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Fill in a Valid 104 R Form

The 104 R form is a Planned Academic Program Worksheet used primarily within the Army Senior ROTC program. This form collects essential information to ensure that students meet the necessary academic requirements for commissioning into the Army. By outlining the academic plan, it helps both students and administrators track progress and maintain eligibility for the program.

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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:

Curr GPA:

CGPA:

Extension Center

a. Total required for degree:

Term:

Cross-Enrolled

(1) ROTC Hours that do not count:

Curr GPA:

CUM:

Curr GPA:

CGPA:

(2) Total Hours Rqd for NAPS:

Term:

b. HOST SCHOOL

c. HOST FICE

Normal Academic Progression Standard

Curr GPA:

CUM:

Curr GPA:

CGPA:

b. Credits toward degree Comp to date:

Term:

c. Transfer Credits accepted:

Curr GPA:

CUM:

Curr GPA:

CGPA:

d. Remaining for Degree:

Term:

e. Number of authorized S/Qs:

Curr GPA:

CUM:

Curr GPA:

CGPA:

7.TERM, YEAR, COURSE NUMBER, COURSE TITLE, COURSE CREDIT HOURS, CREDITS THAT COUNT TOWARDS ACADEMIC DEGREE, AND ACHIEVED GRADES.

Term:		Year:
No.	Course Title	Hrs. Cts. Grd.

Total Term Hours:

Term:		Year:
No.	Course Title	Hrs. Cts. Grd.

Total Term Hours:

Term:		Year:
No.	Course Title	Hrs. Cts. Grd.

Total Term Hours:

Term:		Year:
No.	Course Title	Hrs. Cts. Grd.
No.	Course Title	Hrs. Cts. Grd.

Total Term Hours:

Term:		Year:
No.	Course Title	Hrs. Cts. Grd.

Total Term Hours:

Term:		Year:

No.	Course Title	Hrs. Cts. Grd.

Total Term Hours:

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

Page 1 of 3

PLANNED ACADEMIC PROGRAM WORKSHEET

For use of this form, see USACC Pam 145-4, the proponent agency is ATCC-PA-C

7.TERM, YEAR, COURSE NUMBER, COURSE TITLE, COURSE CREDIT HOURS, CREDITS THAT COUNT TOWARDS ACADEMIC DEGREE, AND ACHIEVED GRADES. (CONTINUED)

Term:		Year:
No.	Course Title	Hrs. Cts. Grd.

Total Term Hours:

Term:		Year:
No.	Course Title	Hrs. Cts. Grd.

Total Term Hours:

Term:		Year:
No.	Course Title	Hrs. Cts. Grd.

Total Term Hours:

	j.			k.			l.
Term:		Year:	Term:		Year:	Term:		Year:
No.	Course Title	Hrs. Cts. Grd.	No.	Course Title	Hrs. Cts. Grd.	No.	Course Title	Hrs. Cts. Grd.

Total Term Hours:

Term:

Year:

Term:

Year:

Term:

Year:

No.

Course Title

Hrs.

Cts.

Grd.

No.

Course Title

Hrs.

Cts.

Grd.

No.

Course Title

Hrs.

Cts.

Grd.

Total Term Hours:

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.	DATE: (MM/DD/YYYY)

USACC Form 104-R, SEP 13

Page 2 of 3

		PLANNED ACADEMIC PROGRAM WORKSHEET
		For use of this form, see USACC Pam 145-4, the proponent agency is ATCC-PA-C

		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)

(Date) (MM/DD/YYYY)

(PROFESSOR OF MILITARY SCIENCE SIGNATURE)

USACC Form 104-R, SEP 13

Page 3 of 3

Document Information

Fact Name	Description
Form Purpose	The 104 R form is used to provide information necessary for administering the Army Senior ROTC program.
Governing Authority	It operates under Title 10 of the U.S. Code, specifically sections 2101 and 2104.
Privacy Act Compliance	This form complies with the Privacy Act Statement of 1974, ensuring personal data protection.
Voluntary Disclosure	Providing information is voluntary but essential for determining eligibility in the Army ROTC program.
Academic Requirements	The form helps assess if an applicant meets the public law requirements for two remaining academic years.
Initials and Counseling	Students must initial and date beside each term to confirm they have been counseled on their academic plan.
Course Tracking	The form includes sections for tracking courses, credit hours, and grades necessary for degree completion.
Certification	It requires signatures from both the student and the registrar to validate the academic program outlined.

104 R - Usage Guidelines

Filling out the 104 R form is a crucial step for students participating in the Army Senior ROTC program. This form helps to outline your academic plan and ensures that you meet the necessary requirements for commissioning. Here's how to complete the form step by step.

Fill in your name: Write your last name, first name, and middle initial in the designated section.
Enter your academic major: Specify your major field of study.
Provide the CIP code: Input the Classification of Instructional Programs (CIP) code associated with your major.
Record the date: Write the date you are filling out the form in MM/DD/YYYY format.
Indicate your academic school: Name the institution where you are enrolled.
List credit hours: Fill in the total number of credit hours required for your degree.
Enter your GPA: Provide your current Grade Point Average (GPA) and cumulative GPA.
Select semester or quarter: Choose whether you are on a semester or quarter system.
Detail your courses: For each term, list the year, course number, course title, credit hours, and achieved grades. Ensure you total the hours for each term.
Initial and date: Have the student initial and date beside each term to confirm counseling.
Review course requirements: Indicate whether all listed courses are required for degree completion by checking 'YES' or 'NO'.
Sign the form: The student must sign and date the form, followed by the registrar or certifying official's signature and date.
Complete the statement of understanding: Both the cadet and the professor of military science need to sign and date this section.

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Dos and Don'ts

When filling out the 104 R form, attention to detail is crucial. Here’s a straightforward list of dos and don’ts to guide you through the process.

Do read all instructions carefully before starting.
Do ensure all personal information is accurate and up-to-date.
Do use clear and legible handwriting or type your responses.
Do double-check your GPA and credit hours for accuracy.
Don't leave any required fields blank; this can delay processing.
Don't forget to sign and date the form at the end.
Don't submit the form without reviewing it for errors.

Taking these steps will help ensure that your application is processed smoothly and efficiently. Good luck!

Common mistakes

Incorrect Student Name: Ensure the name is filled out correctly, using the format Last, First, MI. A mistake here can lead to processing delays.
Missing Academic Major: Do not leave the academic major blank. This is essential for determining eligibility in the program.
Wrong CIP Code: Double-check the CIP code. An incorrect code can affect the evaluation of your academic program.
Inaccurate Date: The "As of Date" must be current. An outdated date may cause confusion in your application.
Credit Hours Miscalculation: Verify that the total credit hours are accurate. Errors can lead to issues with degree progression.
Missing GPA Information: Do not forget to include both the current GPA and cumulative GPA. This information is crucial for assessment.
Course Information Errors: Ensure all course details, including course numbers, titles, and grades, are correctly filled out. Inaccuracies can affect your academic record.
Lack of Student Initials: Each term requires the student’s initials and date. Missing this can indicate a lack of counseling.
Incomplete Review Section: Marking "YES" or "NO" in the review section is necessary. Failing to do so can delay processing.
Missing Signatures: Ensure that all required signatures, including the student and registrar, are present. Missing signatures can halt the application process.

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