STATEMENT OF IMMEDIATE SUPERIOR
ADMINISTRATIVE SEPARATION STATEMENT OF CHARACTERInstructions: Type or print legibly. This statement will be reviewed by the Commanding General to determine whether to separate the subject Marine or Sailor and if separated, with what characterization of service. Be candid and thorough and provide a balanced picture to include negative and positive aspects. Use additional blank pages if necessary.1. Person making statement:_____________________________________________________________Rank Name (First, MI, Last) MOS Unit Phone#2. Statement of character regarding:___________________________________________________________________Rank Name (First, MI, Last) Unit 3. Position/billet in relation to above-named individual:___________________________________________________________________4. State when your acquaintance or supervision of this individual began and, if applicable, when it ended:______________________________________________________________________________________________________________________________________5. During this period, what were his/her specific duties?_________________________________________________________________________________________________________________________________________________________________________________________________________6. Frequency of contact with this individual?___________________________________________________________________7. What is your opinion of his/her work performance?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8. What is your opinion of his/her conduct, both in the workplace and, to the extent you are aware, after working hours? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________9. What is your opinion as to his/her character, such as truthfulness, honesty, work ethic, etc.?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________10. What steps have you taken to rehabilitate and improve this Marine or Sailor? Have you taken any steps beyond informal counseling? Why or why not?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________11. Do you believe he/she has potential for further honorable service? Explain.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________12. How willing are you to serve with him/her in the future in garrison? In combat?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________13. Based upon his/her entire record of service, including the current basis for discharge, what disposition do you recommend?(Circle one)a. RETENTIONb. HONORABLEc. GENERALd. OTHER THAN DISCHARGE DISCHARGE HONORABLE DISCHARGEe. SUSPENSION OF Af. SUSPENSION OF AN OTHER GENERAL DISCHARGE THAN HONORABLE DISCHARGE__________________________________________________________Printed NameDateSignatureDate Revised Sep 09 ................
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