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

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

The DD Form 2792-1 is completed to identify a family

SPECIAL EDUCATION/EARLY INTERVENTION SUMMARY

member with special educational/early intervention needs.
DD Form 2792-1 is completed by the parents and school or
DEMOGRAPHICS.

early intervention staff. Only this form should be provided to
school or early intervention staff. Do not include medical

Items 1 - 7. Completed by sponsor or spouse.

information forms that may be used for EFMP screening or
enrollment.

Item 1. Request (X one):
- EFMP Registration/Enrollment Update - first
exceptional family member (EFM) application

Items 1.a. - d. Sponsor Information. Completed by sponsor or

for the family member or to update a previous

spouse. Self-explanatory.

EFM evaluation for the family member.
- Government sponsored travel and/or Command
Sponsorship.
- Change in EFMP Status.

Items 2.a. - d. Child/Student Information. Completed by
sponsor or spouse. Self-explanatory.

D R A F T

Items 3.a. - e. EIP Information. Completed by EIP or school

Items 2.a. - g. Child/Student Information. Self-explanatory.

personnel. Mark (X) Yes or No for each item. Include additional
information as noted.

Items 3.a. - j. Sponsor Information. Self-explanatory.
Items 4.a. - g. School Information. Completed by school
Item 3.k. Is family member enrolled in DEERS? Military

personnel. Mark (X) Yes or No for each item. Include additional

only. Self-explanatory.

information as noted.

Items 4.a. - d. Self-explanatory.

Item 5. Completed by school personne. Mark (X) eligibility
category. Mark only one. (Codes are for Army coding only.)

Item 5. Completed for children age birth to 3 only.
Self-explanatory.

Item 6. Completed by school personnel. X all related services
provided and indicate total time services are provided.

Item 6. Completed for children ages 3 to 21 only.
Self-explanatory.

Item 7. Completed by EIP and school personnel.
Self-explanatory.

Items 7.a. - c. Signature of sponsor or spouse who
completed the form. Self-explanatory.

Item 8. Completed by EIP provider/school official information
completing form. Self-explanatory.

Items 8.a. - f. Administrative Review. Completed by
EFMP/Special Needs Office resonsible for screening or
enrollment in the MTF.

DD FORM 2792-1, 20091105 DRAFT

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 3 Pages
Adobe Professional 8.0

SPECIAL EDUCATION/EARLY INTERVENTION SUMMARY

OMB No. 0704-0411
OMB approval expires

(Page 1, Items 1 - 7 to be completed by sponsor, parent or legal guardian.)
(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, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (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. Documentation may also be used by the Managed Care Support Contractor to support your organization for further entitlement, i.e., the Extended Care Health
Option (ECHO); and other Service-specific programs that require registration in the Exceptional Family Member Program (EFMP).
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.

D R A F T
DEMOGRAPHICS

1. REQUEST (X one)

EFMP Registration/Enrollment Update

No longer requires IEP/IFSP services
No longer qualifies as a dependent*

(*Provide documentation for change in status)

Divorce/change in custody*

2.a. CHILD/STUDENT NAME (Last, First, Middle Initial)

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

d. CHILD/STUDENT DATE OF BIRTH (YYYYMMDD)

e. CHILD/STUDENT GENDER (X one)

c. CHILD/STUDENT CURRENT MAILING
ADDRESS (Street, Apartment Number, City,
State, ZIP Code, APO/FPO)

FEMALE
MALE
g. HOME TELEPHONE NUMBER
(Include Area Code/Country Code)

f. FAMILY HOME E-MAIL ADDRESS

3.a. SPONSOR RANK OR GRADE

Other (Explain):

Change in EFMP Status:

Government Sponsored Travel and/or Command
Sponsorship

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

e. DUTY TELEPHONE NUMBER
(Include Area Code/Country Code)

d. SPONSOR'S OFFICIAL E-MAIL ADDRESS

g. SPONSOR'S CURRENT UNIT MAILING ADDRESS

c. INSTALLATION OF CURRENT ASSIGNMENT

h. STATUS (X one)

f. MOBILE NUMBER
(Include Area Code/Country Code)
d. BRANCH OF SERVICE (Military only)

Regular Active Service
Member
Active Guard/Reserve
Program (AGR)

Reservist

Army

Air Force

National Guard

Navy

Marine Corps

Civilian

j. DOES CHILD RESIDE WITH SPONSOR? (X one. If No, explain.)
YES

NO

k. IS THE CHILD/STUDENT ENROLLED IN DEERS UNDER A SPONSOR OTHER THAN THE ONE LISTED ABOVE? (X one. If Yes, name of sponsor:)
YES

NO

4.a. ARE BOTH SPOUSES ON ACTIVE DUTY?(Military only) (X one. If Yes, answer b. - d. below)
b. ACTIVE DUTY SPOUSE'S NAME (Last, First, Middle Initial)
YES

c. BRANCH OF SERVICE

d. RANK/RATE

NO

5. FOR CHILDREN FROM BIRTH TO AGE THREE ONLY:
YES

NO

Is your child being evaluated for, or receiving, early intervention services on an Individualized Family Service Plan (IFSP)?
(X one. If No, sign Item 7 and return to the requesting office. If Yes, have early intervention professional complete Page 2.)

6. FOR STUDENTS AGES 3 - 21 WHO ARE ELIGIBLE FOR ELEMENTARY AND SECONDARY EDUCATION:
a. Is your child being home-schooled? (X one. If No, sign Item 7 and take Page 2 to your child's school. If Yes, complete the following
and sign Item 7.)
b. When did you start home-schooling? (YYYYMMDD)
YES

NO

c. List any special education-related services received in the last 3 years:

d. Name/title home school program, if known:

7.a. SIGNATURE

b. PRINTED NAME (Last, First, Middle Initial)

8. ADMINISTRATIVE REVIEW (Completed after review of entire form by local military MTF or office receiving form)
a. SPONSOR SSN

b. SPOUSE SSN (If dual military)

d. FAMILY MEMBER PREFIX

e. MILITARY MTF OR OFFICE RECEIVING COMPLETED FORM

DD FORM 2792-1, 20091105 DRAFT

c. DATE (YYYYMMDD)

STAMP

c. SSN USED IN DEERS (If different from sponsor's)
f. DATE (YYYYMMDD)

Page 2 of 3 Pages

SPECIAL EDUCATION/EARLY INTERVENTION SUMMARY
NOTE TO EDUCATIONAL AUTHORITY 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. Your support in completing this form
is appreciated. (If applicable, attach a copy of the child's most recent active Individualized Family Service Plan (IFSP) or Individualized Education Program (IEP) or Section
504 Plan 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 the attached reports to personnel of the Military Departments. This information will be used to
evaluate and document my child/student's needs for educational services for the purpose of assignment/coordination, EFMP registration or eligibility for other educationally
related benefits.
a. SIGNATURE OF SPONSOR, SPOUSE, OR STUDENT b. PRINTED NAME
c. RELATIONSHIP TO CHILD/
d. DATE
WHO HAS REACHED THE AGE OF MAJORITY
STUDENT
(YYYYMMDD)

D R A F T

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

b. CURRENT GRADE LEVEL
(If school age)

c. DATE OF BIRTH (YYYYMMDD)

d. GENDER (X one)
FEMALE

MALE

3. EARLY INTERVENTION (EI) SERVICES - FOR CHILDREN UNDER 3 YEARS OF AGE (To be completed by EI representative)
YES NO
a. Is the child currently being evaluated for early intervention services? (If Yes, go directly to Item 8.)
b. Does this child receive early intervention services under a current Individualized Family Services Plan (IFSP)?
(If Yes, please attach current IFSP.) Date of next annual review (YYYYMMDD):
c. Basis for eligibility:

High probability for developmental delay

Developmental delay

d. Identified disability for diagnosis:

4. SCHOOL INFORMATION - FOR STUDENTS AGES 3 - 21 (To be completed by school representative)
YES NO
a. Is the student receiving services under a 504 plan? (If Yes, please attach a copy of the current 504 plan.)
b. Has this child ever been evaluated for, or been offered, special education services by your school? (If No, skip to Item 8.)
c. Is this student currently being evaluated for special education services? (If Yes, skip to Item 8.)
d. If your school determined the student eligible for special education services within the past 3 years, did the parent decline special education services?
(If Yes, complete eligibility information in Item 5 and proceed to Item 8.)
e. Does this child/student receive special education services under a current Individualized Education Program (IEP)? (If Yes, please attach a copy of the
current IEP, and complete Items 5 and following.) Date of next annual review (YYYYMMDD):
f. Were IEP services terminated by the IEP team within the last 2 years? (If Yes, skip to Item 8.) Date of IEP termination (YYYYMMDD):
g. Was the IEP terminated at the request of the parents within the last year (parents withdrew student from special education)? (If Yes, complete Items 5
and following.)

5. ELIGIBILITY CATEGORY FOR CHILDREN 3 TO 21 YEARS OF AGE (X only one)
N07 Autism Spectrum Disorder:
Autism
PDD-NOS
Asperger's Syndrome
N01 Deaf
N02 Blind
N13 Deaf/Blind
N11 Visually Impaired

N12
N10
N16
N04

Specific Learning Disability
Emotionally Impaired
Behavioral/Conduct Disorder
Mental Retardation:
Mild/Moderate
Moderate/Severe
Severe/Profound
N08 Other Health Impaired (Specify)

N09 Communication Impaired:
Articulation
Dysfluency
Voice
Language/Phonology
N05 Traumatic Brain Injury
N03 Hearing Impaired
N06 Orthopedically Impaired

6. RELATED SERVICES ON IEP (X boxes next to related services and indicate total number of minutes or hours that services are provided.)
SERVICE: M = Minutes, H = Hours per W = Week, M = Month Example:
R01 Counseling
R02 Occupational Therapy
R03 Physical Therapy
R04 Speech Therapy
R05 Intensive Behavioral Intervention (Such as ABA)

20

M

per

W

per

R06 Special Transportation (Describe):

per
per

R07 Other (Describe):

per
per

7. BEHAVIOR/COMMUNICATION (X all that apply and explain in comments section.)
YES NO

g. COMMENTS
a. Child exhibits high risk or dangerous behavior.
b. Child is verbal (If No, answer c.-f. The student uses:)
c. Signing (Specify language or system)
d. Picture Exchange Communication System (PECS)
e. Communication Device (Specify)
f. Other (Specify)

8. PROVIDER/SCHOOL INFORMATION
a. NAME OF EARLY INTERVENTION PROGRAM OR SCHOOL

b. SCHOOL DISTRICT

c. ADDRESS (Street, City, State,ZIP Code, APO/FPO)

d. TELEPHONE NUMBER (Include Area Code/
Country Code)

e. FAX NUMBER (Include Area Code/
Country Code)

f. E-MAIL ADDRESS

h. SIGNATURE

DD FORM 2792-1, 20091105 DRAFT

g. NAME OF INDIVIDUAL COMPLETING THIS SECTION
j. DATE SIGNED
(YYYYMMDD)

i. TITLE

Reset

Page 3 of 3 Pages