(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
Page 1 of 2
Schmidlapp, Joe
01 Jan 2015
A Company 1st Battalion, 35th Armor Regiment
o Event-oriented counseling for PFC Schmiplapp
o The purpose of this counseling is to discuss PFC Schmiplapp's violation of
Article 92: Failure to obey order or regulation
Article 107: False official statements
Article 86: Failure to report
PFC Schmidlapp, last Friday 01 Jan during the platoon closeout formation I put out the standards once again of how you go about any appointments. Show your
appointments to your leadership and they will write it on the appointment board. Also I put out for all soldiers not going to the Solder's Academy the following
Monday to in the conference room at 0930 for work call.
Monday morning 02 Jan, before PT formation you informed your team leader SGT Smith that you had a appointment at the pain center off post in Tenino at 0900.
That afternoon around 1400, you were not in the company area and I had SPC Doe have you report to me. You returned to the company around 1315 (late from lunch)
and were told to work on your leave packet in your room. When I asked you about your appointment you said that you were contacted by your PEBLO by phone that
you had an appointment that morning at 0930. My reason for asking was due to you not being in the company area (your place of duty). You said that you left at 0915
to report there by 0930 and that you had the appointment slip in your room. I already checked my appointment board and saw that you had no scheduled appointments
written down at all for the week. You told me that you have at least 5 appointments each week, also that your PEBLO can just call you to appointment without giving
you a slip or anything.
After giving mixed information I took you to the battalion where SGT Smith was attending the Soldier's Course and asked him in front of you what you told him that
morning exactly about your appointment. He confirmed that you told him that you had an off post appointment at the pain center at 0900. You also did not return to
the company area as you were suppose to but went to the PX instead and did not get back until 1030-1050. The PX or shopette does not take 1 hour to drive to and get
cigarettes. I took you to the 1SG and Commander to inform them of what had happened. Once we left the office I took you to the Soldier Support Center. By now
you said that you did not have an appointment but had to drop off your jump log and that you were mistaken about having an appointment slip. Once we arrived at the
Med Board office on the seventh floor, the ladies at the front desk said that they did not have your jump log on file and you could not remember who you left it with.
The ladies said you were not assigned to their office but in the downstairs PEBLO office.
You signed into your PEBLO's office where I found out you had never been to, nor did they have your jump log. We then spoke with your PEBLO and his assistant
whom confirmed that you can receive a phone call informing you of an appointment but that you would also have an e-mail to confirm it. Your PEBLO (whom you
have never met with) then accompanied us upstairs to help find this missing jump log. He and the receptionist upstairs never still could not find this. PFC Schmidlapp,
I believe that you never took your jump log to the office that morning. PFC Schmidlapp on 02 Jan you made false statements (Art. 107) to two non-commissioned
officers about your appointment off base, at the Soldier Support Center and about having an appointment slip in your room. You failed to obey an order (Art. 92) by
not providing proof of your appointment to your team leader. You also failed to report (Art. 86) to your place of duty after going to the SSC to drop off a jump log that
isn’t there, then going to the PX and for returning to work at 1315 when you are to report by 1300.
I am counseling you for the conduct noted above. Be advised that continued conduct of this nature may result in initiation of a bar to reenlistment, administrative action
to include your separation from the service, and/or punitive action (i.e. UCMJ action). If this conduct continues, action may be initiated to involuntarily separate you
from the service under AR 635-200, Chapter 5, 11, 13 or 14. If you are involuntarily separated, you could receive an Honorable, General Under Honorable Conditions,
Other Than Honorable, or Uncharacteristic Discharge. An Honorable Discharge may be awarded under Chapter 5, 13 and 14. An Uncharacteristic Discharge may be
awarded under Chapter 11. A General Under Honorable Conditions Discharge may be awarded under Chapter 5, 13 and 14. An Other Than Honorable Discharge may
be awarded under Chapter 14. If you receive an Honorable Discharge, you will be qualified for most benefits resulting from your military service.
******Continue magic bullet******
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
Page 2 of 2
o PFC Schmidlapp will report all appointments to me until I state otherwise.
o PFC Schmidlapp will report to first call by 0545 every work morning unless instructed to be somewhere else by your chain of command. You will be at your place
of duty. Not in your room for any reason during the duty day unless told otherwise by your chain of command
o PFC Schmidlapp cover down on 2 weekend CQ shifts for corrective action. The shifts will run from Saturday to Sunday.
o If PFC Schmidlapp is not at his place of duty, on time, disobeying an order or found making false statements, then he will be recommended for UCMJ action.
o I will ensure that the PFC Schmidlapp is fully briefed on what is expected of him.
o I will make sure the Soldier fully understands what was outlined in the key points of discussion and plan of action.
o I will see all of PFC Schmidlapp's appointment slips, e-mails, etc..
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