(Last, First, MI)
Rank/Grade Date of Counseling
Organization Name and Title of Counselor
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.)
Key Points of Discussion:
For use of this form, see ATP 6-22.1; the proponent agency is TRADOC.
5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army.
To assist leaders in conducting and recording counseling data pertaining to subordinates.
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.
Complete this section during or immediately subsequent to counseling.
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, JUL 2014
APD LC v1.03ES
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21st Special Troops Battalion (S4)
Event Oriented: Weekend Safety Briefing
1. Encourage safety awareness
2. Establish procedures for notifying the chain of command in the event of an accident
3. Ensure proper planning of travel time
4. Encourage Stewardship of the Army Profession
5. Encourage Ethical Leadership (Steward and Servant) and the decision making process.
Every Soldier has a responsibility to Steward the Army's profession. As a fundamental of leadership, this may require some form of servant leadership, meaning your
actions should be taken for the "good of the group". Insubordination, unruly behavior, and lack of concern for safety and the law are indications of poor stewardship
and an absence of leadership that can diminish the U.S. Army's reputation. Thus, your actions, whether on or off duty can effect the entire organization in either
positive or negative ways. Utilize an ethical approach to decision making, while remaining true to yourself and your organization. For more about ethical leadership,
visit URL: and read ADP 6-22.
Initial each to indicate your understanding:
_____ SHARP - If you need help, say something. If you witness something inappropriate, intervene. If you wish to report an incident of sexual assault, please contact
the 21st TSC SHARP hot line at DSN 484-7280 or commercial 0631-413-7280. The line is open 24-hours a day, seven days a week and covers the Kaiserslautern
Military Community, Baumholder and Stuttgart. As always, you can report incidents to you Chain of Command or file a restricted report with the Unit SARC.
_____ Suicide Awareness/Help - Seeking help is a sign of strength, not weakness. If you observe a suicidal ideation, utilize the "Ask, Care, Escort" technique to ensure
the individual is safe. DO NOT Leave him or her unattended until professional help has been attained. For emergencies, call 0631-536-6060.
_____ Domestic Violence will not be tolerated. Family advocacy (0631-46-2370), the Chaplin, and your chain of command are all at your disposal for help and advise.
_____ Illegal substances - The Army has zero tolerance for the use, possession, or sale of illegal substances or abuse of prescription drugs. For a comprehensive list of
prohibited substances, visit URL: or see AR 600-85.
_____ Maximize the use of the buddy system and take the time to understand the current threat conditions and current illegal trends in the area. Avoid spontaneous
group gatherings or demonstrations. Stay vigilant and report any suspicious activity to the MPs @ 0631-536-6060 or the German Polizei @ 0631-369-2150.
_____ If you consume alcohol, do so in moderation.
_____ Only swim in approved areas with a lifeguard present.
_____ Do not patronize off limit establishments or any establishment that promotes, supports, or facilitates human trafficking, violence, or illegal substances.
_____ Do not attempt to participate in activities that are clearly outside of your physical/mental capabilities or state of mind if affected by alcohol or medication. Use
caution if you are going to mix alcohol and sporting events as the risk of injury is increased.
_____ Practice safe sex.
_____ Fire Safety - Check your smoke detectors in your home. When grilling or barbecuing, practice safe techniques to avoid burns to yourself, children or property.
Are you planning extended travel outside Germany or more than a 250 mile radius from the local area? YES NO
If so, do you have an extended travel pass? N/A YES NO
If leaving the country, do you have a country clearance from G2? YES NO
Note: you are not authorized to leave the country or travel further than 250 miles until a DA Form 31 is processed.
_____ When traveling, be sure to afford yourself adequate time for rest stops. Adjust your speed to the posted speed limit and weather conditions.
_____ Check with you banking institution to ensure your debit/credit cards will work once you reach your destination to avoid delays in your return.
_____ Do not drive after you have consumed alcoholic or mood altering medication. Do not ride in a vehicle if the operator is impaired in any way.
_____ Do not allow other Soldiers to operate vehicles or endanger themselves if you believe them to be impaired. If you are unable to resolve this situation yourself,
inform the MPs and your chain of command immediately.
_____ Ensure your vehicle has been inspected and is in safe running condition. This includes ensuring you comply with Host Nation Laws regarding seasonal tires.
_____ Do not wear your military uniform off base, except when traveling to and from your residence, unless there is an emergency.
_____ If you find your self in a situation and need help, contact me as soon as it is safe to do so. My numbers is (phone # of 1st line leader). If I am not available,
utilize your alert roster, which will provide you any number for your Chain of Command, CQ, Staff Duty, etc.
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)
Individual counseled remarks:
Leader Responsibilities:
(Leader's responsibilities in implementing the plan of action.)
(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.)
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.
Signature of Individual Counseled: Date:
Signature of Counselor: Date:
Individual Counseled: Date of Assessment:Counselor:
Note: Both the counselor and the individual counseled should retain a record of the counseling.
APD LC v1.03ES
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1. Soldier will comply with the contents of this counseling and all verbal elements of the safety briefing.
2. Soldier will ensure they have their leader contact card and my phone number on their person at all times during the pass period.
3. Soldier agrees to implement the following actions:
4. If he or she encounter any problems they are to contact me immediately
5. If I am unavailable they are to contact {phone # of next higher Soldier in NCO Support Channel or Chain of Command}
6. If the secondary POC is not available, the Soldiers will utilize the Alert roster to contact the Chain of Command. If no response from the chain of command, he or
she will immediately contact the unit staff duty office (CQ or Staff Duty phone #).
1. Ensure Soldier understands the contents of the counseling
2. Ensure Soldier has a unit leader card and/or phone numbers of key leaders in their immediate possession.
3. File copy of the counseling
4. Assist Soldier as required
5. Continue mentoring and coaching the Soldier to reiterate the importance of Ethical Leadership and Stewarding the Army Profession.
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