PLANNED ACADEMIC PROGRAM WORKSHEET
For use of this form, see USACC Pam 145-4, the proponent agency is ATCC-PAS
OMB Control Number: 0702-XXXX
OMB Expiration Date: XX/XX/XXXX
The public reporting burden for this collection of information, 0702-XXXX, is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR COMPLETED
FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO REQUESTING ROTC PROGRAM.
AUTHORITY: PRINCIPAL PURPOSE:
ROUTINES USE(S):
VOLUNTARY DISCLOSURE:
DATA REQUIRED BY PRIVACY ACT STATEMENT OF 1974
Title 10, US Code § 2101 and 2104 and 2107 and 2107a.
To provide information and data necessary for administering Army Senior ROTC program, processing, and managing of selected students for commissioning in the Army IAW established public law and Army Regulations.
To provide a projected academic plan to determine if the applicant meets the public law requirements of two remaining academic years.
Voluntary information is necessary to determine eligibility of the individual for acceptance, continuance, or discontinuance in the Army ROTC program.
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1. NAME OF STUDENT (LAST, FIRST, MI) |
Cadet ID |
2. ACADEMIC MAJOR |
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2a. CIP CODE |
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3. AS OF DATE (MM/DD/YYYY) |
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Reset Form |
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(Date of form preparation) |
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6. GRADE POINT AVERAGE (GPA) |
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Term: |
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Term: |
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4. Type of Degree Currently Pursuing |
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5. CREDIT HOURS |
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Select Semester or Quarter 0 |
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Curr GPA: |
CGPA: |
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Curr GPA: |
CGPA: |
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a. Total Required for degree: |
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Term: |
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Term: |
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7. |
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b. HOST SCHOOL |
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(1) |
ROTC Hours that do not count: |
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Curr GPA: |
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Curr GPA: |
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a. Bde |
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CGPA: |
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CGPA: |
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(2) |
Total Hours Rqd for degree: |
0 |
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Term: |
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Term: |
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c. ACADEMIC SCHOOL |
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Number of Required Hrs per Term: |
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Curr GPA: |
CGPA: |
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Curr GPA: |
CGPA: |
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b. Credits toward degree Comp to date: |
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Term: |
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Term: |
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c. Transfer Credits accepted: |
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Curr GPA: |
CGPA: |
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Curr GPA: |
CGPA: |
8. |
ACADEMIC SCHOOL |
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d. Remaining for Degree: |
0 |
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Term: |
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Term: |
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IDENTIFICATION (Check one): |
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e. Number of Authorized S/Qs: |
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Curr GPA: |
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Curr GPA: |
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CGPA: |
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CGPA: |
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9. TERM, YEAR, COURSE NUMBER (No.), COURSE TITLE, COURSE CREDIT HOURS (Hrs), ACHIEVED GRADES (Grd), AND DISTANCE LEARNING (DL).
Term: |
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Year: |
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No. |
Course Title |
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Hrs. DL? Grd. |
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Year: |
Course Title |
Hrs. DL? Grd. |
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Year: |
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Course Title |
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Hrs. DL? Grd. |
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10. STUDENT INITIALS & DATE: |
TERM 1: |
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TERM 4: |
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TERM 7: |
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TERM 10: |
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(Have the student initial and date beside each term they |
TERM 2: |
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TERM 5: |
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TERM 8: |
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TERM 11: |
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have completed to indicate they have been counseled. |
TERM 3: |
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TERM 6: |
TERM 9: |
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TERM 12: |
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USACC Form 104-R, JULY 2025 |
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PREVIOUS EDITIONS ARE OBSOLETE |
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Page 1 of 3 |
PLANNED ACADEMIC PROGRAM WORKSHEET
For use of this form, see USACC Pam 145-4, the proponent agency is ATCC-PAS
OMB Control Number: 0702-XXXX
OMB Expiration Date: XX/XX/XXXX
11. TERM, YEAR, COURSE NUMBER (No.), COURSE TITLE, COURSE CREDIT HOURS (Hrs), ACHIEVED GRADES (Grd), AND DISTANCE LEARNING (DL). (CONTINUED)
Term: |
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Year: |
No. |
Course Title |
Hrs. DL? Grd. |
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Total Term Hours: |
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0 |
0 |
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Term: |
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Year: |
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No. |
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Course Title |
Hrs. |
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DL? Grd. |
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Term: |
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Year: |
i. |
No. |
Course Title |
Hrs. |
DL? Grd. |
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Total Term Hours: |
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0 |
0 |
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l. |
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Term: |
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Year: |
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No. |
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Course Title |
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Hrs. |
DL? Grd. |
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Term: |
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Year: |
No. |
Course Title |
Hrs. DL? Grd. |
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Total Term Hours: |
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0 |
0 |
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Term: |
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Year: |
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No. |
Course Title |
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Hrs. |
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DL? Grd. |
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n. |
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o. |
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Year: |
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Term: |
Year: |
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Term: |
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Year: |
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Course Title |
Hrs. |
DL? |
Grd. |
No. |
Course Title |
Hrs. |
DL? |
Grd. |
No. |
Course Title |
Hrs. |
DL? |
Grd. |
Total Term Hours: |
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0 |
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0 |
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Total Term Hours: |
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0 |
0 |
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Total Term Hours: |
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0 |
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0 |
12. REVIEW: All of the above courses are required (as minimum) for the completion of the degree:
Completion should result in a (Degree Type) |
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(Academic Discipline) |
Yes |
No (if no, list exceptions on reverse of this form). |
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Completion Date (Month, Year) |
13. SIGNATURE OF STUDENT:
15. SIGNATURE OF REGISTRAR AND EXAMINER OF CREDENTIALS OR ROTC ADVISOR (OR OTHER INSTITUTION CERTIFYING OFFICIAL):
USACC Form 104-R, JULY 2025 |
PREVIOUS EDITIONS ARE OBSOLETE |
Page 2 of 3 |
PLANNED ACADEMIC PROGRAM WORKSHEET
For use of this form, see USACC Pam 145-4, the proponent agency is ATCC-PAS
OMB Control Number: 0702-XXXX
OMB Expiration Date: XX/XX/XXXX
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 |
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(FULL NAME, Last, First, MI) |
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(Name of University or College) |
designed to meet the requirments of a |
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degree; that the degree to be attained is the culmination of an |
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(Type of Degree) |
undergraduate college program of at least four years or graduate degree program of no more than two 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.
IAW USACC Pam 145-4, the worksheet must be reviewed annually (at a minimum) for each contracted Cadet and revised, as necessary. The worksheet must be authenticated by an appropriate school academic official (academic advisor/counselor) when completed or revised. The PMS will review the worksheet with the Cadet each school term to monitor alignment/mission set and academic progress. This review will be noted on Cadet counseling records.
Any changes to this degree plan, adding/dropping classes, or change of major must first be discussed/approved with the PMS.
(Date) (MM/DD/YYYY) |
(CADET SIGNATURE) |
(Date) (MM/DD/YYYY) |
(PROFESSOR OF MILITARY SCIENCE SIGNATURE) |
USACC Form 104-R, JULY 2025 |
PREVIOUS EDITIONS ARE OBSOLETE |
Page 3 of 3 |
Instructions for Planned Academic Program Worksheet USACC 104-R Reset Form button – erases the form.
1.Cadet’s name and Cadet ID
2.Cadet’s Academic Major. 2a. Only used for HQ STEM Scholarships. Not necessary for all other scholarships.
3.Date of form preparation or date of form update.
4.Select type of degree the Cadet is pursuing – Bachelors, Masters, or Associates (MJC Only).
5.Block 5 calculates how many scholarship terms the Cadet needs to graduate.
Dropdown: select appropriate term type and degree plan. NOTE: Making the correct selection is required for Block 5 to calculate correctly.
a.Input the total hours required for the degree
1)Input ROTC hours that are not included in the total for the degree.
2)Populates the sum of 5a and 5a(1)
3)Calculates the average number of hours required for each term based on the selection in the dropdown and the sum from 5a(2).
b.Input the number of credit hours the Cadet has completed (if any) to date at the school.
c.Input any transfer credits the school has accepted.
d.Calculates how many hours the Cadet has remaining for their degree.
e.Calculates the number of scholarship terms the Cadet needs to complete their degree based on calculations from 5a(3) and 5d.
6.Input the term GPA and the cumulative GPA for each term completed.
7.Select the Cadet’s Brigade, ROTC Program, and Academic School.
8.Select Academic School’s identification: If the academic school is the same as the Host School, select Host; If the academic school is not the Host School, select either Extension Unit or Cross-Town.
1.Host – Academic School is the Same as Host School.
2.Extension Unit – Academic School is a manned partner school.
3.Cross-Town – Academic School is an unmanned partner school. NOTE: Cadet must take ROTC classes at Host school or nearest manned Extension Unit.
9.Each group represents one term. Select the term from the dropdown: Fall, Winter (for quarter schools), Spring, or Summer; Select the year for the term selected; input the Course Number, Course Title, course Credit Hours, check the column for DL? if the class is online. Once the term is finished, input the grade received.
10.Student should initial and date beside each term.
11.Follow the instructions for #9 above.
12.Verify that the courses listed above in #9 and #11 are required for the degree. Input the expected graduation date.
13.Signature of Cadet.
14.Date Cadet signed document.
15.Signature of Registrar or ROTC advisor and other institution certifying official.
16.Date certifying official signed document.
17.Statement of Understanding. Cadet should read the Statement of Understanding and then sign and date; PMS should sign and date.