Da Form 67-9-1 Officer Evaluation Report Support Form printable pdf download

Da Form 67-9-1 Officer Evaluation Report Support Form

FOR OFFICIAL USE ONLY (FOUO)

OFFICER EVALUATION REPORT SUPPORT FORM

SEE PRIVACY ACT STATEMENT IN

AR 623-3

For use of this form, see

; the proponent agency is DCS, G-1.

AR 623-3.

PART I - RATED OFFICER IDENTIFICATION

DESIGNATED/PMOS

NAME OF RATED OFFICER (Last, First, MI)

SSN

RANK

DATE OF RANK (YYYYMMDD)

BRANCH

(WO) SPECIALITIES

UNIT, ORG., STATION ZIP CODE OR APO, MAJOR COMMAND

STATUS CODE

FROM DATE

UIC

CMD CODE

PSB CODE

PART II - AUTHENTICATION

NAME OF RATER (Last, First, MI)

SSN

RANK

POSITION

NAME OF INTER. RATER (Last, First, MI)

SSN

RANK

POSITION

NAME OF SENIOR RATER (Last, First, MI)

SSN

RANK

POSITION

PART III - VERIFICATION OF FACE-TO-FACE DISCUSSION

MANDATORY RATER / RATED OFFICER INITIAL FACE-TO-FACE COUNSELING ON DUTIES, RESPONSIBILITIES AND PERFORMANCE OBJECTIVES FOR THE

(Date)

Rated Soldier Initials

Rater Initials

Senior Rater Initials

CURRENT RATING PERIOD TOOK PLACE ON

(Review)

PERIODIC RATER / RATED OFFICER FOLLOW-UP FACE-TO-FACE COUNSELINGS:

Senior Rater Initials

Dates

Rated Soldier Initials

Rater Initials

(Review)

PART IV - RATED OFFICER

(Complete Part IV and Part V below for this rating period)

PRINCIPAL DUTY TITLE

POSITION AOC / BR

a. STATE YOUR SIGNIFICANT DUTIES AND RESPONSIBILITIES:

b. INDICATE YOUR MAJOR PERFORMANCE OBJECTIVES:

Page 1 of 2

DA FORM 67-9-1, OCT 2011

PREVIOUS EDITIONS ARE OBSOLETE.

APD PE v1.00ES

Da Form 67-9-1 Officer Evaluation Report Support Form

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