ITEM
SSC Review
C. FOR DEPENDENT CHILDREN:
YES
NO
N/A
nd
1. DD FORM 2792-1 (Required for ALL children birth to 22
Birthday OR High School Graduation)
FOR INFANTS AND TODDLERS (Birth to 36 Months) ELIGIBLE TO RECEIVE EARLY INTERVENTION SERVICES AS EVIDENCED BY AN
INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP):
2. Copy of the current IFSP and, if available, developmental assessments or evaluations.
nd
FOR PRESCHOOL OR SCHOOL-AGE CHILDREN (Ages 3 to 22
Birthday or High School Graduation) ELIGIBLE TO RECEIVE SPECIAL
EDUCATION AND RELATED SERVICES AS EVIDENCED BY AN INDIVIDUALIZED EDUCATION PROGRAM (IEP):
3. Copy of the current IEP and, if available, developmental assessments or evaluations.
FOR EACH FAMILY MEMBER ENROLLED OR UNDERGOING ENROLLMENT IN THE EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP):
4. Copy of the DD Form 2792 and any EFMP correspondence.
D. FOR SSC USE ONLY
1. Date suitability screening conducted.
Date: ____________________
E. SUITABILITY INQUIRY:
1. Are any of the shaded blocks checked on NAVMED Form 1300/1?
YES (Suitability Inquiry required, proceed to question 2)
NO (Line through question 2 and proceed to section F)
2. Suitability Inquiry:
Medical Care:
Date & Time sent: ___________________________ Reply date & time: ______________________
Potential need identified
Sent by (Sending SSC): ______________________ Reply from: ____________________________
N/A
Sent to (Gaining SSC): _______________________ Contact #: _____________________________
E-Mail: _______________________________
Dental Services:
Date & Time sent: ___________________________ Reply date & time: ______________________
Potential need identified
Sent by (Sending SSC): _______________________ Reply from: ____________________________
N/A
Sent to (Gaining SSC): _______________________ Contact #: _____________________________
E-Mail: _______________________________
Special Education Services:
Date & Time sent: ___________________________ Reply date & time: _______________________
Potential need identified
Sent by (Sending SSC): ______________________
Reply from: ____________________________
N/A
Sent to (Gaining SSC): _______________________ Contact #: _____________________________
E-Mail: _______________________________
Sent to (Gaining DoDEA): _______________________ E-Mail: _______________________________
Other information:
F. SUITABILITY SCREENING COORDINATOR: Facility__________________________________________________________________
Signature
Date
Printed Name: ________________________________
E-mail:
________________________________
Phone:
________________________________
NAVMED 1300/2 (Rev. 12-2015)
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