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Counselings/apft failure.doc

Developmental Counseling FORM

For use of this form, see FM 6-22; the proponent agency is TRADOC

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)

PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.

ROUTINE USES: For subordinate leader development IAW FM 6-22. Leaders should use this form as necessary.

DISCLOSURE: Disclosure is voluntary.

Part I - Administrative Data

Name (Last, First, MI)

Balls, John, W

Rank / Grade

PVT/E1

Social Security No.

Date of Counseling

Organization

Name and Title of Counselor

PART II – Background Information

Purpose of Counseling: (Leader states the reason for the counseling, e.g. Performance/Professional or Event-Oriented counseling and includes the leaders facts and observations prior to the counseling)

Event Oriented:

On ____________ PFC Balls failed a record APFT.

Part III – Summary of Counseling

Complete this section during or immediately subsequent to counseling.

Key Points of Discussion:

• On _____you were administered a Record APFT. You achieved the following scores:

Pushups (reps/score): ____/____ Sit-ups (reps/score): ____/____ 2 Mile run (reps/score): ____/____

• You failed to achieve a passing score in the following event(s): (circled) Pushups / Sit-ups / 2Mile Run

Actions:

• As a result or your performance the following actions will be taken:

You be enrolled in the special populations PT Program beginning _____, located at___________________

In accordance with AR 350-1 Chapter 1-24e (5) you will be flagged under AR 600-8-2 until you pass the APFT.

You be barred from reenlistment

In addition, I am informing you that you have 3 months (90 days following the initial APFT failure) in which to retake and pass your APFT. When you feel you are ready to re-take the APFT, you will require approval from the unit commander IAW AR 350-1 Chapter 1-24e (5). Should you fail two consecutive “For Record” APFTs you could be separated from the military.

OTHER INSTRUCTIONS

This form will be destroyed upon: reassignment (other than rehabilitative transfers), separation at ETS, or upon retirement. For separation requirements and notification of loss of benefits/consequences see local directives and AR 635-200

DA FORM 4856, MAR 2006 EDITION OF JUN 99 IS OBSOLETE

Plan of Action: (Outlines actions that the subordinate will do after the counseling session to reach the agreed upon goal(s). The actions must be specific enough to modify or maintain the subordinate’s behavior and include a specific time line for implementation and assessment (Part IV below).)

· Soldier received and signed notification of possible separation for continued substandard performance IAW AR 635-200 Para 1-18 (a)

· Soldier gave the following reasons for poor performance during this APFT:

· We will conduct a follow up on this counseling two weeks from today to discuss progress.

Session Closing: (The leader summarizes the key points of the session and checks if the subordinate understands the plan of action. The subordinate agrees/disagrees and provides remarks if appropriate.)

Individual counseled:  I agree  disagree with the information above

Individual counseled remarks:

Signature of Individual Counseled: ______________________________________________Date: ____________________

Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action.)

· Encourage the soldier to conduct PT after duty hours

· Provide the soldier the opportunity to meet with the unit master fitness NCO and dietitian

· Monitor progress

Signature of Counselor: __________________________________________________Date: ________________________

Part IV - ASSESSMENT OF THE PLAN OF ACTION

Assessment: (Did the plan of action achieve the desired results? This section is completed by both the leader and the individual counseled and provides useful information for follow-up counseling.)

(When the plan of action is complete, use this area to explain the outcome. Did the Soldier successfully complete the plan of action? Has the Soldier's performance/attitude improved?)

Counselor: ____________________ Individual Counseled:_________________ Date of Assessment: ______________

Note: Both the counselor and the individual counseled should retain a record of the counseling.

REVERSE, DA FORM 4856, MAR 2006

Counselings/bar to reenlist.doc

Developmental Counseling FORM

For use of this form, see FM 6-22; the proponent agency is TRADOC

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)

PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.

ROUTINE USES: For subordinate leader development IAW FM 6-22. Leaders should use this form as necessary.

DISCLOSURE: Disclosure is voluntary.

Part I - Administrative Data

Name (Last, First, MI)

Balls, John, W

Rank / Grade

PVT/E1

Social Security No.

Date of Counseling

Organization

Name and Title of Counselor

PART II – Background Information

Event-Oriented:

• Counsel Soldier on being bared from reenlistment

• Inform Soldier about the appeals process

Part III – Summary of Counseling

Complete this section during or immediately subsequent to counseling.

Key Points of Discussion:

On ___________, a Bar to Reenlistment was initiated in accordance with AR 601-280, Chapter 6, for ___________.

On ______________, under the provisions of AR 601-280, paragraph 6-5e, I am informing you that you have 7 days from this date to summit an appeal to the Bar to Reenlistment. Your appeal, if you decide to submit one, must be returned to me by ______hrs, on _____________. On case by case basis an extension of this period may by granted. Appeals will be endorsed personally by each commander (or acting commander) in the chain of command. For soldiers with less than 10 years active Federal service at ETS, the approval or disapproval authority is the Commanding General of Ft______________. For soldiers with more than 10 years active Federal service at ETS, the approval authority is the Commander, MACOM. You are also informed the bar will be reviewed every 6 months or 30 days prior to your PCS or ETS. Mandatory separation proceedings will be initiated if you fail to overcome the bar by the completion of the second 6 months of review. If you believe you will be unable to overcome the bar to reenlistment you may apply for immediate discharge IAW Para 6-5f, AR 601-280 and under the provisions of AR 635-200, Chapter 16. You are now in a non-promotable status IAW Para 7-6, AR 600-200. I will forward a recommendation to lift this bar to reenlistment anytime I believe your duty performance warrants retention.

OTHER INSTRUCTIONS

DA FORM 4856, MAR 2006 EDITION OF JUN 99 IS OBSOLETE

(the plan of action should be based on the Soldier's past performance and the nature of the offense)

Individual counseled:  I agree  disagree with the information above

Individual counseled remarks:

Signature of Individual Counseled: ______________________________________________Date: ____________________

Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action.)

Signature of Counselor: __________________________________________________Date: ________________________

Part IV - ASSESSMENT OF THE PLAN OF ACTION

(When the plan of action is complete, use this area to explain the outcome. Did the Soldier successfully complete the plan of action? has the Soldier's performance/attitude improved?)

Counselor: ____________________ Individual Counseled:_________________ Date of Assessment: ______________

Note: Both the counselor and the individual counseled should retain a record of the counseling.

REVERSE, DA FORM 4856, MAR 2006

Counselings/disrespect nco.doc

Developmental Counseling FORM

For use of this form, see FM 6-22; the proponent agency is TRADOC

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)

PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.

ROUTINE USES: For subordinate leader development IAW FM 6-22. Leaders should use this form as necessary.

DISCLOSURE: Disclosure is voluntary.

Part I - Administrative Data

Name (Last, First, MI)

Balls, John, W

Rank / Grade

PVT/E1

Social Security No.

Date of Counseling

Organization

Name and Title of Counselor

PART II – Background Information

Event-Oriented:

Violation of article 91 (Insubordinate conduct toward a Warrant Officer, Noncommissioned Officer, or Petty Officer) of the Uniform Code Of Military Justice in that on or about (date) at (location) you were disrespectful/disobeyed (NCO's name) your superior Noncommissioned Officer. (State in detail what happened).

Part III – Summary of Counseling

Complete this section during or immediately subsequent to counseling.

Key Points of Discussion:

Disrespect/Disobeying superior Noncommissioned Officers is a crime and is unacceptable behavior that will not be tolerated. If found guilty of this offense, the maximum punishment is ______________________. Your misconduct has been detrimental to unit morale and the discipline of this organization and will not be repeated. (I am recommending that the commander impose non-judicial punishment for your misconduct) OR (You will receive corrective training as outlined in the plan of action).

You are here by notified that if this type of conduct continues, actions may be initiated under the Uniform Code of Military Justice to separate you from the Army prior to your scheduled ETS date IAW AR 635-200. If you are involuntarily separated, you could receive an Honorable Discharge, a General Discharge, or a Under Other Than Honorable Conditions Discharge. If you receive a discharge Under Other Than Honorable Conditions, you will not be eligible for reenlistment and will loose most of your benefits, including all payments, the Montgomery GI Bill, VA benefits, and you may face prejudice from civilian employers.

OTHER INSTRUCTIONS

DA FORM 4856, MAR 2006 EDITION OF JUN 99 IS OBSOLETE

(the plan of action should be based on the Soldier's past performance and the nature of the offense)

Individual counseled:  I agree  disagree with the information above

Individual counseled remarks:

Signature of Individual Counseled: ______________________________________________Date: ____________________

Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action.)

Signature of Counselor: __________________________________________________Date: ________________________

Part IV - ASSESSMENT OF THE PLAN OF ACTION

(When the plan of action is complete, use this area to explain the outcome. Did the Soldier successfully complete the plan of action? has the Soldier's performance/attitude improved?)

Counselor: ____________________ Individual Counseled:_________________ Date of Assessment: ______________

Note: Both the counselor and the individual counseled should retain a record of the counseling.

REVERSE, DA FORM 4856, MAR 2006

Counselings/initial counseling.doc

Developmental Counseling FORM

For use of this form, see FM 6-22; the proponent agency is TRADOC

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)

PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.

ROUTINE USES: For subordinate leader development IAW FM 6-22. Leaders should use this form as necessary.

DISCLOSURE: Disclosure is voluntary.

Part I - Administrative Data

Name (Last, First, MI)

Balls, John, W

Rank / Grade

PVT/E1

Social Security No.

Date of Counseling

Organization

Name and Title of Counselor

PART II – Background Information

Event-Oriented Counseling:

Conduct Initial Performance and Guidance Counseling

Part III – Summary of Counseling

Complete this section during or immediately subsequent to counseling.

Key Points of Discussion:

1. Live the Army Values [LDRSHIP], Warrior Ethos, and Soldier's Creed.

2. Maintain Standards IAW AR 670-1 & AR 600-9. Everyone should be within body fat standards, and be able to pass a Record APFT, anytime.

3. Be in the right place, at the right time, ready to do the right thing, with the right equipment, and the right attitude.

4. Know yourself and seek self improvement. Finish military correspondence courses, civilian education courses, and go after some "Hoowaah" stuff while you’re still young and healthy (EFMB, Air Assault, CLS, max APFT).

5. Adhere to all clinic (Infection Control, HAZCOM, and Sterilization), unit, and local regulations and guidance.

6. Follow my instructions to the letter. Be prepared to ask questions if you don't fully understand the task you’re being asked to complete. To ask WHEN/WHERE/WHAT/WHY/HOW is your responsibility. This practice will save you time, and doing the tasks again.

7. If you make a mistake, own up to it. Everyone makes mistakes; don't try to cover it up. We can work it out if you come forward. If you wait until it's discovered later, then be prepared to accept stiffer consequences. I have an open door policy. You can talk to me anytime.

8. Meet suspense. If you receive an email that there is a suspense due on a certain date, fulfill your obligations. If you know that you'll be on leave, or on absence, knock it out before you leave. If you have trouble meeting a suspense, don't wait until the last minute to ask for help. Get help when you first sense you may not make the suspense.

9. Know the difference between reasons & excuses. There's a huge difference.

10. Medical appointments and leaves should have at least a 2 week lead time. You need to make sure we can cover you before you start planning absences. This will avoid you from having to cancel/ reschedule appointments.

11. The Army is a "dictatorship formed to protect a democracy". It's not about what you want, or like to do. It's about what the mission requires. You took the time and energy to go to the recruiting station, and asked to join. Now your here, and you will execute orders, regardless of what your feelings are.

12. I will never give favoritism to one soldier over another. I will never take your dignity, or sacrifice your safety. I will never ask you to do something that I have not already done.

13. I welcome ideas and suggestions that may help to make the organization more efficient. Just because you make a recommendation doesn't guarantee that were going do it. All guidance and changes to, will come from the OIC/ NCOIC, or thereby endorsed by the same. We must have ONE voice.

14. Memorize at least 3 running cadences; you will be called out to call cadence during PT runs.

15. I believe in having fun, but I don't play games. If you want to be "hard headed", you may see a rank change. I give verbal counselings (usually accompanied by push-ups), then come written counselings, then the "bat", then the "axe".

16. Get HOT, Stay HOT !!!

OTHER INSTRUCTIONS

DA FORM 4856, MAR 2006 EDITION OF JUN 99 IS OBSOLETE

· Sign up for military and civilian education

· Use down time wisely to accomplish suspenses, help out others, or get with the NCOIC to see if there's anything for you to help with.

· Stay in top physical condition. Give your best at PT sessions, but realize that Unit PT is more of a maintenance tool, and will not allow you to achieve a 300 on an APFT, or bring you back from poor fitness.

· Meet any and all suspenses and requirements on, or ahead of time.

· Once identified, prepare for Soldier of the Month and Quarter Boards.

· Strive to achieve goals on Prosperity Plan.

· Get Hot, Stay HOT!!

Individual counseled:  I agree  disagree with the information above

Individual counseled remarks:

Signature of Individual Counseled: ______________________________________________Date: ____________________

Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action.)

· Monitor the Soldier's performance, offering mentorship and training.

· Ensure Unit PT program offers a high degree of intensity.

· Protect Soldier's safety and dignity.

· Accomplish the mission, while taking care of the welfare of my Soldiers.

Signature of Counselor: __________________________________________________Date: ________________________

Part IV - ASSESSMENT OF THE PLAN OF ACTION

(When the plan of action is complete, use this area to explain the outcome. Did the Soldier successfully complete the plan of action? Has the Soldier's performance/attitude improved?)

Counselor: ____________________ Individual Counseled:_________________ Date of Assessment: ______________

Note: Both the counselor and the individual counseled should retain a record of the counseling.

REVERSE, DA FORM 4856, MAR 2006

Counselings/monthly counseling.doc

Developmental Counseling FORM

For use of this form, see FM 6-22; the proponent agency is TRADOC

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)

PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.

ROUTINE USES: For subordinate leader development IAW FM 6-22. Leaders should use this form as necessary.

DISCLOSURE: Disclosure is voluntary.

Part I - Administrative Data

Name (Last, First, MI)

Balls, John, W

Rank / Grade

PVT/E1

Social Security No.

Date of Counseling

Organization

Name and Title of Counselor

PART II – Background Information

Professional:

Conduct monthly Counseling for the month of July 2010

Part III – Summary of Counseling

Complete this section during or immediately subsequent to counseling.

Key Points of Discussion:

STRENGTHS: As the supply NCO you always ensure that we have the necessary supplies to complete our mission to the highest standards. As Senior KATUSA you ensure that the KATUSA assigned to our clinic have the knowledge and guidance to succeed. You are always willing to help out in any way you can.

WEAKNESSES: You are doing a fine job, but push your self a bit more to attain your goals. English language.

WAYS TO IMPROVE: Stay focused on helping your team members, and continue working on learning more English and ask for help if you need it.

PROSPERITY PLAN GOALS:

· Personal Goals: Learn more about American Culture and English language

· Professional Goals: Read books on veterinary medicine

· Spiritual Goals: Read the Bible More

· Family/ Friends/ Marriage: Visit my family more often

OTHER INSTRUCTIONS

DA FORM 4856, MAR 2006 EDITION OF JUN 99 IS OBSOLETE

· Continuously seek self improvement by enrolling in Rosetta stone English courses.

· Use you time wisely during PT sessions. Don't cheat your body. You must maintain a 255 or higher in order to stay off of remedial PT. Soot for the MAX 300, and earn the PT Patch.

· Utilize the prosperity plan worksheet to the fullest. Goal setting is what makes successful people achieve more. Once you put something on paper it becomes real, and better aids you in achieving your goals, and living a more prosperous life.

· Keep your appearance and bearing squared away. Live the Army Values.

Individual counseled:  I agree  disagree with the information above

Individual counseled remarks:

Signature of Individual Counseled: ______________________________________________Date: ____________________

Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action.)

· I will ensure Soldiers have a productive an d intense unit physical fitness program.

· Conduct monthly counselings to help Soldiers develop professionally.

· Review with Soldier’s Prosperity Plans to aid them in staying on track, and accomplish some goals.

Signature of Counselor: __________________________________________________Date: ________________________

Part IV - ASSESSMENT OF THE PLAN OF ACTION

(When the plan of action is complete, use this area to explain the outcome. Did the Soldier successfully complete the plan of action? Has the Soldier's performance/attitude improved?)

Counselor: ____________________ Individual Counseled:_________________ Date of Assessment: ______________

Note: Both the counselor and the individual counseled should retain a record of the counseling.

REVERSE, DA FORM 4856, MAR 2006

Counselings/promotion counseling.doc

Developmental Counseling FORM

For use of this form, see FM 6-22; the proponent agency is TRADOC

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)

PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.

ROUTINE USES: For subordinate leader development IAW FM 6-22. Leaders should use this form as necessary.

DISCLOSURE: Disclosure is voluntary.

Part I - Administrative Data

Name (Last, First, MI)

Balls, John, W

Rank / Grade

PVT/E1

Social Security No.

Date of Counseling

Organization

Name and Title of Counselor

PART II – Background Information

Promotion/developmental Counseling:

· Conduct promotion counseling

· Inform PFC Ball of the reason why he will not appear before the promotion board for the month of February

Part III – Summary of Counseling

Complete this section during or immediately subsequent to counseling.

Key Points of Discussion:

SPC Ball, In order to be considered for promotion to Sergeant without a waiver you must have 36 months Time in Service and 8 months Time in Grade. To be considered for promotion to Sergeant with a waiver a you must have 18 months Time in Service and 4 months Time in Grade. You currently have 29 months Time in Service and 11 months Time in Grade.

Based upon your overall performance and my assessment of your potential; You are eligible for promotion with a waiver at this time, However you will not appear before the promotion board in the month of February because you are not fully prepared to challenge the promotion board. You will be afforded the opportunity to appear before the promotion board in the month of March if you are ready. In the mean time I highly encourage you to use the Company board study guides and to continue to improve your level of physical fitness as this will help prepare you for promotion.

OTHER INSTRUCTIONS

DA FORM 4856, MAR 2006 EDITION OF JUN 99 IS OBSOLETE

· SPC Ball will study and prepare to appear before the March promotion board.

· SPC Ball will continue to improve his level of fitness by conducting PT after duty and sustain all areas that were identified in his monthly counseling.

Individual counseled:  I agree  disagree with the information above

Individual counseled remarks:

Signature of Individual Counseled: ______________________________________________Date: ____________________

Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action.)

· Recommend SPC Ball for promotion to the next grade

· Organize mock board for SPC Ball

· Provide professional guidance and support

Signature of Counselor: __________________________________________________Date: ________________________

Part IV - ASSESSMENT OF THE PLAN OF ACTION

(When the plan of action is complete, use this area to explain the outcome. Did the Soldier successfully complete the plan of action? Has the Soldier's performance/attitude improved?)

Counselor: ____________________ Individual Counseled:_________________ Date of Assessment: ______________

Note: Both the counselor and the individual counseled should retain a record of the counseling.

REVERSE, DA FORM 4856, MAR 2006

Counselings/promotion not recommended.doc

Developmental Counseling FORM

For use of this form, see FM 6-22; the proponent agency is TRADOC

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)

PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.

ROUTINE USES: For subordinate leader development IAW FM 6-22. Leaders should use this form as necessary.

DISCLOSURE: Disclosure is voluntary.

Part I - Administrative Data

Name (Last, First, MI)

Balls, John, W

Rank / Grade

PVT/E1

Social Security No.

Date of Counseling

Organization

Name and Title of Counselor

PART II – Background Information

Promotion/developmental Counseling:

· Review SPC Ball's substandard skills, knowledge, and competency over the past 90 days

· Inform SPC Balls that he will not be recommended for promotion for the month of January

Part III – Summary of Counseling

Complete this section during or immediately subsequent to counseling.

Key Points of Discussion:

SPC Ball's your performance over the last 90 days has been substandard and does not show signs of improvement, therefore you will not be recommended for promotion based on these facts. You will have many opportunities to show improvement and leadership abilities before your next evaluation. You have the potential to be great Soldier; don't mess it up and get on the right track.

OTHER INSTRUCTIONS

DA FORM 4856, MAR 2006 EDITION OF JUN 99 IS OBSOLETE

· SPC Ball will complete all assigned tasks in a timely manner and to the best of his abilities

· SPC Ball will ask for guidance from the leadership and seek self improvement

· SPC Ball will not be recommended for promotion the next higher grade until he shows significant improvement

Individual counseled:  I agree  disagree with the information above

Individual counseled remarks:

Signature of Individual Counseled: ______________________________________________Date: ____________________

Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action.)

· Not recommend SPC Ball for promotion to the next grade

· Ensure that SPC Ball completes all assigned tasks on time and to standard

· Provide professional guidance and support

Signature of Counselor: __________________________________________________Date: ________________________

Part IV - ASSESSMENT OF THE PLAN OF ACTION

(When the plan of action is complete, use this area to explain the outcome. Did the Soldier successfully complete the plan of action? Has the Soldier's performance/attitude improved?)

Counselor: ____________________ Individual Counseled:_________________ Date of Assessment: ______________

Note: Both the counselor and the individual counseled should retain a record of the counseling.

REVERSE, DA FORM 4856, MAR 2006

Counselings/weight control negative.doc

Developmental Counseling FORM

For use of this form, see FM 6-22; the proponent agency is TRADOC

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)

PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.

ROUTINE USES: For subordinate leader development IAW FM 6-22. Leaders should use this form as necessary.

DISCLOSURE: Disclosure is voluntary.

Part I - Administrative Data

Name (Last, First, MI)

Balls, John, W

Rank / Grade

PVT/E1

Social Security No.

Date of Counseling

Organization

Name and Title of Counselor

PART II – Background Information

Event-Oriented:

• Unsatisfactory Progress during the monthly weigh-in

Part III – Summary of Counseling

Complete this section during or immediately subsequent to counseling.

Key Points of Discussion:

On you were weighed in during the monthly weigh-in IAW 600-9. The results were as follows:

Previous Months Weight: 200 lbs. Current Months Weight: 210 lbs. (Loss / Gain) of: 10 lbs.

Previous Months Body Fat%: 35 % Current Months Body Fat%: 37 % (Loss / Gain) of: 2 %

You have lost / gained 2 % of Body Fat since your last weigh-in.

You have lost / gained 10 lbs. since your last weigh-in.

You have not made satisfactory progress for this month. You are here by notified If you should fail to achieve satisfactory progress for 2 consecutive months, actions may be initiated under the Uniform Code of Military Justice to separate you from the Army prior to your scheduled ETS date IAW AR 635-200. If you are involuntarily separated, you could receive an Honorable Discharge, a General Discharge, or an Under Other Than Honorable Conditions Discharge. If you receive a discharge Under Other Than Honorable Conditions, you will not be eligible for reenlistment and will loose most of your benefits, including all payments, the Montgomery GI Bill, VA benefits, and you may face prejudice from civilian employers.

_________

initials

OTHER INSTRUCTIONS

DA FORM 4856, MAR 2006 EDITION OF JUN 99 IS OBSOLETE

• Monitor PVT Ball’s progress and weight loss program

• Conduct assessment portion of previous counseling

• Discuss possible courses of action with PVT Balls

Individual counseled:  I agree  disagree with the information above

Individual counseled remarks:

Signature of Individual Counseled: ______________________________________________Date: ____________________

Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action.)

• Continue to monitor PVT Ball’s performance

• Supervise PVT Ball’s PT program

• Continue to encourage and support PVT Ball

Signature of Counselor: __________________________________________________Date: ________________________

Part IV - ASSESSMENT OF THE PLAN OF ACTION

(When the plan of action is complete, use this area to explain the outcome. Did the Soldier successfully complete the plan of action? has the Soldier's performance/attitude improved?)

Counselor: ____________________ Individual Counseled:_________________ Date of Assessment: ______________

Note: Both the counselor and the individual counseled should retain a record of the counseling.

REVERSE, DA FORM 4856, MAR 2006

Counselings/wlc counseling.doc

Developmental Counseling FORM

For use of this form, see FM 6-22; the proponent agency is TRADOC

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Authority: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)

PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.

ROUTINE USES: For subordinate leader development IAW FM 6-22. Leaders should use this form as necessary.

DISCLOSURE: Disclosure is voluntary.

Part I - Administrative Data

Name (Last, First, MI)

Balls, John, W

Rank / Grade

PVT/E1

Social Security No.

Date of Counseling

Organization

Name and Title of Counselor

PART II – Background Information

Professional:

• Counsel Soldier for Warrior Leader Course

• Inform soldier that WLC class will begin 17 Dec 09

Part III – Summary of Counseling

Complete this section during or immediately subsequent to counseling.

Key Points of Discussion:

• Review WLC checklist

• Review The Army School System (TASS) Unit Pre-Execution Checklist

• You may be expected to conduct an interview with the 1SG/CSM

• Ensure uniforms are in accordance with AR 670-1.

• Your sponsor is SGT Tango and his phone number is 123-456-7890.

• Work on giving PT, conducting drill and ceremonies, and practice conducting a class

• Inspect all equipment for serviceability and accountability and DX unserviceable TA-50

• Ensure you have sufficient funds to defray the cost of personal expenses

• Ensure that all pay, personal issues are taken care of prior to the start of the course.

• You must be able to pass the APFT and body fat percentage.

• Learn The NCO/Soldiers Creed.

OTHER INSTRUCTIONS

DA FORM 4856, MAR 2006 EDITION OF JUN 99 IS OBSOLETE

• Lead unit PT til the start of class

• prepare a class for Sergeants Time Training

• Inspect equipment on 05 Nov 09

• Conduct APFT on 04 Nov 09

• Obtain orders and meal card if required

• Storage of POV and personal property plan was reviewed

• Ensure all bills are paid in advance

• Give family contact information in case of emergency

Individual counseled:  I agree  disagree with the information above

Individual counseled remarks:

Signature of Individual Counseled: ______________________________________________Date: ____________________

Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action.)

• Help Soldier prepare for WLC

• Conduct APFT

• Schedule appointment with 1SG

• Provide a sponsor/inform family

Signature of Counselor: __________________________________________________Date: ________________________

Part IV - ASSESSMENT OF THE PLAN OF ACTION

(When the plan of action is complete, use this area to explain the outcome. Did the Soldier successfully complete the plan of action? Has the Soldier's performance/attitude improved?)

Counselor: ____________________ Individual Counseled:_________________ Date of Assessment: ______________

Note: Both the counselor and the individual counseled should retain a record of the counseling.

REVERSE, DA FORM 4856, MAR 2006