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

APPENDIX A
SAMPLE LETTER
ADMINISTRATIVE SEPARATION WAIVER REQUEST
Trom: Conunanding Officer, (insert command name)
?'I : Commander, Navy Personnel Command (PERS-832)
a : Chief af Naval Operations (N135F)
.;ub 1 : REQIJEST FOR ADMINISTRATIVE SEPARATION WAIVER
OPNAVINST 5350.4D
4 Jun 09
Znc;: tl! Attach all relevant documents, include copy of
DAAR(s) (*see note)
Ser 001
Date
. ;lJalver for administrative separation is requested in case of
':nsert member's Rate/Rank, Full Name, Branch of Service).
The fciiowing amplifying data is submitted:
4, r~-~sert treatment requested, confirmation of dependency/
ibuse, t-reatment recommended by SARP (i.e., Level I (Out-
~jatient) ; L~vel I1 (Intensive Out-patient); Level 111
'Residentld. 1 , etc . )
. rnser t type of referral , e. g. , command referral, self -
rererra;, an alcohol incident referral.
. St-dte reason for requesting waiver. If incident
efer E d,, .riclude date of incident and date(s) of previous
ticohol inc:dent(s) (any alcohol incident, i.e., DUI/DWI, public
-ntoxication, drunk and disorderly conduct) after member has
~ecei~ed treatment from a previous incident.
r i . lndlcdte member's EAOS, PRD, and ADSD.
r. Irlsert amenability pending treatment date, treatment
:aclilty ana Yocation if available.
Appendix A to
Enclosure (1)