EXCEPTIONAL FAMILY MEMBER
Form Approved
SPECIAL EDUCATION/EARLY INTERVENTION SUMMARY
OMB No. 0704-0411
(Page 1 completed by service member or civilian employee.)
Expires Sep 30, 2006
(Read Instructions before completing this form.)
The public reporting burden for this collection of information 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 Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0411)
1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. 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 FORM TO THE ABOVE ADDRESS.
PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 3013, 5013, and 8013; 20 USC 921 - 932; and EO 9397.
PRINCIPAL PURPOSE(S): To obtain information needed to evaluate and document the special education needs of: (1) Family
members of all service members and (2) Family members of civilian employees processing for an assignment to a location
outside the United States where family member travel is authorized at Government expense.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary for civilian employees and applicants for civilian employment; failure to respond will preclude
identification of educational needs and the successful processing of an application for family travel/command sponsorship.
Mandatory for military personnel; failure or refusal to provide the information or providing false information may result in
administrative sanctions or punishment under either Article 92 (dereliction of duty) or Article 107 (false official statement),
Uniform Code of Military Justice.
DEMOGRAPHICS
1.a. APPLICATION STATUS
(X one)
b. FAMILY STATUS
INITIAL SCREENING/
ADDITIONAL FAMILY MEMBERS
UPDATED INFORMATION
REQUEST DISENROLLMENT
ENROLLMENT
IDENTIFIED WITH SPECIAL NEEDS
2. IDENTIFICATION
a. SPONSOR NAME (Last, First, Middle Initial)
b. SSN
c. RANK OR GRADE
d. BRANCH OF SERVICE (Military only)
e. DESIG/NEC/MOS/AFSC (Military only)
f. HOME ADDRESS (Street, Apartment Number, City, State, ZIP Code)
g. DUTY STATION ADDRESS
h. E-MAIL ADDRESS
i. HOME TELEPHONE NUMBER
j. FAX NUMBER
k. DUTY TELEPHONE NUMBER (Include Area Code)
(Include Area Code)
(Include Area Code)
(1) COMMERCIAL
(2) DSN
3. ARE YOU CURRENTLY ON COMPASSIONATE OR HUMANITARIAN ASSIGNMENT?
YES
NO
(Military only) (X one)
4. ARE BOTH SPOUSES ON ACTIVE DUTY?
(X one. If Yes, answer
YES
NO
N/A
a., b., and c. below)
a. SPOUSE'S NAME (Last, First, Middle Initial)
b. RANK/RATE
c. SSN
5.a. EXCEPTIONAL FAMILY MEMBER NAME
(Last, First, Middle Initial)
b. RELATIONSHIP TO SPONSOR
c. DATE OF BIRTH (YYYYMMDD)
)
6. DOES FAMILY MEMBER RESIDE WITH SPONSOR
(X one
YES
NO
IF NO, PROVIDE ADDRESS OF FAMILY MEMBER (Include ZIP Code) AND EXPLAIN WHY.
7. IS FAMILY MEMBER ENROLLED IN DEERS
)
(Military only) (X one
IF YES, UNDER WHAT SSN:
FAMILY MEMBER PREFIX
YES
NO
DD FORM 2792-1, SEP 2003
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