DA Form 7762-2 "Nuclear Personnel Screening and Evaluation Record"

What Is DA Form 7762-2?

This is a military form that was released by the U.S. Department of the Army (DA) on November 1, 2018. The form, often mistakenly referred to as the DD Form 7762-2, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 3-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;

Download an up-to-date fillable DA Form 7762-2 down below in PDF format or browse hundreds of other DA Forms stored in our online database.

ADVERTISEMENT
ADVERTISEMENT

Download DA Form 7762-2 "Nuclear Personnel Screening and Evaluation Record"

262 times
Rate (4.7 / 5) 16 votes
(
UNCLASSIFIED
)
NUCLEAR PERSONNEL SCREENING AND EVALUATION RECORD
For use of this form, see AR 50-5; 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 nuclear
personnel reliability program.
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. NAME OF INDIVIDUAL (Last, First, MI)
B. ORGANIZATION
C. JOB TITLE
D. DATE OF BIRTH
E. I
do
do not object to the nuclear PRP screening requirements
(Individual's initials)
F. NAME OF INTERVIEWER
G. SIGNATURE
H. DATE
PART II - PERSONNEL SECURITY INVESTIGATION (PSI) SCREENING
not applicable
A. Interim certification authorized pending completion of PSI
(Certifying official initials)
B. PSI completed on
DATE
Type (NACLC, ANACI, SSBI, etc.)
None
Confidential
Secret
Top Secret
C. Security Clearance:
found
not found
D. PSI report was reviewed. Information requiring additional review was
E. NAME OF SCREENING OFFICIAL
F. SIGNATURE
G. DATE
PART III - PERSONNEL RECORDS SCREENING
A. Personnel records were screened. Information requiring review was
found
not found
B. NAME OF SCREENING OFFICIAL
C. SIGNATURE
D. DATE
PART IV - MEDICAL RECORDS SCREENING
A. Medical records were screened. Information requiring review was
found and forwarded to the certifying official
not found
B. NAME OF SCREENING OFFICIAL
C. SIGNATURE
D. DATE
PART V - DRUG TESTING
certified negative
A. Specimen collected on
DATE (YYYYMMDD) Test results were
forwarded to the certifying official
B. NAME OF OFFICIAL
C. SIGNATURE
D. DATE
PART VI - SUBSTANCE ABUSE RECORDS SCREENING
A. Substance abuse record screening is authorized per AR 600-85 for military and Public Law 100-71, Section 503(e) for civilian personnel
Information requiring review was
found and forwarded
not found
The individual is not and has never been a client
The civilian employee cannot be confirmed as a client
B. NAME OF OFFICIAL
C. SIGNATURE
D. DATE
PART VII - CERTIFYING OFFICIAL'S EVALUATION/ASSIGNMENT BRIEFING
A. After thorough review of information provided, I find this individual:
suitable for the PRP (Complete Part VII).
unsuitable for the PRP (Complete Part VII, B, C, D and Part X)
authorized for Interim Certification (Complete Part VIII)
B. NAME OF OFFICIAL
C. SIGNATURE
D. DATE
E. Individual's signature indicates a briefing on
F. SIGNATURE
G. DATE
standards and objectives of the PRP was
received and understood.
APD AEM v1.00
DA FORM 7762-2, NOV 2018
Page 1 of 3
(
UNCLASSIFIED
)
NUCLEAR PERSONNEL SCREENING AND EVALUATION RECORD
For use of this form, see AR 50-5; 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 nuclear
personnel reliability program.
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. NAME OF INDIVIDUAL (Last, First, MI)
B. ORGANIZATION
C. JOB TITLE
D. DATE OF BIRTH
E. I
do
do not object to the nuclear PRP screening requirements
(Individual's initials)
F. NAME OF INTERVIEWER
G. SIGNATURE
H. DATE
PART II - PERSONNEL SECURITY INVESTIGATION (PSI) SCREENING
not applicable
A. Interim certification authorized pending completion of PSI
(Certifying official initials)
B. PSI completed on
DATE
Type (NACLC, ANACI, SSBI, etc.)
None
Confidential
Secret
Top Secret
C. Security Clearance:
found
not found
D. PSI report was reviewed. Information requiring additional review was
E. NAME OF SCREENING OFFICIAL
F. SIGNATURE
G. DATE
PART III - PERSONNEL RECORDS SCREENING
A. Personnel records were screened. Information requiring review was
found
not found
B. NAME OF SCREENING OFFICIAL
C. SIGNATURE
D. DATE
PART IV - MEDICAL RECORDS SCREENING
A. Medical records were screened. Information requiring review was
found and forwarded to the certifying official
not found
B. NAME OF SCREENING OFFICIAL
C. SIGNATURE
D. DATE
PART V - DRUG TESTING
certified negative
A. Specimen collected on
DATE (YYYYMMDD) Test results were
forwarded to the certifying official
B. NAME OF OFFICIAL
C. SIGNATURE
D. DATE
PART VI - SUBSTANCE ABUSE RECORDS SCREENING
A. Substance abuse record screening is authorized per AR 600-85 for military and Public Law 100-71, Section 503(e) for civilian personnel
Information requiring review was
found and forwarded
not found
The individual is not and has never been a client
The civilian employee cannot be confirmed as a client
B. NAME OF OFFICIAL
C. SIGNATURE
D. DATE
PART VII - CERTIFYING OFFICIAL'S EVALUATION/ASSIGNMENT BRIEFING
A. After thorough review of information provided, I find this individual:
suitable for the PRP (Complete Part VII).
unsuitable for the PRP (Complete Part VII, B, C, D and Part X)
authorized for Interim Certification (Complete Part VIII)
B. NAME OF OFFICIAL
C. SIGNATURE
D. DATE
E. Individual's signature indicates a briefing on
F. SIGNATURE
G. DATE
standards and objectives of the PRP was
received and understood.
APD AEM v1.00
DA FORM 7762-2, NOV 2018
Page 1 of 3
(
UNCLASSIFIED
)
PART VIII - CONTINUING EVALUATION
Document changes in individual's status and/or administrative data. Use continuation sheets as needed.
A. INDIVIDUAL'S SIGNATURE
C. REASON FOR UPDATE
D. DATE
B. CERTIFYING OFFICIAL'S SIGNATURE
PART IX - ADMINISTRATIVE DECERTIFICATION
EFFECTIVE
DATE
PART X - DISQUALIFICATION/DECERTIFICATION
A. Status at time of disqualification/decertification
1. Being screened for PRP
2. Assigned to a critical nuclear PRP duty position
3. Assigned to a controlled nuclear PRP duty position
B. Employment Status
1. Military
2. Civilian
3. Contractor
C. Reason for disqualification/decertification
4. Criminal conduct
1. Personal conduct
2. Emotional, mental, or personality disorders
3. Financial
5. Substance or drug misuse and drug incidents
6. Alcohol use disorder and alcohol-related incidents
7. Sexual harassment and assault
8. Security violations
9. Misuse of information technology systems
10. Revocation of security clearance
11. Medical conditions
D. Rationale
E. Individual was notified of disqualification/decertification on
DATE
by
F. NAME OF CERTIFYING OFFICIAL
G. SIGNATURE
H. DATE
I. NAME OF REVIEWING OFFICIAL
J. SIGNATURE
K. DATE
DA FORM 7762-2, NOV 2018
Page 2 of 3
(
UNCLASSIFIED
)
NUCLEAR PERSONNEL SCREENING AND EVALUATION RECORD
For use of this form, see AR 50-5; the proponent agency is DCS, G-3/5/7.
A. NAME OF INDIVIDUAL (Last, First, MI)
PART VIII - CONTINUING EVALUATION (Continued)
Document changes in individual's status and/or administrative data.
A. INDIVIDUAL'S SIGNATURE
C. REASON FOR UPDATE
D. DATE
B. CERTIFYING OFFICIAL'S SIGNATURE
DA FORM 7762-2, NOV 2018
Page 3 of 3
Page of 3