Da Form 7246 - Exceptional Family Member Program (Efmp) Screening Questionnare
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1
2NAME OF MEDICAL TREATMENT FACILITY
EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP)
SCREENING QUESTIONNAIRE
For use of this form, see AR 608-75; the proponent agency is OACSIM
DATA REQUIRED BY THE PRIVACY ACT OF 1974
PL 94-142 (Education for all Handicapped Children Act of 1975) , PL 95-561 (Defense Dependents' Education Act
AUTHORITY:
of 1978); DODI 1342.12 (Education of Handicapped Children in DODDS), 17 December 1981; DODI 1010.13
(Provision of Medically Related Services to Children Receiving or Eligible to Receive Special Education in DOD
Dependents Schools Outside the United States), 28 August 1986, 10 USC 3013; 20 USC 921-932 and 1401 et seq.
PRINCIPAL PURPOSE:
To obtain information needed to evaluate and document the special education and medical needs of family members.
This will permit consideration of special education and medical needs of family members in the personnel
Information will be used by personnel of the Military Departments to evaluate and document special education and
ROUTINE USES:
medical needs of family members for consideration in personnel assignments.
DISCLOSURE:
The provision of requested information is mandatory. Failure to respond will preclude U.S. Total Personnel
Command from enrolling soldiers in the EFMP. Soldiers who knowingly refuse to enroll exceptional family members
will receive, at a minimum, a general officer letter of reprimand. Refusal to provide information may preclude
successful processing of an application for family travel/command sponsorship.
SERVICE MEMBER'S NAME/RANK
DATE (YYYYMMDD)
BRANCH
UNIT
DUTY PHONE
PROJECTED PCS ASSIGNMENT
DSN
HOME PHONE
HOME ADDRESS
DUTY ADDRESS
PROJECTED PCS DATE
FAMILY
CHECK IF
DATE OF BIRTH
LIST ALL FAMILY MEMBERS
MEMBER
SEX
ENROLLED
(YYYYMMDD)
PREFIX
IN EFMP
PLEASE ANSWER ALL QUESTIONS - FOR FAMILY MEMBERS ONLY
MEDICAL
YES
NO
1. Do any family members, excluding service member, have any medical records (civilian or military) other than the records
you have provided us to screen? If yes, please list conditions/services received and address of provider.
FAMILY MEMBER
CONDITIONS/SERVICES
NAME/ADDRESS OF PROVIDER
YES
NO
2. In the past five (5) years, have any members of your family, excluding service member, been hospitalized, excluding
hospitalization for normal uncomplicated childbirth? If yes, please explain.
NAME
REASON
YES
NO
3. Are any members of your family, excluding service member, currently receiving medical (includes mental health)
or
educational services from any providers other than a general practitioner or family practice physician?
PREVIOUS EDITION IS OBSOLETE.
APD PE v1.00ES
DA FORM 7246, JUN 2009
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