opnavinst 5350.4 d - Navy Medicine - U.S. Navy

;uhj: REQUEST FOR ADMINISTRATIVE SEPARATION WAIVER
OPNAVINST 5350.4D
4 Jun 09
r. Provide history of previous treatment(s), status of
aftercare 1 ~f any) (e.g., "Member successfully completed
iP~Level 1;: treatment on 28 February 2005 at ARC, Jacksonville,
Jlorida. Member is currently in aftercare or member completed
aftercare 3a 39 October 2005.")
. insert member's history of disciplinary infractions,
~~lcohoi lrlc~dents, all other alcohol related problems, and dates
>f each, : r any.
r:. (:ommanding officer's comrnents/endorsement (provide brief
;ummary ( ~f member ' s performance) .
, ;3mmanil point of contact is: (Insert name of POC, who can
ne reached dt COMM number/DSN, or COMM fax number/DSN, and
-2-maii address. E-mail address for command POC is required.)
Commanding officer's signature
(or XO/Acting or By direction)
*NOTE: Sni4_osures should include NAVPERS 1070/613,
Idmin~strat-ve Remarks relevance, memorandums detailing
2xtrdordinary circumstances, and documentation believed to have
bearing on this request. DAARs should be completed after every
zommand oz self-referral, alcohol incident, and final
llspositiori determination. Submit initial DAARs within 30 days
~i che referral or incident. Incomplete requests cause delays
LX grocess LrLc:.
Contact the NADAP office for any further questions regarding
iicohol waiver requests at COMM 901-874-2485/DSN 882; COMM Fax
3C1-873--4228 DSN 882. )
Ir~gina, _eLter from command will be mailed to:
'hlet c-IF Kdval aperations (N135F)
1~23 integrity Drive
41ilington TK 38055
'opy + i?. c'ommand Security M anager
Appendix A to
Enclosure (1)