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Appendix B
DEPARTMENT OF THE ARMY Form 5164-R (HANDS-ON
EVALUATION) This appendix provides a sample of DA Form 5164-R (figures B-1 and B-2) for the tasks in this STP.
The DA Form 5164-R allows the trainer to keep a record of the performance measures a
Soldier passes or fails on each task. Trainers should use the following instructions when completing DA
Form 5164-R:
Prior to Evaluating the Soldier.
Obtain a blank copy of DA Form 5164-R, which you may locally reproduce on 8 x 11-inch
paper. The form can be downloaded from the U.S. Army Publishing Agency web site
(www.usapa.army.mil/forms).
Enter the task title and 10-digit number for the task from the evaluation guide of
the Soldier’s Manual (SM) task summary.
In column (a), enter the number of each performance measure from the evaluation guide.
In column (b), enter the performance measure corresponding to the performance measure
number in column (a). (You may abbreviate this information if necessary.)
Enter the feedback statement from the evaluation guide just below the last performance
measure.
Locally reproduce the partially completed form if you are evaluating more than one Soldier on
the task or the same Soldier on more than one task.
During the Evaluation.
Enter the date just before evaluating the Soldier's task performance.
Enter the evaluator's name and the Soldier's name and unit.
For each performance measure in column (b), enter a check in column (c) PASS or column (d)
FAIL as appropriate.
Compare the number of performance measures the Soldier passes (and if applicable, which
ones) against the task standard shown in the feedback statement. If the standard is met or exceeded,
check the GO block under STATUS; otherwise, check the NO-GO block.
19 November 2009
B-1