or (c) the conclusion, to include all appeals, of any personnel action, worker's
compensation cases, or equal employment opportunity complaint in which my enrollment, progress, or attendance in the
ASAP is an issue.
SIGNATURE OF EMPLOYEE
DATE (YYYYMMDD)
APD LC v2.01ES
DA FORM 5017-R, JAN 1999, IS OBSOLETE
DA FORM 5017, NOV 2001

Download DA Form 5017 Civilian Employee Consent Statement

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