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Disclosure of this information is voluntary. NAME Last First Middle Initial GRADE DIVISION/WORK CENTER/DUTY SECTION NAME/GRADE OF COUNSELOR SSN REASON FOR COUNSELING PERFORMANCE RESPONSIBILITIES OJT PROGRESS CAREER ADVANCEMENT SUPPORT OF DEPENDENTS PRIVATE INDEBTEDNESS SUBSTANDARD APPEARANCE PERSONAL BEHAVIOR OTHER Specify REASONS WHICH CAUSED THE COUNSELING REQUIREMENT Give facts details sequence of events specific dates etc. - NAVPERS 1616/25 5-90 NSN 0106-LF-010-1000 PLAN DEVELOPED BY THE MEMBER AND COUNSELOR TO CONTINUE SUPERIOR PERFORMANCE OR TO OVERCOME PROBLEM S AND PRECLUDE FUTURE INVOLVEMENT Outline all resolutions discussed and indicate which actions the member has personally elected to pursue. DATE RECORD OF ENLISTED COUNSELING PRIVACY ACT STATEMENT The authority for requesting the following information is contained in 5 U*S*C. sec* 301 10 U*S*C. 5947 44 U*S*C. sec* 3101 and Executive Order No* 9397. This information will be used to document quality force counseling actions not prescribed in other directives. Department of the Navy personnel may also use the information for evaluations and determinations in disciplinary punitive and/or administrative actions. Signature of Counselor/Date Signature of Member/Date I do/do not desire to make a statement. U*S* GPO 19W-704-119/20152. DATE RECORD OF ENLISTED COUNSELING PRIVACY ACT STATEMENT The authority for requesting the following information is contained in 5 U*S*C. sec* 301 10 U*S*C. 5947 44 U*S*C. sec* 3101 and Executive Order No* 9397. This information will be used to document quality force counseling actions not prescribed in other directives. sec* 301 10 U*S*C. 5947 44 U*S*C. sec* 3101 and Executive Order No* 9397. This information will be used to document quality force counseling actions not prescribed in other directives. Department of the Navy personnel may also use the information for evaluations and determinations in disciplinary punitive and/or administrative actions. DATE RECORD OF ENLISTED COUNSELING PRIVACY ACT STATEMENT The authority for requesting the following information is contained in 5 U*S*C. sec* 301 10 U*S*C. 5947 44 U*S*C. sec* 3101 and Executive Order No* 9397. This information will be used to document quality force counseling actions not prescribed in other directives. Department of the Navy personnel may also use the information for evaluations and determinations in disciplinary punitive and/or administrative actions. .

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