Form 4380 - Air Force Special Needs Screener

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AIR FORCE SPECIAL NEEDS SCREENER
(Completed by all Sponsors with Family Members)
AUTHORITY: 10 U.S.C. 55. 10 U.S.C. 8013 and E.O. 9397 (SSN) as amended.
Used to document, plan, and coordinate the health care of family members during relocation; determine eligibility and suitability for benefits for
PURPOSE(S):
various programs; and compile statistical data.
ROUTINE USE:
Used to accumulate information for determining family member special needs.
Voluntary; however, failure to provide SSN or other requested information may delay screening of family member's suitability for relocation at
DISCLOSURE:
government expense or delay issuance of PCS orders.
TO:
SPECIAL NEEDS COORDINATOR AND AIR FORCE PERSONNEL CENTER (AFPC)
FROM:
Air Force Family Member Special Needs Identification Screener
The Air Force makes an effort to ensure specialized medical and educational services are available for all military family members. In order to help us do
this, we need to know if any special medical and/or educational needs exist for your family members. You are required to complete this form as part of
your relocation processing, if you have family members, whether they are living with you or not.
SPONSOR'S INFORMATION
Sponsor's Name (Last, First, MI)
Rank
Social Security Number
(SSN)
Home Telephone Number
Current Unit and Duty Station
Duty Telephone Number
Projected Installation For Relocation
Projected Departure Date
SPONSOR'S FAMILY INFORMATION
Please read and answer all questions. Indicate (X) the appropriate box.
Thank you.
Yes
1.
Are your currently enrolled in any Service's Exceptional Family Member Program (EFMP)?
No
If yes, stop here.
2.
Do any of your children receive Special Education Services?
Yes
No
Do any of your children receive Early Intervention Services?
3.
Yes
No
4.
Do any of your children receive speech therapy, occupational therapy, physical therapy, or
counseling services?
Yes
No
Has any dependent member of your family been hospitalized for the same condition more than
5.
once?
Yes
No
Has any dependent member of your family been seen by a medical provider or mental health provider
6.
for the same condition more than six times in the last year?
Yes
No
7.
Do any of your family members have a chronic medical condition that requires at least annual eval-
uation or follow-up by a specialist (such as cardiology, internist, psychology, neurology, counseling, etc.)?
Yes
No
8.
Do any of your dependent family members have reactive airway disease or asthma?
Yes
No
If YES to any questions numbered 2 - 8, please contact the Exceptional Family Member Program (EFMP-M) Office at the Military
Treatment Facility for assistance prior to pursuing any further relocation actions.
I certify that this information is complete and accurate to the best of my knowledge. I understand that insufficient and/or inaccurate
information may affect family member travel at government expense. I understand that making a knowing and willful false official
statement can be punishable by fine or imprisonment. (See U.S. Code, Title 18, Section 1001; Title 10, Section 907; Article 107 UCMJ).
Sponsor's Signature
Date
AF FORM 4380, 20110819

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