DD X678 TEST Screening Verification

INSTRUCTIONS
DD FORM X678 TEST, SCREENING VERIFICATION
(This User Guide provides clarifying descriptions and notes on the DD Form TEST X678, Screening Verification.)
GENERAL

packet to the losing FMTS Office for completion of PART C.

The DD Form X678 TEST, Screening Verification, identifies the
dependent(s) of a Service member who is requesting travel at
government expense and / or consideration for Command
Sponsorship. The DoD requires the dependent(s) to be screened
prior to approving family travel. One (1) form is completed for
the entire family.

Army: Soldier takes form to local MPD for Part B completion
and then submits FMTS packet to the losing FMTS Office for
completion of PART C.

Sections of this form are completed by the Service member,
Personnel / Transferring Command Office Representative,
losing Family Member Travel Screening (FMTS) Office
Administrative Reviewer and Appointed FMTS Medical
Screener, and the gaining FMTS Office and Appointed FMTS
Medical Reviewer.
NOTE: The Personnel / Transferring Command Office
Representative refers to each of the following:
Army: Personnel
Air Force: Personnel
Navy: Transferring Command and PERS
Marine Corps: Transferring Command and Manpower
Management

PART A: SERVICE MEMBER INFORMATION
Completed by the Service member.

Navy: Sailor attaches copy of Overseas Screening Notification
or orders and the NAVPERS 1300/16 PART I and then
submits FMTS packet to the losing FMTS Office for
completion of PART C.
Marine Corps: Marine attaches copy of Web Orders and the
NAVPERS 1300/16 PART I and then submits FMTS packet to
the losing FMTS Office for completion of PART C.
PART B: ORDERS AUTHENTICATION
For Soldiers ONLY. Completed by the Army Military Personnel
Division (MPD) Representative. The other Services’ authorized
Personnel/Transferring Command Office Representative do not
complete this section.
BLOCKS 11-17: Authenticates a Soldier’s orders.

PART C: FAMILY MEMBER TRAVEL SCREENING SUMMARY
Completed by the losing Appointed FMTS Medical Screener. The
Appointed FMTS Medical Screener must be a Medical Doctor
(MD), Doctor of Osteopathic Medicine (DO), Nurse Practitioner
(NP), or Physician Assistant (PA).

BLOCKS 1-3: Provides Service member information.
NOTE: The complete Social Security Number is required in order
to retrieve the correct Military Healthcare System files and may
be needed by Personnel.
BLOCK 4: For Airmen Only. Identifies the Servicing PAS CODE
for the current assignment location.
BLOCKS 5-8: Provides Service member and spouse information.
NOTE: Spouse information is only required for dual or former
military spouses. This should be blank if not applicable.
BLOCKS 9a-e: Lists the full names of the registered
dependent(s) of the Service member who is requesting travel at
government expense and / or consideration for Command
Sponsorship.

NOTE: If there is a second attached form for BLOCKS 1-3 and
9a-10b, information for those dependents must be included on
BLOCKS 18a-e of that second form.
BLOCKS 18a-e: Lists the name of each dependent indicated in
PART A and indicates if there are or are not special medical,
educational, and / or dental needs for each dependent. The
information here must match the DD Form X678-1 TEST,
Medical and Educational Information, BLOCKS 34a-b. If any
needs are identified, the applicable DD Forms and / or
Individualized Family Service Plan (IFSP) / Individualized
Education Program (IEP) must be included for forwarding to the
gaining FMTS Office.
BLOCKS 19a-b: Indicates whether or not there are needs that
require this form and any additional documents to be sent
forward to the gaining FMTS Office. ONE of these boxes must
be checked for the family.

NOTE: The Service member should not be listed here.
NOTE: If there are more than six (6) dependents, a second form
must be attached with BLOCKS 1-4 and 9a-10b completed.
SERVICE MEMBER CERTIFICATION
Completed by the Service member.
BLOCKS 10a-b: Certifies the information provided by the
Service member in PART A.
NOTE: Upon completing PART A, each Service member should
follow his/her Service-specific instructions:

APPOINTED FMTS MEDICAL SCREENER AUTHENTICATION
Completed by the losing Appointed FMTS Medical Screener.
BLOCKS 20-21: Provides Appointed FMTS Medical Screener
information and authenticates the information in PART C.

PART D: ADMINISTRATIVE REVIEWER AUTHENTICATION
AND DISPOSITION
Completed by the losing Administrative Reviewer.
BLOCK 22a: Provides the location of the screening.

Air Force: Airman attaches RIP and then submits FMTS
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BLOCK 22b: Validates the losing FMTS Office portion of the
form.
BLOCK 23a-c: Provides instructions based on the Service
member’s affiliation.

PART F: GAINING FMTS OFFICE REVIEW
Completed by the gaining FMTS Office and Appointed FMTS
Medical Reviewer.
BLOCKS 26a-d: For Soldiers ONLY. Indicates the availability of
medical, educational, and / or dental support services for the
family.
BLOCKS 27a-d: For Airmen, Sailors, and Marines ONLY.
Indicates the availability of medical, educational, and / or dental
support services for each dependent.
BLOCK 28: Provides any additional comments from the gaining
Appointed FMTS Medical Reviewer.
NOTE: This must not include PHI, in compliance with HIPAA.
BLOCKS 29a-b: Provides gaining FMTS Office information.
BLOCK 30a-c: Provides gaining Appointed FMTS Medical
Reviewer information and the date the form is signed.
BLOCK 30d: Validates the gaining FMTS Office portion of the
form.
BLOCK 31: Provides instructions based on the Service
member’s affiliation.

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SCREENING VERIFICATION
FAMILY MEMBER TRAVEL SCREENING

20%1R

(All white BLOCKS completed by Service member. All gray BLOCKS completed by Personnel/Transferring Command Office representative, losing
Appointed FMTS Medical Screener and Administrative Reviewer, and gaining Appointed FMTS Medical Reviewer. One (1) form per family.)

20%DSSURYDOH[SLUHV

The public reporting burden for this collection of information is estimated to average 30 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, Directives Division, 4800 Mark Center
Drive, Alexandria, VA 22350-3100 (XXXX-XXXX). 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. RETURN

COMPLETED FORM AS DIRECTED UNDER "SERVICE MEMBER CERTIFICATION" BELOW.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 20 U.S.C. 927, Allotment Formula; DoDI 1315.19, Authorizing Special Needs
.
Families Travel Overseas at Government Expense;
DoDI 1342.12, Provision of Early Intervention and Special Education Services to Eligible DoD Dependents; and
E.O. 9397 (SSN) as amended.
PRINCIPAL PURPOSE(S): Information will be used by the Military Services to identify dependents with special medical and/or educational needs and to determine if
additional screenings and evaluations are required to determine the extent of the dependents’ needs. This information will enable Military Assignment Personnel to match
the needs of dependents against the availability of services.
ROUTINE USE(S): Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. Applicable Blanket Routine Use(s) are:
Law Enforcement Routine Use, Congressional Inquiries, Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the National Archives
and Records Administration Routine Use, and Data Breach Remediation Purposes Routine Use. The DoD Blanket Routine Uses set forth at the beginning of the Office of the
Secretary of Defense (OSD) compilation of systems of records notices may apply to this system. The complete list of DoD Blanket Routine Uses can be found online at:
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. The applicable system of records notices are: DMDC 02 DoD; Defense Enrollment Eligibility
Reporting Systems (DEERS), EDHA 07: Military Health Information System. EDHA 16: Special Needs Program Management Information System (SNPMIS), DoDEA 26:
DoDEA Educational Records, DoDEA 29: DoDEA Non-DoD Schools Program. The SORNs may be found at http://dpclo.defense.gov/Privacy/SORNsIndex
DISCLOSURE: Voluntary for civilian employees and applicants for civilian employment. 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. The Social Security Number of the sponsor (and the sponsor's spouse if dual military) allows the Military Healthcare System and Service personnel
offices to work together to ensure any special medical needs of your dependent can be met at your next duty assignment. Dependent special needs are noted in the
official military personnel files which are retrieved by name and Social Security Number.

PART A: SERVICE MEMBER INFORMATION

(Completed by Service member. Attach additional form if more than six (6) dependents.)
1. SERVICE MEMBER NAME (LAST, FIRST, MI)
2. RANK/GRADE
3. SERVICE MEMBER SSN
4. SERVICING PAS CODE
(Air Force Only)
5a. SERVICE (Check as appropriate) ☐ AIR FORCE
5b. SERVICE STATUS (“X” as appropriate)

☐ ARMY

☐ NAVY

☐ MARINE CORPS

☐ REGULAR ACTIVE SERVICE

☐ COAST GUARD

☐ AGR RESERVE

☐ AGR GUARD

☐ OTHER UNIFORMED SERVICES
☐ RESERVE

6a. CURRENT PHYSICAL DUTY LOCATION

6b. PROJECTED PHYSICAL DUTY LOCATION

7a. PREFERRED PHONE (Include area/country codes)

7b. PREFERRED E-MAIL ADDRESS

8a. DUAL OR FORMER MILITARY SPOUSE NAME (If applicable)
9a. DEPENDENT NAME
(LAST, FIRST, MI)

8b. RANK/GRADE

9b. RELATIONSHIP
(Spouse, son, daughter, etc.)

☐ NATIONAL GUARD

8c. MILITARY SPOUSE SSN
9c. BIRTHDATE
(YYYY/MM/DD)

9d. AGE

D R A F T

9e. TRAVEL REQUESTED
YES
NO

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SERVICE MEMBER CERTIFICATION

I certify that the above entries made by me are true, complete, and correct to the best of my knowledge and belief. I understand that insufficient and/or
inaccurate information may affect dependent travel. I understand that a knowing and willful false statement on this form can be punishable by fine or
imprisonment. (See U.S. Code, Title 18, Section 1001, Section 907; Article 107 UCMJ.)
10a. SIGNATURE

10b. DATE (YYYY/MM/DD)

(Upon completing PART A, each Service member should follow his/her Service-specific instructions. Air Force: Airman attaches RIP and submits FMTS packet to the
losing FMTS Office for completion of PART C. Army: Soldier takes form to local MPD for Part B completion and submits FMTS packet to the losing FMTS Office for
completion of PART C. Navy: Sailor attaches copy of Overseas Screening Notification or orders and the NAVPERS 1300/16 PART I and submits FMTS packet to the
losing FMTS Office for completion of PART C. Marine Corps: Marine attaches copy of Web Orders and the NAVPERS 1300/16 PART I and submits FMTS packet to the
losing FMTS Office for completion of PART C.)

PART B: ORDERS AUTHENTICATION

(For Soldiers ONLY. Completed by Army Military Personnel Division (MPD) representative.)
I verify that the Service member has an assignment instruction to a location that requires medical/educational coordination, the listing of dependents in 9a is
complete and accurate, and dependents will not be authorized travel until medical/educational coordination is complete.
11a. PROJECTED ASSIGNMENT LOCATION(S)
11b. PROJECTED REPORT DATE (YYYY/MM/DD)
12a. MPD REPRESENTATIVE NAME (LAST, FIRST, MI)

12b. RANK/GRADE

13. PERSONNEL OFFICE ADDRESS
15. OFFICIAL E-MAIL ADDRESS

DD FORM X678 TEST, 20150910 DRAFT

16. SIGNATURE

12c. TITLE
14. OFFICIAL PHONE (Include area/country codes)
Commercial:
DSN:
17. DATE (YYYY/MM/DD)

Page 1 of 3 Pages
Adobe Professional X

SCREENING VERIFICATION
FAMILY MEMBER TRAVEL SCREENING
SERVICE MEMBER NAME (LAST, FIRST, MI)

RANK/GRADE

SERVICE MEMBER SSN

SERVICING PAS CODE
(Air Force Only)

PART C: FAMILY MEMBER TRAVEL SCREENING SUMMARY

(Completed by losing Appointed FMTS Medical Screener to document any identified needs of dependents.)
18a. DEPENDENT NAME (LAST, FIRST, MI)
18b. NO NEEDS
18c. MEDICAL NEEDS 18d. DENTAL NEEDS
18e. EARLY INTERVENTION/
SPECIAL EDUCATION NEEDS

19. Check one (1) of the following boxes:

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D R A F T

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a. There ARE special medical, educational, and/or dental needs as identified by a DD Form 2792, DD Form X678-2 TEST, and/or IFSP/IEP. This requires formal
coordination with the gaining FMTS Office. (Only check this BLOCK if BLOCK 18c, d, or e is checked for any dependent.)

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b. There are NO identified special medical, educational, and/or dental needs.
(Only check this BLOCK if BLOCK 18b is checked for all dependents.)

APPOINTED FMTS MEDICAL SCREENER AUTHENTICATION

I certify that the dependents listed above were screened and their needs were documented as stated.
20a. APPOINTED FMTS MEDICAL SCREENER NAME (LAST, FIRST, MI)
20b. SIGNATURE
21a. TITLE

21b. OFFICIAL PHONE (Include area/country codes)
Commercial:
DSN:

21c. DATE (YYYY/MM/DD)

PART D: ADMINISTRATIVE REVIEWER AUTHENTICATION AND DISPOSITION
22a. MTF – LOCATION OF SCREENING

(Completed by losing FMTS Office Administrative Reviewer to document disposition.)

22b. OFFICIAL FMTS STAMP

23. Check the appropriate box and follow the instructions based on the Service member’s affiliation:
a. For Airmen: In all cases, return all forms and attachments to the Servicing PAS code FMTS Office listed in PART A BLOCK 4.
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b. For Soldiers: In all cases, return the form and all attachments to either the Soldier or spouse for processing or directly to
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Personnel Reassignments, depending on local policy procedures.
c. For Sailors and Marines: If special needs are found (BLOCK 19a box checked), send the form to the gaining FMTS Office for
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completion of PART F. If no needs are found (BLOCK 19b box checked), this marks the end of the screening process. Return the
form to the Service member or spouse to submit to the Transferring Command.

PART E: SERVICE AUTHENTICATION

(For Airmen ONLY. Completed by the Air Force Servicing SGH only if PARTS C and D were accomplished at another Service’s FMTS Office.
Upon completion of PART E, proceed with Air Force assignment coordination protocol.)
24a. NAME OF SERVICING SGH (LAST, FIRST, MI)
24b. SIGNATURE
24c. DATE (YYYY/MM/DD)
25a. SERVICING FMTS OFFICE

25b. LOCATION

25c. OFFICIAL PHONE (Include area/country codes)
Commercial:
DSN:

PART F: GAINING FMTS OFFICE REVIEW

26a. PROJECTED ASSIGNMENT LOCATION

(Completed by the gaining FMTS Appointed Medical Reviewer.)
(For Soldiers ONLY: Complete BLOCKS 26a-d for the entire family.)
26b. MEDICAL CARE
26c. DENTAL SERVICES
☐ AVAILABLE
☐ AVAILABLE
☐ NOT AVAILABLE
☐ NOT AVAILABLE
☐ N/A
☐ N/A

26d. SPECIAL EDUCATION SERVICES
☐ AVAILABLE
☐ NOT AVAILABLE
☐ N/A

(For Airmen, Sailors, and Marines ONLY: Complete BLOCKS 27a-d for each dependent requesting travel.)
27a. DEPENDENT NAME (LAST, FIRST, MI)
27b. MEDICAL CARE
27c. DENTAL SERVICES
27d. SPECIAL EDUCATION SERVICES
Not
Not
Not
Available
N/A
Available
N/A
Available
N/A
Available
Available
Available

DD FORM X678 TEST, 20150910 DRAFT

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SCREENING VERIFICATION
FAMILY MEMBER TRAVEL SCREENING
SERVICE MEMBER NAME (LAST, FIRST, MI)

RANK/GRADE

SERVICE MEMBER SSN

SERVICING PAS CODE
(Air Force Only)

28. ADDITIONAL COMMENTS (Do not include PHI on this form, in compliance with HIPAA.)

D R A F T

29a. GAINING FMTS OFFICE
30a. APPOINTED FMTS MEDICAL REVIEWER NAME
(LAST, FIRST, MI)

29b. LOCATION
30b. SIGNATURE

30c. DATE (YYYY/MM/DD)

30d. OFFICIAL FMTS STAMP

31. FINAL DISPOSITION: Check the appropriate box and follow the instructions based on the Service member’s affiliation:
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a. For Airmen: Return the form to the losing FMTS Office.

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b. For Soldiers: Return the form to losing Personnel, who will coordinate with the losing FMTS Office following local procedures.
NOTE: Army in Europe will instead upload the form to an approved automated system.

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c. For Sailors and Marines: Return the form to the losing FMTS Office to return to the Service member (Service member will
return to Transferring Command).

DD FORM X678 TEST, 20150910 DRAFT

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