ARMY CHILD AND YOUTH SERVICES HEALTH SCREENING TOOL
For use of this form, see AR 608-75; the proponent agency is OACSIM.
PRIVACY ACT STATEMENT
10 U.S.C. 3013, Secretary of the Army; 29 U.S.C. 794, Nondiscrimination Under Federal Grants and
Programs; DoDD 1342.17 Family Policy; AR 608-75, Exceptional Family Member Program; AR 608-10,
Child Development Services; and E.O. 9397 (SSN).
Information will be used to assist Army activities in their responsibilities in overall execution of the
Army's Exceptional Family Member Program (EFMP) and the Army Child and Youth Services Program.
The DoD "Blanket Routine Uses" that appear at the beginning of the Army's compilation of systems of
records apply to this system.
Disclosure of requested information is voluntary; however, if information is not provided individual may
not be able to participate in Army Child and Youth Services Program.
Part A - General Information
1. Child's Name
2. Date of birth (YYYYMMDD)
3. Family member prefix
4. Type of placement requested
5. Date (YYYYMMDD)
6. Sponsor name
7. SSN (last four digits)
8. Spouse name
9. Home phone
10. Duty phone
11. Cell phone
Part B - Identification of Child/Youth Condition/Restrictions
Child has any of the following conditions/restrictions: (Check yes or no)
a. Life threatening reaction
b. Epi-pen required
c. Other allergic reations (hives, rash, diarrhea)
2. Asthma reactive airway disease
a. Triggers exist for child's asthma attacks (stress, environmental, exercise)
b. Child routinely (greater than 10 days per month/four months per year) uses inhaled anti-inflammatory agents and/or bronchodilators
c. Child has taken steroids during the past year (prednisone, prednisolone)
Yes (indicate number of days in past year)
Page 1 of 3
DA FORM 7625-1, NOV 2006