DEVELOPMENTAL COUNSELING FORM
For use of this form. see ATP 8-221: 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.
PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.
ROUTINE USES: The Do!) Blanket Routine Uses set forth at the beginning of the Army's compilation of systems or records notices also
apply to this system.
DISCLOSURE: Disclosure is voluntary.
PART I - ADMINISTRATIVE DATA
Name (Last. First. Mt} Dale of Counseling
Richardson, Gib T. LTCIOS 12 Sep 20! 6
Organization Name and Title of Counselor
391h B83 [36

 

 

 

PART II - BACKGROUND INFORMATION

 

Fur use of Counseling: (Leader. states the reason for the counseling. 9 Permanence/Professional or Event-Oriented counseling. and includes the
lee er's facts and observations poor to the counseling.)

The purpose of this counseling is to inform you that I am relieving you of command from the 39th Brigade Support Bauahon for your failure of leadershIp on Range
IOU at FL Chaffee on 14 June 2016, During the execution of the training multiple Soldiers became heat casualties that ultimately lead to one of their deaths

 

PART - SUMMARY OF COUNSELING
Complete this section during or immediately subsequent to counseling.

 

Key Points of Discussion:

l. Your relief of command is effective immediately.
2 Under the revisions of AR 623-3, Evaluation Report System, paragraph 3-54 and AR 600-20, paragraph Z-I 7' a relIef for cause of?cer evaluations Is directed
3 requested to keep you for the Kosovo deployment and I have approved his request.

 

OTHER INSTRUCTIONS
This form will be destroyed upon' reassignment (other than rehabilitative transfers]. separation at ET 3. or upon retirement. For separation requirements

 

and noti?cation of loss of bene?tsiconsequences see local directives and AR 635-200.

 

 

DA FORM 4856, JUL 2014 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 2

APO LC 

 

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
speci?c enough to modify or maintain the subordinates behavior and include a speci?ed trrne line for implementation and assessment (Part lv below}

i . You Will coordinate with the Chief of Staff today to work out the details of your future full time and M-Dav 

 

Session Closing: {The leader summanzes the key points of the 565510? and checks if the subordinate understands the plan of action The subordinate
agrees/disagrees and provides remarks if appropriate 1

individual counseled agree disagree with the iniorrnation above.
Individual counseled rks.

 

Signature of individual Counseied:

 

Date. Iggy/?

Leader Responsibilities: {Leade responsibilities in implementing the plan of action 
Follow up with the Chiefof StaiT to ensure SM understands their next assignment and duties

Signature of Counselor:

  

 

Dare \2 69? ICC,
PART IV - ASSESSMENT OF THE PLAN 0 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.
on FORM 4856, JUL 2014

 

 

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