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PRESEPARATION COUNSELING CHECKLIST
FOR ACTIVE COMPONENT (AC), ACTIVE GUARD RESERVE (AGR), ACTIVE RESERVE (AR),
FULL TIME SUPPORT (FTS), AND RESERVE PROGRAM ADMINISTRATOR (RPA) SERVICE MEMBERS
(Please read Privacy Act Statement and Instructions in Section III before completing this form.)

SECTION I - PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 1142, Preseparation Counseling; transmittal of medical records to Department of Veterans Affairs, and E.O. 9397 (SSN) as amended.
PRINCIPAL PURPOSE(S): To record preseparation services and benefits requested by and provided to Service members; to identify preseparation counseling areas of
interest as a basis for development of an Individual Transition Plan (ITP). The signed preseparation counseling checklist will be maintained in the Service member’s official
personnel file. Title 10 U.S.C. 1142 requires that not later than 90 days before the date of separation, for anticipated losses, preseparation counseling for Service members
be made available