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