Technical Exhibit 6 - eForm (2648).pdf

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SERVICE MEMBER PRE-SEPARATION/TRANSITION COUNSELING AND CAREER READINESS STANDARDS EFORM

FOR SERVICE MEMBERS SEPARATING, RETIRING, RELEASED FROM ACTIVE DUTY (REFRAD)

SECTION I - PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 1142, Pre-separation Counseling; transmittal of medical records to Department of Veterans Affairs.

PURPOSE(S): To record pre-separation counseling services and benefits requested by and provided to Service members; to identify pre-separation counseling areas of interest as a basis for development of an Individual Transition Plan (ITP). The signed pre-separation counseling checklist will be maintained in the Service member’s official personnel file. Title 10 USC 1142, requires that not later than 365 days before the date of separation, for anticipated losses, pre-separation counseling for Service members be made available. For unanticipated losses, or in the event a member of a reserve component is being demobilized under circumstances in which operational requirements make the 365-day requirement unfeasible, pre-separation counseling shall be made available as soon as possible within the remaining period.

ROUTINE USE(S): Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. Applicable Routine Use(s) are: To the Department of Veterans Affairs for available benefits to the Service member; additional routine uses are listed in the applicable system of records notice, DMDC 01, Defense Manpower Data Center Data Base; at https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570563/dmdc-01

DISCLOSURE: Voluntary; however, it may not be possible to initiate pre-separation counseling and other transition assistance services or develop an Individual Transition Plan (ITP) for a Service member if the information is not provided.

SECTION II – SERVICE MEMBER PERSONAL INFORMATION

1. NAME 2. DOD ID NUMBER 3. GRADE 4. DATE OF BIRTH 5. SERVICE 5a. COMPONENT

6. UNIT NAME 6a. UNIT ID CODE 7. MILITARY INSTALLATION

8. ANTICIPATED DATE OF SEPARATION 8a. REASON FOR SEPARATION 8b. TYPE OF SEPARATION 9. DATE FORM WAS INITIATED

10. MEMBER ALLOWS THIS FORM TO BE SENT TO FEDERAL AGENCIES FOR ADDITIONAL TRANSITION ASSISTANCE POST SEPARATION:

10a. MEMBER ALLOWS THIS FORM TO BE SENT TO FEDERAL AND OTHER AGENCIES WHO LOOK FOR CRITICAL LANGUAGE SKILLS AND/OR REGIONAL EXPERTISE THAT COULD BE VITAL DURING TIMES OF NEED, CRISIS, AND/OR NATIONAL EMERGENCIES:

10b. MEMBER ALLOWS THIS FORM TO BE SENT TO STATE AGENCIES FOR ADDITIONAL TRANSITION ASSISTANCE POST SEPARATION:

10c. POST-SEPARATION EMAIL: 10d. POST-SEPARATION PHONE NUMBER:

SECTION III – INITIAL COUNSELING

Service members shall receive individualized initial counseling pursuant to Title 10 U.S.C., Section 1142 and DoD policies.

11. SPOUSE/CAREGIVER/LEGAL GUARDIAN/DESIGNEE GOING TO BE PRESENT DURING PRE-SEPARATION COUNSELING:

12. HAS THE SERVICE MEMBER COMPLETED A PERSONAL SELF-ASSESSMENT:

13. HAS THE SERVICE MEMBER COMPLETED AN INITIAL COUNSELING: 13a. INITIAL COUNSELING COMPLETION DATE:

14. WHAT ARE THE SERVICE MEMBER'S POST-TRANSITION GOALS:

15. REQUIRED CRS AND SESSIONS BY SELECTED PATHWAY AND TIER:

SECTION IV – PRE-SEPARATION / TRANSITION COUNSELING, PRE-SEPARATION / TRANSITION COUNSELING NEEDS ASSESSMENT, REVIEW, AND VERIFICATION TO MEET CAREER READINESS STANDARDS (CRS), AND TITLE 10 U.S.C. COMPLIANCE Service members will be counseled on all items prescribed in Title 10, United States Code (U.S.C.), Sections 1142(b) (1-18), Sections 1143, 1144, 1145, 1146, 1147, 1148, 1149, 1150, 1151, 1154, and 1155 and DoD policies. Involuntarily separated Service members receive alternative benefits and programs that apply to them. Service member completed the following to meet Career Readiness Standards (CRS): *Required

16. Completed Pre-Separation Counseling* Pre-Sep Assessment

Capstone CRS Review

17. Registered on eBenefits *

18. Completed resume or provided employment verification in support of the Individual Transition Plan (ITP)

19. Prepared a criterion-based, post separation financial plan

20. Completed a criterion-based Individual Transition Plan (ITP) *

21. Completed a Continuum of Military Service Opportunity Counseling (Required Active Component Only)

22. Verify a completed Gap Analysis or provide verification of employment

23. Completed a comparison of higher education or vocational technical training institution options

24. I WAS COUNSELED AND RECEIVED DOCUMENTATION ON ALL ITEMS IN SECTION IV, WHICH INCLUDES ALL ITEMS LISTED ON THE PRE-SEPARATION /

TRANSITION COUNSELING ADDENDUM SHEET:

25. PRE-SEPARATION / TRANSITION COUNSELING WAS COMPLETED WITH 364 DAYS OR LESS REMAINING BEFORE SEPARATION:

25a. PRE-SEPARATION / TRANSITION COUNSELING COMPLETED 364 DAYS OR LESS JUSTIFICATION:

26. SERVICE MEMBER SIGNATURE & DATE 27. TRANSITION COUNSELOR SIGNATURE & DATE

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SECTION V – MANDATORY CURRICULUM ATTENDANCE

28. DoD TRANSITION DAY:

29. VETERANS AFFAIRS (VA) SERVICES AND BENEFITS:

30. DOL ONE-DAY:

SECTION VI – OTHER CURRICULUM ATTENDANCE

31. DOL EMPLOYMENT TRACK:

32. DOD EDUCATION TRACK:

33. SBA ENTREPRENEURSHIP TRACK:

34. DOL VOCATIONAL TRACK:

SECTION VII – WARM HANDOVER REQUIREMENTS

35. EVALUATED POST-TRANSITION TRANSPORTATION REQUIREMENTS AND DEVELOPED A PLAN TO MEET PERSONAL/FAMILY NEEDS:

36. EVALUATED POST-TRANSITION HOUSING REQUIREMENTS AND DEVELOPED A PLAN TO MEET PERSONAL/FAMILY NEEDS:

37. EVALUATED POST-TRANSITION PEER SUPPORT REQUIREMENTS AND DEVELOPED A PLAN TO MEET THESE NEEDS:

SECTION VIII – WARM HANDOVER TO SUPPORTING AGENCIES CONTACT INFORMATION

38. VETERANS AFFAIRS:

39. DEPARTMENT OF LABOR:

40. MILITARY ONE SOURCE:

41. OTHER RESOURCE:

SECTION IX – CAPSTONE REVIEW

42. SERVICE MEMBER SIGNATURE & DATE: 43. TRANSITION COUNSELOR SIGNATURE & DATE:

SECTION X – COMMANDER OR COMMANDER’S DESIGNEE VERIFICATION

44. APPLICABLE CAREER READINESS STANDARDS MET: 47. COMMANDER OR COMMANDER’S DESIGNEE SIGNATURE & DATE:

45. VIABLE ITP COMPLETED:

46. WARM HANDOVERS EXECUTED:

SECTION XI – REMARKS

48. REMARKS

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SECTION XI – REMARKS (CONTINUED)

48. REMARKS