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:
PRINCIPAL PURPOSE:
5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army.
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 notices also
apply to this system.
Disclosure is voluntary.
DISCLOSURE:
PART I - ADMINISTRATIVE DATA
Name (Last, First, MI)
Obama, Barack
Organization
Rank/Grade
Date of Counseling
PFC/E3
16 July 2013
Name and Title of Counselor
69th MP Company
George W. Bush, SSG, Squad Leader
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 Discuss:
Soldier’s Army Physical Fitness Test Failure (APFT) IAW Army Regulation 350-1
Best ways in which to correct substandard performance
Consequences of consecutive Record APFT failures
PART III - SUMMARY OF COUNSELING
Complete this section during or immediately subsequent to counseling.
Key Points of Discussion:
Results of APFT:
• On {DATE} you were administered a record APFT. You achieved the following scores:
Pushups (reps/score): ____/____ Sit-ups (reps/score): ____/____
2-mile run (time/score): ____/____
• You failed to achieve a passing score in the Push-up Event and missed by # points.
Actions:
As a result or your performance I am Recommending that the following actions be taken (indicated by check mark):
_____You be enrolled in the special populations PT Program beginning {DATE}, located at {LOCATION}
_____You be removed from participating in unit sports teams
_____ In accordance with AR 350-1 you will be flagged under AR 600-8-2 until you pass the APFT. This flag will stop all favorable
actions (to include Tuition Assistance), and will only be removed when 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.
Should you fail two consecutive “For Record” APFTs you may be separated from the military.
Soldier gave the following reasons for poor performance during this APFT:
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
PREVIOUS EDITIONS ARE OBSOLETE.
APD PE v1.01ES
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 specified time line for implementation and assessment (Part IV below)
The Soldier will follow the diet plan designed by the Master Fitness Trainer and will conduct after duty PT sessions with his
squad leader to improve performance. The Soldier will be given a Not for record APFT in 2 weeks to measure any
improvement in performance. Failure to follow this plan of action will result in further administrative action and training for
the Soldier.
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:
Individual counseled remarks:
I agree
disagree with the information above.
Signature of Individual Counseled:
Date:
Leader Responsibilities: (Leader's responsibilities in implementing the plan of action.)
Conduct Flag counseling or Bar to Reenlistment as required
Schedule the Soldier an appointment with the dietitian
Review the Soldier's physical conditioning with the unit master fitness trainer
Closely supervise the Soldier during unit PT; Conduct assessment as required.
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.)
WRITE HERE ANY PROGRESS OR DECLINE IN PERFORMANCE AT THE TIME OF THE FOLLOW UP
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, AUG 2010
APD PE v1.01ES