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. Disclosure of this information is voluntary.
NAME (Last, First, Middle Initial)
DIVISION/WORK CENTER/DUTY SECTION
NAME/GRADE OF COUNSELOR
REASON FOR COUNSELING
SUPPORT OF DEPENDENTS
REASONS WHICH CAUSED THE COUNSELING REQUIREMENT
(Give facts, details, sequence of events, specific dates, etc.)
NAVPERS 1616/25 (5-90)