DD-2792-1 Exceptional Family Member Special Education/Early Interv

INSTRUCTIONS FOR COMPLETING DD FORM 2792-1,
EXCEPTIONAL FAMILY MEMBER
SPECIAL EDUCATION/EARLY INTERVENTION SUMMARY

The DD Form 2792-1 is completed to identify a
family member with special educational/early
intervention needs.

SPECIAL EDUCATION/EARLY INTERVENTION
SUMMARY
DD Form 2792-1 is completed by the parents and
school or early intervention staff. Only this form should
be provided to school or early intervention staff. Do
not include medical information forms that may be
used for EFMP screening or enrollment.

DEMOGRAPHICS.
Items 1 - 7 (Completed by sponsor or spouse).
Item 1.a. Application Status (X one).
Initial Screening/Enrollment - First Exceptional Family
Member (EFM) application for the family member
noted.
Updated Information - Update to a previous EFM
evaluation for the family member noted.
Request Disenrollment - Used to disenroll a child when
he/she no longer requires special education or early
intervention services, or when the child no longer
qualifies as a dependent.
Item 1.b. Family Status. Place an "X" in the box if there
are any other family members who have been
identified as EFMs.
Items 2.a. - k. All items refer to sponsor.
Self-explanatory.

Items 1 and 2 are completed by parents. The remainder
of this form is completed by school or early intervention
staff.
Item 1.a. Release of information. Sponsor name.
Self-explanatory. Completed by sponsor, spouse, or
student who has reached the age of majority.
Item 1.b. Rank. Enter the sponsor's rank.
Item 1.c. Sponsor SSN. Enter the sponsor's social
security number.
Item 1.d. Signature of sponsor, spouse, or student who
has reached the age of majority. Self-explanatory. Sign
and date before providing form to school or early
intervention program.
Item 1.e. Date signed. Self-explanatory.

Item 3. Answer Yes if both spouses are on active duty;
otherwise answer No.
If Yes, complete Items 3.a. - c.
Item 4.a. Exceptional family member name. Enter
name for the family member for whom this form will be
completed.
Item 4.b. Relationship to sponsor. (Son, daughter,
etc.)
Item 4.c. Date of birth. Self-explanatory.

Items 2.a. - e. Child information. Self-explanatory.
Completed by sponsor or spouse.
Items 3.a. - e. EIP/School information. Completed by EIP
or school personnel. Mark (X) Yes or No for each item. If
Yes is marked in Items 3.b. or c., remainder of form must
be completed.
Items 4.a. - b. Eligibility criteria. Mark only one. (Codes
in 4.a. are for Army coding only.)
Item 4.c. Identify the disability, if known. (For example,
blindness, autism, PDD.)

Item 5. Self-explanatory.
Item 5. Severity. Mark only one.
Item 6. Is family member enrolled in DEERS? Military
only. Self-explanatory.

DD FORM 2792-1, 20060621 DRAFT

Item 6. Provider/school official information.
Self- explanatory.

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 3 Pages
FormFlow/Adobe Professional 7.0

EXCEPTIONAL FAMILY MEMBER
SPECIAL EDUCATION/EARLY INTERVENTION SUMMARY

OMB No. 0704-0411
OMB approval expires

(Page 1 completed by service member or civilian employee.)
(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 the Department of Defense, Executive Services Directorate (0704-0411). 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 ORGANIZATION.

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)
INITIAL SCREENING/
ENROLLMENT

b. FAMILY STATUS
REQUEST DISENROLLMENT

ADDITIONAL FAMILY MEMBERS
IDENTIFIED WITH SPECIAL NEEDS

a. SPONSOR NAME (Last, First, Middle Initial)

b. SSN

c. RANK OR GRADE

d. BRANCH OF SERVICE (Military only)

e. DESIGNATION/NEC/MOS/AFSC (Military only)

f. HOME ADDRESS (Street, Apartment Number, City, State, ZIP Code)

g. DUTY STATION ADDRESS

UPDATED INFORMATION

2. IDENTIFICATION

h. OFFICIAL E-MAIL ADDRESS
i. HOME TELEPHONE NUMBER
(Include Area Code)

j. FAX NUMBER
(Include Area Code)

3. ARE BOTH SPOUSES ON ACTIVE DUTY? (X one. If Yes, answer
a., b., and c. below) (Military only)

k. DUTY TELEPHONE NUMBER (Include Area Code)
(1) COMMERCIAL

YES

(2) DSN

NO

N/A

a. SPOUSE'S NAME (Last, First, Middle Initial)

b. RANK/RATE

c. SSN

4.a. EXCEPTIONAL FAMILY MEMBER NAME (Last, First, Middle Initial)

b. RELATIONSHIP TO SPONSOR

c. DATE OF BIRTH (YYYYMMDD)

5. DOES FAMILY MEMBER RESIDE WITH SPONSOR (X one)
YES
NO

IF NO, PROVIDE ADDRESS OF FAMILY MEMBER (Include ZIP Code) AND EXPLAIN WHY.

6. IS FAMILY MEMBER ENROLLED IN DEERS (Military only) (X one)
YES

NO

IF YES, UNDER WHAT SSN:

DD FORM 2792-1, 20060621 DRAFT

FAMILY MEMBER PREFIX

Page 2 of 3 Pages

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.
a. NAME OF SPONSOR

b. RANK

d. SIGNATURE OF SPONSOR, SPOUSE, OR STUDENT e. DATE
WHO HAS REACHED THE AGE OF MAJORITY
(YYYYMMDD)

c. SSN

2. DEPENDENT CHILD INFORMATION (To be completed by sponsor or spouse)
a. NAME OF CHILD (Last, First, Middle Initial)

b. CURRENT GRADE LEVEL
(If school age)

c. DATE OF BIRTH
(YYYYMMDD)

e. SEX (X one)

d. AGE (Years/months)

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

N11 VISUALLY IMPAIRED

LANGUAGE/PHONOLOGY

SEVERE/PROFOUND
N12 SPECIFIC LEARNING DISABILITY

N03 HEARING IMPAIRED

N05 TRAUMATIC BRAIN INJURY

N10 EMOTIONALLY IMPAIRED

N14 PERVASIVE DEVELOPMENTAL

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:
DEVELOPMENTAL DELAY

c. DISABILITY (Identify if known, e.g., blindness)
HIGH PROBABILITY FOR
DEVELOPMENTAL DELAY

5. SEVERITY OF THE DISABILITY
MILD

MODERATE

SEVERE

PROFOUND

6. PROVIDER/SCHOOL OFFICIAL INFORMATION
a. NAME OF INDIVIDUAL COMPLETING THIS SECTION
(Last Name, First Name)

e. NAME OF SCHOOL/EARLY INTERVENTION PROGRAM

b. TITLE

c. TELEPHONE NUMBER d. FAX NUMBER
(Include area code)
(Include area code)

f. ADDRESS (Include ZIP Code)

g. SCHOOL DISTRICT
h. E-MAIL ADDRESS

DD FORM 2792-1, 20060621 DRAFT

i. SIGNATURE

j. DATE SIGNED
(YYYYMMDD)

Page 3 of 3 Pages