Free army counseling form 18
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HURT FEELINGS REPORT
(Army Negative Counseling Form)
For use of this form, see FM 22-102; the proponent agency is TRADOC
AUTHORITY:
PRINCIPAL PURPOSE:
ROUTINE USES:
DISCLOSURE:

DATA REQUIRED BY THE PRIVACY ACT OF 1974
5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)
To assist whiners in documenting hurt feelings, and to provide leaders with a list of soldiers who require additional counseling,
NCO leadership, and extra duty..
For subordinate leader development IAW FM 22-102. Leaders & whiners should use this form as necessary.

Disclosure is voluntary, but repeated disclosure may result in a DA Form 779-1A, Report of Wall To Wall Counseling

PART I – ADMINISTRATIVE DATA
A. WHINER’S NAME (Last, First, MI)

B. RANK/GRADE

E. ORGANIZATION

C. SOCIAL SECURITY NUMBER

D. DATE OF REPORT

F. NAME & TITLE OF THE PERSON FILLING OUT THIS FORM

PART II – INCIDENT REPORT
A. DATE FEELINGS WERE HURT

B. TIME OF HURTFULNESS

E. NAME OF REAL MAN/WOMAN WHO HU