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                                  DEVELOPMENTAL COUNSELING FORM
                                                                   For use this form see FM 22-100
                                                        DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)
PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates
ROUTINE USES: For subordinate leader development IAW FM 22-100 leaders should use this form as necessary
DISCLOSURE: Disclosure is voluntary  
                                                                       PART I - ADMINISTRATIVE DATA
Name (Last, First, MI)
Rank/Grade
Social Security No.
Date of Counseling
Organization
Name and Title of Counselor
                                                                    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 leaders facts
and observations prior to the counseling)

Event-Oriented: Violation of article 91 (Insubordinate conduct toward a Warrant Officer, Noncommissioned Officer, or Petty Officer) of the
Uniform Code Of Military Justice in that on or about (date) at (location) you were disrespectful/disobeyed (NCO's name) your superior
Noncommissioned Officer. (state in detail what happened).
                                                                   PART III - SUMMARY OF COUNSELING
                                           Complete this section during or immediately subsequent to the counseling

Key Points of Discussion:

Disrespect/Disobeying a superior Noncommissioned Officers is a crime and is unacceptable behavior that will not be
tolerated. If found guilty of this offense, the maximum punishment is ______________________. Your misconduct has
been detrimental to unit morale and the discipline of this organization and will not be repeated. (I am recommending that
the commander impose nonjudicial punishment for your misconduct) OR (You will receive corrective training as outlined in
the plan of action).



You are here by notified that if this type of conduct continues, actions may be initiated under the Uniform Code of Military
Justice to separate you from the Army prior to your scheduled ETS Date IAW AR 635-200.  If you are involuntary
separated, you could receive an Honorable Discharge, a General (Under Honorable Conditions) Discharge, or a Under
Other Than Honorable Conditions Discharge. If you receive a discharge Under Other Than Honorable Conditions, you will
be ineligible for reenlistment and for most benefits, including payments of accrued leave, transitional benefits, the
Montgomery GI Bill, VA benefits, and You may also face difficulty in obtaining civilian employment.   
                                                                                     OTHER INSTRUCTIONS
This form will be destroyed upon reassignment (other than rehabilitative transfers), separations at ETS, or upon retirement. For separation requirements
and                                                                                       notification of loss of benefits/consequenses see local directives and AR 635-200
DA 4856 Counseling, Article 91 Insubordinate conduct toward a warrant officer, Noncommissioned officer, or petty officer: Any Warrant
officer or enlisted member of the armed forces who, (1)strikes  or assaults a Warrant Officer, Noncommissioned Officer, or Petty Officer while
that Officer is in execution of his/her office; (2) Willfully disobeys the Lawful orders of a Warrant Officer, Noncommissioned Officer, or Petty
Officer; (3) treats with contempt or is disrespectful in language or deportment toward a Warrant Officer, Noncommissioned Officer, or Petty
Officer while that Officer is in execution of his/her Office;  may be punished under article 91.
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Insubordinate conduct toward a Noncommissioned officer of the UCMJ. Requires Pure edge viewer
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