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.

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DISABILITY EVALUATION SYSTEM (DES)
COMMANDER'S PERFORMANCE AND FUNCTIONAL STATEMENT
For use of this form see AR 635-40; The proponent agency is DCS, G-1.
PRIVACY ACT STATEMENT
AUTHORITY:
10 USC chapter 61 and 5 USC 301
To provide information to the Physical Evaluation Board (PEB) on the impact of a medical impairment on a Soldier's ability to perform
PURPOSE:
duties and to provide administrative information that impacts disability adjudication and/or benefits if the Soldier is determined unfit.
ROUTINE USES:
The DoD Blanket Routine Uses set forth at the beginning of the Army's compilation of system of records notices may apply to this
system. Information collected in this document is not routinely shared outside of the DOD.
DISCLOSURE:
Voluntary, however failure to provide the information will interfere with the proper adjudication of the Soldier's case in the best interest
of the Soldier and the Army.
SECTION I: SOLDIER DEMOGRAPHIC INFORMATION
1. DATE (YYYYMMDD)
2. SOLDIER'S NAME (Last, First, MI)
3. GRADE
4. PMOS
5. HOME PHONE
6. CELL PHONE
7. DOD E-MAIL
9. ORGANIZATION NAME, ADDRESS,
8. COMPONENT
10. UNIT IDENTIFICATION CODE (UIC)
11. ETS
PHONE NUMBER
SECTION II: ADMINISTRATIVE INFORMATION
Instructions: The information in this section should be confirmed by the appropriate personnel activity and with the Soldier.
DATA ITEM
YES NO
REMARK
1. Is Soldier charged or under investigation for an offense chargeable under the Uniform Code Military
Justice, which could result in dismissal or punitive discharge?
2. Is Soldier pending voluntary or involuntary administrative separation under AR 635-200 or AR 135-178
If YES, specify Chapter/paragraph.
(enlisted) or AR 600-8-24 or AR 135-175 (officer)?
If YES, list date retirement was
3. Does Soldier have an approved voluntary retirement?
approved.
4. ACTIVE COMPONENT OFFICERS: Is officer within 12 months of mandatory retirement for age or years
If YES, list mandatory retirement date.
of service or approved for Selective Early Retirement?
5. ACTIVE COMPONENT SOLDIERS ONLY: Does Soldier have prior service in the Selected or Individual
If YES,specify type of service.
Ready Reserve?
6. RESERVE COMPONENT OFFICERS ONLY: Is officer within 12 months of mandatory removal date?
If YES, list mandatory removal date.
7. RESERVE COMPONENT OFFICERS ONLY: If block 6 is `YES', will officer have 20 qualifying years of
If YES, list mandatory removal date.
service at time of his or her mandatory removal date for purposes of non regular retirement?
8. ACTIVE or RESERVE COMPONENT ENLISTED SOLDIERS ONLY: Is enlisted Soldier within 12
Indicate whether the Active Component
months of his/her Retention Control Point (RCP) and will qualify for a regular retirement at RCP or, if a
member's qualification for retirement is
under the Temporary Early Retirement
member of the Reserves will qualify for a 20-year letter at RCP?
Authority or having 20 years of active
federal service.
9. Was Soldier's retirement for length of service delayed by `Stop Loss'?
If YES, list applicable MILPER Stop
Loss message.
10. If an enlisted Soldier, is the Soldier due an automatic advancement? (See AR 600-8-19 concerning
If YES, list date Soldier due next
promotable status of enlisted Soldiers in the DES.)
automatic advancement.
11. If an enlisted Soldier, is the Soldier on a semi-centralized or centralized promotion list?
12. If an officer, is the Soldier on an approved promotion list?
13. Has Soldier previously held higher rank?
If Yes, list highest rank held. List reason
Soldier is not serving in highest rank
previously held.
14. Was Soldier on 24 September 1975, a member of the Armed Forces, to include the Reserve
components, the National Oceanic and Atmospheric Administration (NOAA and formerly the Coast and
Geodetic Survey), the U.S. Public Health Service, or under a binding written agreement to become such a
member? (NOTE: A Soldier who was a contracted cadet of a U.S. Service Academy or a contracted ROTC
cadet or a member of an Armed Forces of another country on that date is included in the meaning of
Armed Forces.)
15. Was Soldier's current referral to MEB/PEB the result of a MOS Administrative Retention Review
If YES, attach MAR2 results.
(MAR2)?
If YES, specify the reason and date of
16. Is the Soldier flagged IAW any provision of AR 600-8-2?
the flag.
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DA FORM 7652, JAN 2017
APD LF v1.00ES

Download DA Form 7652 Disability Evaluation System (DES) Commander's Performance and Functional Statement

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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:

  1. A wounded, injured, or ill soldier is treated by an attending physician at a medical treatment facility.
  2. 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).
  3. 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.
  4. 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.

  1. 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.
  2. Section II requires administrative information that should be confirmed by the appropriate personnel activity. It includes 16 questions and a column for additional remarks.
  3. 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.
  4. 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.

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