Dd Form 2792-1, Exceptional Family Member Special Education/early Intervention Summary Page 3

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SPECIAL EDUCATION/EARLY INTERVENTION SUMMARY
NOTE TO PERSONNEL COMPLETING THIS FORM:
It is important to the military and to the family that the family be assigned to a location that can meet the child's educational needs. Please
take care in completing the requested information. (Attach a copy of the child's most recent active Individualized Family Service Plan (IFSP) or
Individualized Education Program (IEP) to this page.)
1. RELEASE OF INFORMATION (To be completed by sponsor, spouse, or student who has reached the age of majority)
I hereby authorize the release of information on the DD Form 2792-1 and in the attached reports to personnel of the Military Departments.
This information will be used only to evaluate and document my family member's need for early intervention or special education services for
the purpose of assignment/coordination of my next assignment.
d. SIGNATURE OF SPONSOR, SPOUSE, OR STUDENT
a. NAME OF SPONSOR
b. RANK
c. SSN
e. DATE
WHO HAS REACHED THE AGE OF MAJORITY
(YYYYMMDD)
2. DEPENDENT CHILD INFORMATION (To be completed by sponsor or spouse)
a. NAME OF CHILD (Last, First, Middle Initial)
d. AGE (Years/months)
e. SEX (X one)
b. CURRENT GRADE LEVEL
c. DATE OF BIRTH
(If school age)
(YYYYMMDD)
MALE
FEMALE
3. EARLY INTERVENTION PROGRAM (EIP)/SCHOOL INFORMATION (To be completed by representative of EIP or school)
YES
NO
a. IS THE CHILD CURRENTLY BEING EVALUATED FOR SPECIAL EDUCATION OR EARLY INTERVENTION SERVICES?
b. DOES THIS CHILD RECEIVE EARLY INTERVENTION SERVICES UNDER A CURRENT INDIVIDUALIZED FAMILY SERVICES PLAN (IFSP)?
IF YES, DATE OF NEXT ANNUAL REVIEW:
ATTACH CURRENT IFSP.
c. DOES THIS CHILD RECEIVE SPECIAL EDUCATION SERVICES UNDER A CURRENT INDIVIDUALIZED EDUCATION PROGRAM (IEP)?
IF YES, DATE OF NEXT ANNUAL REVIEW:
ATTACH CURRENT IEP.
d. IS THE CHILD RECEIVING SERVICES UNDER A SECTION 504 PLAN?
e. IS THE CHILD BEING "HOME-SCHOOLED"? IF YES, SPECIFY PROGRAM, IF KNOWN:
IF YOU ANSWERED "YES" to questions 3.b. or 3.c., complete Items 4, 5, and 6. Sign and return to sponsor.
IF YOU ANSWERED "NO" to questions 3.a. through d., DO NOT complete Items 4 and 5, but complete Section 6. Sign and return to sponsor.
4. ELIGIBILITY CRITERIA (Indicate the eligibility criteria under which the child is eligible for Early Intervention or Special Education.)
a. IF THE CHILD IS FROM 3 TO 21 YEARS OF AGE:
N07
AUTISTIC
N09 COMMUNICATION IMPAIRED
N04 MENTAL RETARDATION
N01
DEAF
ARTICULATION
MILD/MODERATE
N02
BLIND
DYSFLUENCY
MODERATE/SEVERE
N13
DEAF/BLIND
VOICE
SEVERE/PROFOUND
N11
VISUALLY IMPAIRED
LANGUAGE/PHONOLOGY
N12 SPECIFIC LEARNING DISABILITY
N03
HEARING IMPAIRED
N05 TRAUMATIC BRAIN INJURY
N10 EMOTIONALLY IMPAIRED
N14
PERVASIVE DEVELOPMENTAL DISORDER
N06 ORTHOPEDICALLY IMPAIRED
N16 BEHAVIORAL/CONDUCT DISORDER
N15
DEVELOPMENTAL DELAY
N08
OTHER HEALTH IMPAIRED (Specify)
b. IF THE CHILD IS FROM BIRTH TO 3 YEARS OLD:
c. DISABILITY (Identify if known, e.g., blindness)
HIGH PROBABILITY FOR DEVELOPMENTAL
DEVELOPMENTAL DELAY
DELAY
5. SEVERITY OF THE DISABILITY
MILD
MODERATE
SEVERE
PROFOUND
6. PROVIDER/SCHOOL OFFICIAL INFORMATION
a. NAME OF INDIVIDUAL COMPLETING THIS SECTION
b. TITLE
c. TELEPHONE NUMBER
d. FAX NUMBER
(Last Name, First Name)
(Include area code)
(Include area code)
e. NAME OF SCHOOL/EARLY INTERVENTION PROGRAM
f. ADDRESS (Include ZIP Code)
g. SCHOOL DISTRICT
h. E-MAIL ADDRESS
i. SIGNATURE
j. DATE SIGNED
(YYYYMMDD)
DD FORM 2792-1, SEP 2003
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