DA Form 3180-2 Chemical and Biological Personnel Screening and Evaluation Record

DA Form 3180-2 or the "Chemical And Biological Personnel Screening And Evaluation Record" 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 3180-2 - was last revised on April 1, 2018. Download an up-to-date fillable DA Form 3180-2 down below in PDF-format or look it up on the Army Publishing Directorate website.

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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.
PRIVACY ACT STATEMENT OF 1974
AUTHORITY:
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.
PRINCIPAL PURPOSE:
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.
ROUTINE USES:
The "Blanket Routine Uses" set forth at the beginning of the Army compilation of systems of records notices also apply to
this system.
DISCLOSURE:
Voluntary. However, failure to provide all or part of the requested information may result in non-selection for duties under
the personnel reliability program.
PART I - INITIAL INTERVIEW
A.
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
B. NAME OF INDIVIDUAL (Last, First, MI)
C. SIGNATURE
D. DATE
E. ORGANIZATION
F. JOB TITLE
G. NAME OF INTERVIEWER
H. INTERVIEWER SIGNATURE
I. DATE
PART II - REVIEW OF PERSONNEL SECURITY INVESTIGATION (PSI) REPORT
A.
Individual eligible for escorted access based on opened investigation
Individual eligible for unescorted access
Escorted access not authorized or not applicable
B. PSI COMPLETED ON (YYYYMMDD)
C. TYPE OF PSI (NACLC, ANACI, SSBI, etc.):
None
Confidential
Secret
Top Secret
D. Security Clearance:
E. NAME OF OFFICIAL REVIEWING PSI REPORT
F. SIGNATURE
G. DATE
PART III - REVIEW OF PERSONNEL RECORDS
B. SIGNATURE
C. DATE
PART IV - MEDICAL RECORDS SCREENING
A.
Medical record information was forwarded to the certifying official for review, or
Medical record information did not require certifying official review
B. NAME OF SCREENING OFFICIAL
C. SIGNATURE
D. DATE
PART V - DRUG TESTING
A. SPECIMEN COLLECTED ON (YYYYMMDD)
B.
Test results were forwarded to certifying official, or
Test results were certified negative by the medical review official.
C. NAME OF OFFICIAL
D. SIGNATURE
E. DATE
PART VI - CERTIFYING OFFICIAL'S EVALUATION/ASSIGNMENT BRIEFING
A. I have conducted a thorough review of the information provided, and
____ I find this individual suitable for the PRP, or
____ I find this individual suitable for interim certification or escorted access, or
____ I find this individual unsuitable for the PRP (Complete Part IX, A to I)
B. NAME OF OFFICIAL
C. SIGNATURE
D. DATE
Individual's acknowledgment: I have received and
E. SIGNATURE
F. DATE
understood the briefing on the standards and objectives
of the personnel reliability program.
PREVIOUS EDITIONS OF THE DA FORM 3180 ARE OBSOLETE.
DA FORM 3180-2, APR 2018
Page 1 of 3
APD AEM v1.01ES
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.
PRIVACY ACT STATEMENT OF 1974
AUTHORITY:
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.
PRINCIPAL PURPOSE:
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.
ROUTINE USES:
The "Blanket Routine Uses" set forth at the beginning of the Army compilation of systems of records notices also apply to
this system.
DISCLOSURE:
Voluntary. However, failure to provide all or part of the requested information may result in non-selection for duties under
the personnel reliability program.
PART I - INITIAL INTERVIEW
A.
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
B. NAME OF INDIVIDUAL (Last, First, MI)
C. SIGNATURE
D. DATE
E. ORGANIZATION
F. JOB TITLE
G. NAME OF INTERVIEWER
H. INTERVIEWER SIGNATURE
I. DATE
PART II - REVIEW OF PERSONNEL SECURITY INVESTIGATION (PSI) REPORT
A.
Individual eligible for escorted access based on opened investigation
Individual eligible for unescorted access
Escorted access not authorized or not applicable
B. PSI COMPLETED ON (YYYYMMDD)
C. TYPE OF PSI (NACLC, ANACI, SSBI, etc.):
None
Confidential
Secret
Top Secret
D. Security Clearance:
E. NAME OF OFFICIAL REVIEWING PSI REPORT
F. SIGNATURE
G. DATE
PART III - REVIEW OF PERSONNEL RECORDS
B. SIGNATURE
C. DATE
PART IV - MEDICAL RECORDS SCREENING
A.
Medical record information was forwarded to the certifying official for review, or
Medical record information did not require certifying official review
B. NAME OF SCREENING OFFICIAL
C. SIGNATURE
D. DATE
PART V - DRUG TESTING
A. SPECIMEN COLLECTED ON (YYYYMMDD)
B.
Test results were forwarded to certifying official, or
Test results were certified negative by the medical review official.
C. NAME OF OFFICIAL
D. SIGNATURE
E. DATE
PART VI - CERTIFYING OFFICIAL'S EVALUATION/ASSIGNMENT BRIEFING
A. I have conducted a thorough review of the information provided, and
____ I find this individual suitable for the PRP, or
____ I find this individual suitable for interim certification or escorted access, or
____ I find this individual unsuitable for the PRP (Complete Part IX, A to I)
B. NAME OF OFFICIAL
C. SIGNATURE
D. DATE
Individual's acknowledgment: I have received and
E. SIGNATURE
F. DATE
understood the briefing on the standards and objectives
of the personnel reliability program.
PREVIOUS EDITIONS OF THE DA FORM 3180 ARE OBSOLETE.
DA FORM 3180-2, APR 2018
Page 1 of 3
APD AEM v1.01ES
PART VII - CONTINUING EVALUATION
Document changes in individual's status and/or administrative data per local procedures. Use continuation sheets as needed.
A. CERTIFYING
B. INDIVIDUAL'S
OFFICIAL'S
C. REASON FOR UPDATE
D. DATE
INITIALS
INITIALS
PART VIII - ADMINISTRATIVE TERMINATION
A.
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.
B. NAME OF OFFICIAL
C. SIGNATURE
D. DATE
PART IX - DENIAL/TERMINATION
A. Status at time of denial/termination
C. Reason for denial/termination
____ 1. Alcohol-related
____ 1. Being screened for the chemical PRP
____ 2. Drug-related
____ 2. Being screened for the biological PRP
____ 3. Suicide attempt or threat and jeopardizing human life or safety
____ 3. Enrolled in the chemical PRP
____ 4. Medical, mental, physical conditions incompatible with PRP
____ 4. Enrolled in the biological PRP
____ 5. Negligence or delinquency in performance of duty
B. Employment Status
____ 6. Poor attitude or untrustworthiness with respect to PRP responsibilities
____ 1. Military
____ 7. Personal conduct involving questionable judgment, untrustworthiness, unreliability,
____ 2. Civilian
lack of candor, or dishonesty
____ 8. Lack or revocation of security clearance eligibility
____ 3. Contractor
D. Rationale
Individual was notified of denial/termination:
E. DATE OF NOTIFICATION
F. METHOD OF NOTIFICATION
G. NAME OF CERTIFYING OFFICIAL
H. SIGNATURE
I. DATE
J. NAME OF REVIEWING OFFICIAL
K. SIGNATURE
L. DATE
DA FORM 3180-2, APR 2018
Page 2 of 3
PART VII - CONTINUING EVALUATION CONTINUATION SHEET
Document changes in individual's status and/or administrative data. Use continuation sheets as needed.
A. CERTIFYING
B. INDIVIDUAL'S
C. REASON FOR UPDATE
D. DATE
OFFICIAL'S
INITIALS
INITIALS
DA FORM 3180-2, APR 2018
Page 3 of 3

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