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Notice:  Required by the Privacy Act of 1974  (5 USC 552a).

 

      Prior to soliciting any personal information in the course of counseling a soldier, the counselor will advise the soldier substantially as follows:

 

      In the course of counseling you concerning the decisions you will have to make in connection with your pregnancy, I will request certain personal information from you.  My only purpose in requesting this information is to assist you in planning how to meet your responsibilities to the child and to the military, and to determine if there is anything that I or the Army can do to assist you in meeting those responsibilities.  Disclosure of your SSN and other personal information is voluntary.  You are not required to provide personal information to me, but Army regulations require that you complete a Statement of Counseling.  If you choose not to provide personal information to me, however, I may not be able to effectively assist you.  No use of the information will be made outside the Department of Defense.  A copy of the Statement of Counseling will be maintained in your MPRJ until this action is completed, at which time it will be destroyed.  My authority for requesting this information is Section 3013, Title 10, United States Code.

 

      The purpose of this counseling is to inform you of the options, entitlements, and responsibilities in connection with your pregnancy.

 

Information on your entitlements:

 

a.        Retention or separation:

 

(1)    You may request separation or elect to remain on active duty.

(2)    For more information, see paragraph 8-9, AR 635-200.

 

b.        Maternity Care

 

(1)    If you remain on active duty you will receive treatment in a military facility or in a civilian facility, if there is no military maternity care available within 30 miles of your location.

(2)    If you separate, you are authorized treatment only in a military facility that has maternity care.  You are NOT authorized care in a civilian facility at Government expense.

(3)    For more information see AR 40-3, paragraph 2-35 for care while on active duty; AR 40-3, paragraph 4-44, for care after separation.

 

c.        Leave:

 

(1)    You may request ordinary leave, advance, and excess leave in order to return home, or other appropriate place, for the birth of your child or to receive other maternity care.  Such leave usually terminates with the onset of labor.

(2)    Non-chargeable convalescent leave for postpartum care is limited to the amount of time essential to meet your medical needs.

(3)    For more information see AR 630-5, chapter 9, section II.

 

d.        Maternity Clothing and Uniforms:

 

(1)    Military maternity uniforms will be provided to soldiers.

(2)    For more information see AR 670-1, chapter 4.

 

e.        BAQ and Government Quarters:

 

(1)    Availability depends upon the status of quarters at your installation.

(2)    For more information see the Post Housing Office.

 

f.        Assignments:

 

(1)    You will not normally receive PCS orders directing movement overseas during your pregnancy.  However, you are considered available for unrestricted worldwide assignment upon completion of postpartum care.

(2)    For more information see AR 614-30, paragraph 3-3.

 

g.        Separation for Unsatisfactory Performance, Misconduct, or Parenthood:

 

(1)    If your performance or conduct warrants separation for unsatisfactory performance, or if parenthood interferes with your duty performance, you may be separated involuntarily even though you are pregnant.

(2)    For more information see paragraph 5-8 and chapters 11, 13, and 14.

 

h.        Family Care Counseling:

 

(1)    You must have an approved family care plan on file stating actions to be taken in the event you are assigned to an area where dependents are not authorized or you are absent from your home on military duty.  Failure to develop an approved care plan will result in a bar to re-enlistment.

(2)    For more information see the Post Housing Office.

 

Should you desire assistance gathering additional information on the above subjects, I will assist you in locating the appropriate information.  Further, if you desire, I will assist you in contacting the American Red Cross or other appropriate agencies.

 


 

 

I affirm that I have been counseled by ___________________ this date on all items on the attached counseling checklist, and I understand my entitlements and responsibilities.  I understand that if I elect separation, I may receive maternity care at Department of Defense expense, on a space available basis for up to 6 weeks postpartum for the birth of my child only in a military medical treatment facility that has maternity care capability and that I may elect a separation date no later than 30 days prior to expected date of delivery of the latest date my physician will authorize me travel, whichever is earlier.  Further, I understand that many military medical treatment facilities cannot provide maternity care and that unforeseen circumstances or medical emergency could force me to use civilian medical treatment facilities following separation from active duty.  Should this happen, I fully understand that UNDER NO CIRCUMSTANCES can TRICARE, any military department, or the Department of Veterans Affairs reimburse my civilian maternity care expenses.  Such costs will be a matter of my personal responsibility.  Further, I understand that if I should remain on active duty, I will be expected to fulfill the terms of my enlistment contract.  If I elect to remain on active duty, I understand that I must remain available for unrestricted service on a worldwide basis when directed and that I will be afforded no special consideration in duty assignments based upon my status as a parent.

 

 

 

___________                         ______________________

(Date)                              (Signature of Soldier)

 

 

TO:  (Soldier Concerned)                                    Date

FROM:  (Commander, Unit)

 

 

Request your election of appropriate option indicated below and return within 72 hours.

 

 

 

                                          _______________________________

                                          CPT, __

                                          Commanding

 

 

TO:  (Commander, Unit)                                      Date

FROM:  (Soldier Concerned)

 

 

_____ During the counseling session, there was no coercion on the part of the counselor influencing my decision.

 

_____ I elect separation for reason of pregnancy per AR 625-200, Chapter 8.  I desire to remain on active duty until __________. 

 

_____ I elect to remain on active duty to fulfill the terms of my enlistment contract.

 

 

 

                                          ______________________________

                                          (Signature of soldier)

1 Copy MPRJ (Action Pending)

1 Copy Soldier

1 Copy File

                                         

 

 

 

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