--- Page 1 --- MARSOF Close Quarters Battle Level 2 (MCQBL2) Command Screening Checklist 1. Purpose: To ensure Marines selected to attend MCQBL2 are fully qualified. 2. Information: In order to preclude Marines from being turned away upon arrival, it is necessary that parent commands ensure their Marines satisfy enrollment prerequisites set forth within this checklist. A failure to satisfy any of the prerequisites on the checklist disqualifies a Marine from attending the course. 3. Action: The student will complete the Command Screening Checklist and attach copies of all certificates. The Command Screening Checklist along with all certificates must be submitted to MSOS S-3 via MSOR S-3 30 days prior to course convene date. Students who fail to submit a Command Screening checklist with all appropriate signatures / printed names and attached certificates will not be approved to attend course. The Command Screening Checklist will be maintained in the Marine's student academic record. The checklist will be destroyed upon completion of TAD. 4. Waivers: All waivers will be routed through the MSOR S-3 and must be received by the MSOS S-3 no later than 30 days prior to the course convene date. MSOS will publish an enrollment message of accepted nominees in AMHS 14 days prior to convene date. If a waiver is required the Command Screening Checklist will be forwarded with the waiver request. Privacy Act Statement This Statement serves to inform you of the purpose of this data collection and to apprise how the collected data will be used. The Privacy Act System of Records Notice that allows for collection of this information is NM01500-2 DON EDUCATION AND TRAINING RECORDS located at http://www.privacy.navy.mil/privacy/noticenumber/NM01500- 2.doc. Please read this Statement carefully. AUTHORITY: 10 U.S.C. ยง 5041, Headquarters U.S. Marine Corps, and E.O. 9397 (SSN) PRINCIPAL PURPOSE: Information is obtained to identify personnel who are assigned as students to course of instruction. ROUTINE USE: Information collected on this form may be shared outside the DoD for those specific purposes and listed organizations identified as DoD Blanket Routine Uses at http://www.defenselink.mil/privacy/dod_blanket_uses.html. RETENTION: Automated MCTIMS records are retained permanently. DISCLOSURE: Providing information on this form, including your Social Security Number, is voluntary. Failure on your part, however, to answer all questions, or any misrepresentation (by omission, concealment, or by misleading, false, or partial answers), may serve as a basis for denied assignment to the course of instruction you are requesting to attend --- Page 2 --- Last Name: Grade First Name: MI: SSN (last 4): Unit: MOS: Contact Phone Number: MARSOC Deployments as CSO: Unit Location Year Prerequisites Yes No Signature and printed name of certifying personnel 1 Certified by Commander to be a mature individual capable of supervising High Risk Training CO 2 GT Score of 110 or higher S-3 3 No alcohol abuse or disciplinary problems SACO 4 Secret Clearance verified JPAS S-2 5 MARSOC Security Badge S-2 6 Medically qualified (current physical) to participate in a challenging combat physical training program. In Full Duty Status. _______________________________ PRINT _______________________ IDC OR MEDICAL OFFICER SIGNATURE 7 Medical and Dental records in hand 8 Capable of handling live ammunition and fire arms per the Lautenberg Amendment to the Gun control Act of 1968 (ALMAR 290/98 & MARADMIN 186/03). ________________________________ PRINT ________________________________ SECURITY OFFICER SIGNATURE 9 Letter of Transmittal, current LTI/PFI for all serialized gear Ops 10 Completed Marine Net Class SAT Overview (UT01AO) Ops Date Complete: 11 Completed Marine Net Class BISC (BISC-010) --- Page 3 --- Date Complete: Ops 12 Completed Marine Net Class Range Safety (C1060120CA) Ops Date Complete: 13 Certified by Command as RSO. RSO card on hand. Ops 14 Meets minimum obligated service (1 year) upon completion of school Ops 15 Student holds rank of SSgt or E6 at a minimum Ops 16 Student has been a CSO for 2 years at a minimum Ops 17 Student has deployed as a CSO for 180 days at a minimum Ops 18 Posses Uniforms and equipment listed in course gear list Ops 19 Student is currently holding the billet of assistant element leader or above Ops 20 Certified in 1000 level DA/WPNS events IAW NAVMC 3500.97 Ops Date Complete: Type of certification (circle one): -MARSOC ITC -Training Cell CQB Course -Special Missions CQB/DA Course -CQB Course for Branch of Service (specify course) 21 Does the nominee meet the above prerequisites ____________________________ List Prerequisites Marked No by number 22 Waivers are requested through the MSOS S-3 and granted by MSOS CO on a case by case basis. 23 Training Information: Last Combat Marksmanship Pistol Qualification (must be within 12 months of course convene date) Date: Score: --- Page 4 --- Last Combat Marksmanship Rifle Qualification (must be within 12 months of course convene date) Date: Score: Date last Conducted CQB Sustainment (must be within 12 months of course convene date) Have you conducted CQB with Explosive Breaching? Yes No Are you a Breacher? Yes No Date of last Sustainment (__________) ___________________ ___________________ _________ Co CO/Ops Chief Signature Date ___________________ ___________________ _________ Bn Ops O/Chief Signature Date ___________________ ___________________ _________ Bn CO/SgtMaj Signature Date