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PERSONNEL ACTION
For use of this form, see PAM 600-8; the proponent agency is DCS, G-1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Title 10, USC, Section 3013, E.O. 9397 (SSN), as amended
AUTHORITY:
PRINCIPAL PURPOSE:
To request or record personnel actions for or by Soldiers in accordance with DA PAM 600-8.
The DoD Blanket Routine Uses that appear at the beginning of the Army's compilation of systems of records may
ROUTINE USES:
apply to this system.
Voluntary; however failure to provide Social Security Number may result in a delay or error in processing the
DISCLOSURE:
request for personnel action.
3. FROM (Include ZIP Code)
1. THRU (Include ZIP Code)
2. TO (Include ZIP Code)
Soldier's Higher Headquarters
U.S. Army Human Resources Command
Soldier's Current Unit of Assignment
Complete mailing address
1600 Spearhead Division Avenue,
Include complete mailing address
Department 480
Fort Knox, KY 40122-5408
SECTION I - PERSONAL IDENTIFICATION
4. NAME (Last, First, MI)
5. GRADE OR RANK/PMOS/AOC
6. SOCIAL SECURITY NUMBER
Doe, John A.
E-5/11B2O
123-45-6789
SECTION II - DUTY STATUS CHANGE (AR 600-8-6)
7. The above Soldier's duty status is changed from
to
effective
hours,
SECTION III - REQUEST FOR PERSONNEL ACTION
8. I request the following action: (Check as appropriate)
(Enl only)
Service School
Special Forces Training/Assignment
Identification Card
(Enl only)
ROTC or Reserve Component Duty
On-the-Job Training
Identification Tags
Volunteering For Oversea Service
Retesting in Army Personnel Tests
Separate Rations
Ranger Training
Reassignment Married Army Couples
Leave - Excess/Advance/Outside CONUS
Reassignment Extreme Family Problems
Reclassification
Change of Name/SSN/DOB
Other (Specify)
(Enl only)
Officer Candidate School
Exchange Reassignment
Award of the Combat XXXXX Badge
Airborne Training
Asgmt of Pers with Exceptional Family Members
9. SIGNATURE OF SOLDIER (When required)
10. DATE (YYYYMMDD)
SECTION IV - REMARKS (Applies to Sections II, III, and V) (Continue on separate sheet)
1. Request that SFC _______________ be awarded the Combat _______ Badge for personally being engaged by the enemy.
2. The following information is provided:
a. Date of Engagement:
b. Location:
c. Soldier (example) was within XX meter(s) from impact of (circle one) Small Arms Fire, Sniper Fire, IED, VBIED, or Artillery.
Soldier performed medical duties while under fire.
3. Situation: While providing security at the New Baghdad Police Station during the Iraqi's Free Elections, SFC ________ came
under direct fire. Additional information is provided in the narrative and eyewitness statements.
Enclosures:
1-DA Form 4187
2-DD Form 214
3-Deployment/Mobilization Orders
4-Narrative
5-ORB/ERB/DA Form 2-1
6-Eyewitness Statements (Minimum 2, other than the recommended recipient)
7-Incident Report
8-Commander's Recommendation
SECTION V - CERTIFICATION/APPROVAL/DISAPPROVAL
11. I certify that the duty status change (Section II) or that the request for personnel action (Section III) contained herein -
HAS BEEN VERIFIED
RECOMMEND APPROVAL
RECOMMEND DISAPPROVAL
IS APPROVED
IS DISAPPROVED
12. COMMANDER/AUTHORIZED REPRESENTATIVE
13. SIGNATURE
14. DATE (YYYYMMDD)
SUPERSEDES DA FORM 4187, JAN 2000
DA FORM 4187, MAY 2014
Page 1 of 2
AND REPLACES DA FORM 4187-1-R, APR 1995
APD LC v1.03ES