Cc Form 104-R, Aug 13 - Military Student Success Center
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1
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3PLANNED ACADEMIC PROGRAM WORKSHEET
For use of this form, see CC Pam 145-4, the proponent agency is ATCC-PA-C
DATA REQUIRED BY PRIVACY ACT STATEMENT OF 1974
1. AUTHORITY: Title 10, US Code 2101 and 2104
2. PRINCIPAL PURPOSE(S): To provide information and data necessary for administering the Army Senior ROTC program, processing, and managing of selected students for commissioning in the Army IAW
established public law and Army Regulations.
3. ROUTINE USE(S): To provide a projected academic plan to determine if the applicant meets the public law requirements of two remaining academic years.
4. VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION : Voluntary information is necessary to determine eligibility of the individual for acceptance,
continuance, or discontinuance in the Army ROTC program.
1. NAME OF STUDENT (LAST, FIRST, MI)
2. ACADEMIC MAJOR
2a. CIP CODE
3. AS OF DATE (MM/DD/YYYY)
(Date of form preparation)
4. Academic School
5. CREDIT HOURS
6. GRADE POINT AVERAGE (GPA)
8
Select Semester or Quarter (S/Q)
Term:
Term:
a. Identification (Check one):
Curr GPA:
CUM:
Curr GPA:
Host
CGPA:
Extension Center
a. Total required for degree:
Term:
Term:
Curr GPA:
CUM:
Curr GPA:
Cross-Enrolled
(1) ROTC Hours that do not count:
CGPA:
Term:
Term:
(2) Total Hours Rqd for NAPS:
c. HOST SCHOOL
d. HOST FICE
Normal Academic Progression Standard
Curr GPA:
CUM:
Curr GPA:
CGPA:
c. Credits toward degree Comp to date:
Term:
Term:
b. Transfer Credits accepted:
Curr GPA:
CUM:
Curr GPA:
CGPA:
d. Remaining for Degree:
Term:
Term:
e. Number of authorized S/Qs:
Curr GPA:
CUM:
Curr GPA:
CGPA:
7.
TERM, YEAR, COURSE NUMBER, COURSE TITLE, COURSE CREDIT HOURS, CREDITS THAT COUNT TOWARDS ACADEMIC DEGREE, AND ACHIEVED GRADES.
a.
b.
c.
Term:
Year:
Term:
Year:
Term:
Year:
No.
Course Title
Hrs. Cts. Grd.
No.
Course Title
Hrs. Cts.
Grd.
No.
Course Title
Hrs. Cts. Grd.
Total Term Hours:
Total Term Hours:
Total Term Hours:
d.
e.
f.
Term:
Year:
Term:
Year:
Term:
Year:
No.
Course Title
Hrs. Cts.
Grd.
No.
Course Title
Hrs. Cts.
Grd.
No.
Course Title
Hrs.
Cts.
Grd.
Total Term Hours:
Total Term Hours:
Total Term Hours:
TERM 4:
TERM 7:
8. STUDENT INITIALS & DATE:
TERM 1:
TERM 5:
TERM 8:
(Have the student initial and date beside each
TERM 2:
term to indicate they have been counseled)
TERM 6:
TERM 9:
TERM 3:
Page 1 of 3
CC Form 104-R, AUG 13
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