The 104 R form is a Planned Academic Program Worksheet used by the Army Senior ROTC program. This form collects essential information to manage and process students for commissioning in the Army, ensuring they meet the academic requirements set by public law and Army regulations. Completing this form is crucial for students to outline their academic plans and demonstrate eligibility for the ROTC program.
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The 104 R form, known as the Planned Academic Program Worksheet, is essential for managing the Army Senior ROTC program. It collects information necessary for assessing a student's eligibility and academic progress. Several other documents are commonly used alongside this form to ensure a comprehensive understanding of a student's academic journey and requirements.
These documents collectively support the administration of the ROTC program and help students navigate their academic paths effectively. Each plays a role in ensuring that students meet the necessary requirements for success in their educational and military endeavors.
PLANNED ACADEMIC PROGRAM WORKSHEET
For use of this form, see USACC Pam 145-4, the proponent agency is ATCC-PA-C
DATA REQUIRED BY PRIVACY ACT STATEMENT OF 1974
1.AUTHORITY: Title 10, US Code 2101 and 2104
2.PRINCIPAL PURPOSE(S): To provide information and data necessary for administering the Army Senior ROTC program, processing, and managing of selected students for commissioning in the Army IAW established public law and Army Regulations.
3.ROUTINE USE(S): To provide a projected academic plan to determine if the applicant meets the public law requirements of two remaining academic years.
4.VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Voluntary information is necessary to determine eligibility of the individual for acceptance,
continuance, or discontinuance in the Army ROTC program.
1. NAME OF STUDENT (LAST, FIRST, MI)
2. ACADEMIC MAJOR
2a. CIP CODE
3. AS OF DATE (MM/DD/YYYY) (Date of form preparation)
4. ACADEMIC SCHOOL
5. CREDIT HOURS
6. GRADE POINT AVERAGE (GPA)
Select Semester or Quarter (S/Q)
Semester
Term:
a. IDENTIFICATION (Check one):
Host
Curr GPA:
CUM:
CGPA:
Extension Center
a. Total required for degree:
1
Cross-Enrolled
(1) ROTC Hours that do not count:
(2) Total Hours Rqd for NAPS:
b. HOST SCHOOL
c. HOST FICE
Normal Academic Progression Standard
b. Credits toward degree Comp to date:
c. Transfer Credits accepted:
d. Remaining for Degree:
e. Number of authorized S/Qs:
7.TERM, YEAR, COURSE NUMBER, COURSE TITLE, COURSE CREDIT HOURS, CREDITS THAT COUNT TOWARDS ACADEMIC DEGREE, AND ACHIEVED GRADES.
a.
Year:
No.
Course Title
Hrs. Cts. Grd.
Total Term Hours:
d.
b.
e.
c.
f.
8. STUDENT INITIALS & DATE:
(Have the student initial and date beside each term to indicate they have been counseled)
TERM 1:
TERM 2:
TERM 3:
TERM 4:
TERM 7:
TERM 5:
TERM 8:
TERM 6:
TERM 9:
USACC Form 104-R, SEP 13
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7.TERM, YEAR, COURSE NUMBER, COURSE TITLE, COURSE CREDIT HOURS, CREDITS THAT COUNT TOWARDS ACADEMIC DEGREE, AND ACHIEVED GRADES. (CONTINUED)
g.
h.
i.
j.
k.
l.
m.
n.
o.
Hrs.
Cts.
Grd.
9. REVIEW: All of the above courses are required (as minimum) for the completion of the degree:
YES
NO (if no, list exceptions on reverside of this form).
Completion should result in
degree, during (Month, Year):
10.
SIGNATURE OF STUDENT:
11.
DATE: (MM/DD/YYYY)
12.
SIGNATURE OF REGISTRAR AND EXAMINER OF CREDENTIALS (OR OTHER INSTITUTION CERTIFYING OFFICIAL):
13.
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STATEMENT OF UNDERSTANDING
We, the undersigned, hereby declare that the program outlined on the worksheet (on the reverse side of this statement) that
Cadet
is about to under take a formally structured program approved by
(FULL NAME, Last, First, MI)
(Name of University or College)
designed to meet the requirments of a
degree; that the degree to be attained is the culmination of an
(Type of Degree)
undergraduate college program of at least four years; and that the remaining credit hours shown on the worksheet are necessary either to fulfill
discipline requirements or to fulfill credit hour requirements, or both, for the attainment of the degree. If the Cadet is an ROTC Scholarship
participant, the scholarship will be in force for the number of semesters indicated in Block 5.
(Date) (MM/DD/YYYY)
(CADET SIGNATURE)
(PROFESSOR OF MILITARY SCIENCE SIGNATURE)
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