Adverse Action Checklist for Deciding Officials

1. Employee's Name:_________________________________________

2. Action Proposed and Date of Proposal:__________________________

3. Reply. Check one or more of the following:

• The employee did not reply.

• The employee replied in writing (original is attached).

• The employee replied orally (original of MFR, signed by the employee,
  is attached).

4. Below is a list of everything I have considered in reaching my decision in this case (You may consider the material which was used to develop the charges against the employee, such as witness statements, photographs, documents, and the proposal letter. You may not consider unrelated charges or evidence to which the employee has not been given an opportunity to respond. For example, if the employee has a charge of stealing before you for make a decision and you hear from another individual that he was AWOL yesterday, you may not consider the AWOL).

5. Douglas Factors. The following factors may weigh for, or against, the
employee in determining the appropriateness of a penalty for misconduct. I have
considered each of the following in reaching a final decision. (Document your consideration, including a "none" or "not applicable" if the factor was not applicable in this case).

• The nature and seriousness of the offense and its relation to the
  employee's duties, position, and responsibilities, including whether the
  offense was intentional or technical or inadvertent, or was committed
  maliciously or for personal gain, or was frequently repeated.

• The employee's job level and type of employment, including supervisory or fiduciary role, contact with the public, and prominence of the position.

• The employee's past disciplinary record.

• The employee's past work record, including length of service, performance on the job, ability to get along with fellow workers, and dependability.

• The effect of the offense upon the employee's ability to perform at a
  satisfactory level and its effect upon supervisors' confidence in the employee's ability to perform assigned duties.

• Consistency of the penalty with those imposed upon other employees for the same or similar offenses.

• Consistency of the penalty with the DA Table of Penalties Pertaining to Various Offenses (AR 690-700, Chapter 751, C5, Table 1-1).

• The notoriety of the offense or its impact upon the reputation of the
  Department of Army.

• The clarity with which the employee was on notice of any rules that
  were violated in commiting the offense, or had been previously warned about the
  conduct in question.

• The potential for the employee's rehabilitation.

• Mitigating circumstances surrounding the offense such as unusual job
  tensions, personality problems, mental impairment, harassment, bad faith, malice, or provocation on the part of the others involved in the matter.

  
  

• Specify:
  ___________________________________________________________________
  ___________________________________________________________________
  ___________________________________________________________________

• The adequacy and effectiveness of alternative sanctions to deter such
  conduct in the future by the employee or others.

• Other:
  __________________________________________________________________
  __________________________________________________________________
  __________________________________________________________________

5. The employee raised the issue of discrimination on the basis of race, color, religion, sex, national origin, age, or handicap. He/she brought this matter to my attention on _________________(date) on the basis of ___________(factor).

6. Decision. After giving full and imparital consideration to the circumstances
surrounding the proposed action, the employee's reply (ies), and factors above, I have decided to (check one of the following:)

• Cancel the proposed action in its entirety.

• Sustain the action as proposed.

• Reduce the penalty to _____________________________________________
  __________________________________________________________________

7. Additional Comments:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

_______________________________________________________________
_______________________________________________________________
Name, Title, and Signature of Deciding Official and Date