Friday, February 3, 2012

Failure To Report

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Developmental Counseling FORM

For use this form, see FM 6-22; the proponent agency in 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: The DoD Blanket Routine Uses set forth at the beginning of the Army’s compilation of systems or records also
                                 apply to this system
DISCLOSURE:  Disclosure is voluntary.
Part I - Administrative Data
Name (Last, First, MI)

Rank/Grade

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 leader’s facts and observations prior to the counseling):

To:

            •  Determine why soldier was not at the appointed place of duty
            •  Implement measures to prevent future situations of this type     
              possible repercussions of consecutive Record APFT failures



                                                  
Part III - Summary of Counseling
Complete this section during or immediately subsequent to counseling.
Key Points of Discussion


On DATE you failed to be at your appointed place of duty. (Location)

This type of action will not be tolerated.  As a result of this incident the following action(s) will be taken: (indicated by the checkmark)

____ Corrective Training:     
____ Summary Article 15 (recommend)
____ Field Grade Article 15 (recommend)
____ Revocation of privileges (recommend)
____ Other:

Verbal/Formal counseling’s for past incidents of failure to report:  DATE(S) OR N/A

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, AUG 2010                            PREVIOUSE EDITIONS ARE 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): 

Check one:
                _____  Soldier received and signed memorandum of notification of possible separation for continued substandard performance IAW AR 635-200 Para 1-18 (a)

                _____  Memorandum of notification of possible separation was reviewed with the soldier to ensure that the soldier understood the possible consequences for                                    continued substandard performance
               
                * Will conduct follow up counseling in two weeks from today’s date:     

Soldier gave the following reasons for FTR:






Measures to be taken to prevent reoccurrence:
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):

•  Monitor soldier’s performance in this area
•  Conduct follow up assessment    


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):




Counselor: ___________________    Individual Counseled:  __________________  Date of Assessment:  __________
Note:  Both the counselor and the individual counseled should retain a record of the counseling.
DA FORM 4856, AUG 2010