DA Form 7652 Disability Evaluation System (DES) Commander's Performance and Functional Statement
What Is a DA Form 7652?
DA Form 7652, Disability Evaluation System (DES) Commander's Performance and Functional Statement is a form used for recording information on the impact of a medical impairment on the ability of a Soldier to perform their duties in the U.S. Army.
The latest version of the form – sometimes incorrectly referred to as the DD Form 7652 – was released by the Department of the Army in January 2017. An up-to-date DA Form 7652 fillable version is available for download and digital filing below or can be found through the Army Publications Directorate website.
The document presents information necessary for the Physical Evaluation Board (PEB). If the soldier is determined unfit, this data affects disability adjudication and benefits. The disclosure of the information required to complete the DA 7652 is voluntary. However, failure to file may influence the adjudication of the soldier’s case.
Download DA Form 7652 Disability Evaluation System (DES) Commander's Performance and Functional Statement
DA Form 7652 Instructions
See the Army Regulation 635–40, Disability Evaluation for Retention, Retirement, or Separation, released in January 2017 for additional information and filing guidelines. The Disability Evaluation System (DES) evaluates a service members fitness to perform their duties. The evaluation procedures can be divided into four steps:
- A wounded, injured, or ill soldier is treated by an attending physician at a medical treatment facility.
- If the wound, injury, or illness has a long-lasting effect or results in a permanent condition, the attending physician refers the soldier to the DES. During this stage, the soldier is assigned a Physical Evaluation Board Liaison Officer (PEBLO).
- The Medical Evaluation Board - or MEB, for short - determines if the service member can return to their duties straightaway or if they will be able to perform them within a year. If the soldier does not meet medical retention standard, the case is transferred to the PEB.
- The PEB reviews the MEB report to determine if the soldier is fit for duty. If determined fit, the soldier may return to duty, but their role may be modified. Otherwise, the command will initiate a separation or retirement process.
The DA 7652 Form is requested by the Physical Evaluation Board Liaison Officer (PEBLO). The document is prepared by the soldier’s commander and contains important data for MEB and PEB. Medical terminology is not necessary, common descriptions are accepted. The soldier may take part in filling out the DA 7652 to make sure that it reflects their medical condition adequately.
The description of the soldier’s current duty performance must include the following:
- The branch of service and age of the soldier;
- Any special limitations that may result from their physical condition.
- The tasks expected of an individual of this office, grade, rank or rating.
- A description of the current duty assignment of the soldier, along with anticipated future assignments and career specialties.
How to Fill Out DA Form 7652?
The document consists of four sections.
- Section I contains the following boxes: the date of filling, the soldier’s name and grade, PMOS, home phone, cell phone, a DOD email, their component, the name, address and phone number of their organization, a unit identification code, and ETS.
- Section II requires administrative information that should be confirmed by the appropriate personnel activity. It includes 16 questions and a column for additional remarks.
- Section III is a performance assessment made by the commander. It has to be filled with a description of the effect of soldiers current condition on their ability to perform their duties. This part may also contain any additional comments necessary to clarify information provided in Section II. The bottom part of Section III requires the commander’s name, signature, date, DOD email, a phone number, component, and grade.
- Section IV is for a battalion or first LTC-level commander’s comments and review. The comments may be provided as the individual in charge sees fit. It can be detailed additional data or a simple validation of the first-line commander’s observations. Section IV should be certified with the name, signature, date, DOD email, phone number, component and grade of the battalion or first LTC-level commander.
The completed form is submitted to PEBLO within 5 days of the receiving the request.