Army Child And Youth Services Health Screening Form Page 3
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3SPECIAL NEEDS ACCOMMODATION PROCESS (SNAP) ACTION PLAN – TOOL #2
(copy to be kept in child/youth’s care module)
Child’s Name
Date of Birth (YYYYMMDD)
Date of SNAP
Diagnosis:
Date of Annual
Review:
Approved for the following CYS Program:
□ All CYS Programs/services
□ CDC
□ FCC
□ SAS
□ Middle School/Teen
□ Sports
□ SKIES/instructional classes
□ Other:________________________________________________________
Approved for the following CYS Service:
□ Hourly
□ Part Day
□ Full Day
RECOMMENDATION
□ IEP goals/interventions
□ IFSP goals/interventions
□ Copy of 504 goals/interventions
□ Copy of Behavioral Assessment/Plan
□ Copy of MAP Type: _______________________________
Other:____________________
Medications: (only list medications to be administered while child is at the CYS program site)
Activity Restrictions/Adaptive Equipment, etc:
Training for CYS Staff/Provider Required:
Recommendation Summary:
I concur with this plan as outlined above.
___________________________________________________
_________________________________________
Printed Name & Signature of EFMP Manager, Chair SNAP Team
Date (YYYYMMDD
___________________________________________________
_________________________________________
Printed Name & Signature of Child/Youth Services Coordinator/Designee
Date (YYYYMMDD)
___________________________________________________
_________________________________________
Printed Name & Signature of Army Public Health Nurse
Date (YYYYMMDD)
___________________________________________________
_ ________________________________________
Printed Name & Signature of Parent
Date (YYYYMMDD)
Form Updated: 11 Mar 09
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