PRESEPARATION COUNSELING CHECKLIST
(Please read Privacy Act Statement below before completing this form.)
SECTION I - PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 1142, E.O. 9397.
PRINCIPAL PURPOSE(S): To record preseparation services and benefits requested by and provided to Service members; to identify
preseparation counseling areas of interest as a basis for development of an Individual Transition Plan (ITP). The signed preseparation
counseling checklist will be maintained in the Service member's official personnel file. Title 10, USC 1142, requires that not later than 90
days before the date of separation, preseparation counseling for Service members be made available.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, it will not be possible to initiate preseparation services or develop an Individual Transition Plan (ITP) for a
Service member if the information is not provided.
SECTION II - PERSONAL INFORMATION (To be filled out by all applicants)
1. NAME (Last, First, Middle Initial)
2. SSN
3. GRADE
6. EXPECTED SEPARATION DATE
7. DATE CHECKLIST PREPARED
4. SERVICE
5. DUTY STATION
(YYYYMMDD)
(YYYYMMDD)
SECTION III. ALL TRANSITIONING SERVICE MEMBERS MUST READ AND SIGN.
I was offered preseparation counseling on the above date (Item 7) on my transition benefits and services as appropriate. I understand that
this preseparation counseling is provided to assist my transition process as required by Title 10, USC 1142.
I
accept
decline (X appropriate block) further transition assistance counseling. (If you declined further transition assistance
counseling, sign and date.) I have checked those items where I desire further information or counseling. I have also been advised where to
obtain assistance in developing an Individual Transition Plan (ITP).
b. DATE (YYYYMMDD)
8a. SERVICE MEMBER SIGNATURE
b. DATE (YYYYMMDD)
9a. TRANSITION COUNSELOR SIGNATURE
SECTION IV. Please indicate (by checking YES or NO) whether you (or your spouse if applicable) desire counseling for the following services
and benefits. All benefits and services checked YES should be used in developing your ITP. The following services and benefits are
available to all Service members, unless otherwise specified:
SERVICE MEMBER
SPOUSE
REFERRED TO
(Input is optional)
NO
N/A
YES
NO
N/A
YES
10. INDIVIDUAL TRANSITION PLAN (ITP)
11. EFFECTS OF A CAREER CHANGE
12. EMPLOYMENT ASSISTANCE
a. Dept. of Labor sponsored Transition Assistance Program and
Service sponsored Transition Seminars/Programs
b. Use of DD Form 2586 (Verification of Military
Experience and Training)
c. DoD Job Search (dod.jobsearch.org) and
Public and Community Service (PACS) Register
d. Transition Bulletin Board (TBB)
e. Teacher and Teacher's Aide Opportunities
f. Federal Employment Opportunities
g. Hiring Preference in Non-Appropriated Fund (NAF) jobs
(VSI, SSB, Eligible Involuntary Separatees)
h.
State Employment Agencies/America's Job Bank
13.
RELOCATION ASSISTANCE
*NOTE: Status of Forces Agreement limitations apply for overseas Service members.
a.
Permissive (TDY/TAD) and Excess leave
*b.
Travel and transportation allowances
*c. Military family housing extension (VSI, SSB, and
Eligible Involuntary Separatees)
*d. Commissary, exchange benefits extension and MWR Privileges
(VSI, SSB, Eligible Involuntary Separatees)
*e. DODDS school extension (Eligible Involuntary Separatees)
DD FORM 2648, NOV 1999
PREVIOUS EDITION MAY BE USED UNTIL EXISTING STOCK IS EXHAUSTED.
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