Anny Personnel Selection and Classification Testing - Washington ...

TEST ADMINISTRATION STATEMENTF01' U. 01 tt111 form, ... AR e, 1-5; the proponent -olney I, USASSC·NCR.FOR IN-SERVICE EXAMINEES ONLYDATA REQUIRED BY THE PRIVACY ACT OF 1174AUTHORITY:PRINCIPAL PURPOSE(S):ROUTINE USES:DISCLOSURE:10 USC SOlTo determine an individual', menlol and pbyl1ca1ability prior to beinrlelted. Additionel1y. uaedin place of••parate privacy ltatement on theanJ1fer .heet. The answer .heet it then used tocollect and meuure an individual', aptitude forenliltment. reenliltment. traininau a commiuionedor warrant officer for uaienment to varloUi otherAnny joha.The leora' an individual mak.. wiD be tranacribedonto the appropriate Anny recorda and furniahedto evaluation boards and officlala.Completine thia form la mandatory. Your SSN isuaed to verify that the score you make ia correcUytranlcribed on your Army per.annel record. Shouldyou fail to answer any or all of theae questiona youmay not be telect.ed or may be dWqualified for preferredtrainine: or duty aMipment.NAME AND RANK OF EXAMINEE SSN DATEUNIT OF ASSIGNMENTNAME OF TEST DR BATTERYTEST CONTROL OFFiCER NO. (TCO)I understand that I am not required to take the above named test, thisdate, provided that there are extenuating circumstances Ncb asfatigue, illness, emotional distress, family or financial problems etc.,which may interfere with my performance in the test; and that thetest will be administered at another time acceptable to me, the TeOconcernetl antl my unit commander.o I AM PHYSICALLY AND MENTALLY ABLE TO BE TESTED THIS DATE.DI AM NOT PHYSICALLY AND OR MENTALLY ABLE TO BE TESTED THIS DATE.I WILL BE ADMINISTERED THIS TEST AT ANOTHER TIME.SIGNATURE OF EXAMINEE SIGNATURE OF TEST EXAMINEA DATEDA FORM 5180-R, NOV B2,U.s. GOVf.H..~"1!' PRINTING or'FleE 1993 0 - 342-421 (61052)