Form DD X678-4 TEST DD X678-4 TEST Administrative Review Checklist

ADMINISTRATIVE REVIEW CHECKLIST
FAMILY MEMBER TRAVEL SCREENING INSTRUCTIONS
GENERAL
The DD Form X678-4 TEST, Administrative Review Checklist,
tracks the Family Member Travel Screening (FMTS) documentation
process. This form assists the losing FMTS Office Administrative
Reviewer in tracking documents for each dependent throughout the
FTMS process. It provides a snapshot of screening activities.
This form is completed by the losing FMTS Office
Administrative Reviewer. The information pertains to the FMTS
packet, which includes:
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BLOCK 7e: Review each dependent’s DD Form X678-1 TEST
PART C to determine if they require a DD Form 2792.
If any circle is checked in PART C, a DD Form 2792 is
REQUIRED. Check the “REQUIRED” box and note the date
once received. If required and not received, document actions
taken in BLOCK 8.
If no circles are checked in PART C, a DD Form 2792 is NOT
REQUIRED. Check the “NOT REQUIRED” box.

BLOCK 7f: Review each dependent’s DD Form X678-1 TEST
BLOCKS 1d-e to determine if they require a DD Form 2792-1.
DD Form X678 TEST, Screening Verification
DD Form X678-1 TEST, Medical and Educational Information
If BLOCK 1d on the DD Form X678-1 TEST indicates a dependent
DD Form X678-2 TEST, Dental Health Information (as applicable)
child is under the age of 22, then review BLOCK 1e.
DD Form X678-3 TEST, Patient Care Review (as applicable)
If BLOCK 1e on the DD Form X678-1 TEST is checked
All associated documents, e.g., DD Form 2792 Family
"NO", then a DD Form 2792-1 is REQUIRED. Check the
Member Medical Summary and/or DD Form 2792-1
“REQUIRED” box and note the date once received. If
Special Education/Early Intervention Summary with an
required and not received, document actions taken in
Individualized Family Service Plan (IFSP)/Individualized
BLOCK 8.
Education Plan (IEP)

D R A F T

One (1) form is completed for the entire family.

Review DD Form X678 TEST to determine the number of dependents.
When a required form is received, note the date (MM/DD). Do not
proceed with the FMTS process until each form that is required
is received.
BLOCKS 1-4: Self-explanatory.
BLOCK 5: Refer to the DD Form X678 TEST after PART A for
Service-specific required attachments.
BLOCK 6: Self-explanatory.
BLOCK 7a: Review the DD Form X678 TEST BLOCK 9a and list
each dependent’s name (LAST, FIRST, MI).
BLOCK 7b: The DD Form X678-1 TEST is always REQUIRED for a
listed dependent. Check the “REQUIRED” box and note the date
once received for each dependent. If not received, document actions
taken in BLOCK 8.
BLOCK 7c: Review each dependent’s DD Form X678-1 TEST
BLOCK 1d to determine if he/she requires a DD Form X678-2 TEST.
For Airmen: If the dependent is two (2) years of age and older,
a DD Form X678-2 TEST is REQUIRED.
For Soldiers, Sailors, and Marines: If the dependent is six (6)
months of age and older, a DD Form X678-2 TEST is REQUIRED.
If a DD Form X678-2 TEST is REQUIRED, check the “REQUIRED”
box and note the date once received. If required and not received,
document actions taken in BLOCK 8.
If a dependent is below the Service-specific required age, a DD
Form X678-2 TEST is NOT REQUIRED. Check the “NOT
REQUIRED" box.

If BLOCK 1e on the DD Form X678-1 TEST is checked
"YES", then DD Form 2792-1 is NOT REQUIRED. Check
“the NOT REQUIRED” box.

If BLOCK 1d on DD Form X678-1 TEST indicates the dependent
is 22 years of age and older, then a DD Form 2792-1 is NOT
REQUIRED. Check the “NOT REQUIRED” box.
BLOCK 7g: Review each dependent’s DD Form X678-1 TEST
PART D to determine if they require an IFSP/IEP attached to the
DD Form 2792-1.
If any circle is checked in PART D, an IFSP/IEP is REQUIRED.
Check the “REQUIRED” box and note the date once received. If
required and not received, document actions taken in BLOCK 8.
If the “N/A” box (located at the top of PART D) is checked or if
no circles are checked, an IFSP/IEP is NOT REQUIRED. Check
the “NOT REQUIRED” box.
An IFSP/IEP is NOT REQUIRED if a DD Form 2792-1 is also
not required (DD Form X678-4 TEST BLOCK 7f checked “NOT
REQUIRED”).
BLOCKS 8-9: Self-explanatory.
BLOCK 10: Forward the completed applicable DD Form 2792
and/or 2792-1 with IFSP/IEP to the appropriate Service EFMP POC
so that they can determine EFMP enrollment or update the DD
Forms on file, if needed. For further Service-specific instructions,
refer to the EFMP Quick Reference Guide (QRG) available at

http://download.militaryonesource.mil/12038/MOS/ResourceGuides/
EFMP-QuickReferenceGuide.pdf. Check the appropriate “YES”/“NO”

response.

BLOCKS 11-17: Self-explanatory.

BLOCK 7d: Review each dependent’s DD Form X678-1 TEST
BLOCK 1f to determine if they require a DD Form X678-3 TEST.
If BLOCK 1f is checked “YES”, a DD Form X678-3 TEST is
REQUIRED. Check the “REQUIRED” box and note the date once
received. If required and not received, document actions taken in
BLOCK 8.
If BLOCK 1f is checked “NO”, a DD Form X678-3 TEST is NOT
REQUIRED. Check the “NOT REQUIRED” box.

DD FORM X678-4 TEST, 20161011 DRAFT

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Adobe Professional X

ADMINISTRATIVE REVIEW CHECKLIST
FAMILY MEMBER TRAVEL SCREENING
(Completed by losing FMTS Office Administrative Reviewer. One (1) form per family.)

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.

1. SPONSOR NAME (LAST, FIRST, MI)

2. RANK/GRADE

3. SPONSOR SSN

5. Has the family submitted the DD Form X678 TEST Screening Verification with Service-specific attachments?

4. SERVICING PAS CODE
(Air Force only)
☐ YES

☐

NO

6. Indicate the year of the screening (YYYY) _________
7a. NAME (LAST, FIRST, MI)

7b. DD FORM
X678-1 TEST
Required

7c. DD FORM
X678-2 TEST
Required

Rec'd 00''

Rec'd 00''

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7d. DD FORM
X678-3 TEST

7e. DD FORM
2792

7f. DD FORM
2792-1

7g. IFSP/IEP

(Attached to DD
Form 2792-1)

Not
Not
Not
Not
Not
Required
Required
Required
Required
Required Rec'd 00'' Required Rec'd 00'' Required Rec'd 00'' Required Rec'd 00'' Required

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8. If the FMTS packet is not complete, list actions taken to obtain required information and the corresponding dates. (Provide information in chronological order. Attach an
additional sheet if necessary.)

9. Comments for losing Appointed FMTS Medical Screener’s review. (Attach an additional sheet if necessary.)

10. I have forwarded any applicable DD Form 2792 and/or 2792-1 with IFSP/IEP to the appropriate Service-specific EFMP enrollment POC. ☐ N/A

☐ YES

☐ NO

ADMINISTRATIVE REVIEWER AUTHENTICATION AND DISPOSITION

(Do not complete until after the face-to-face interview.)
I have completed the DD Form X678 TEST Screening Verification PART D and forwarded the FMTS packet following Service-specific guidance.
11. ADMINISTRATIVE REVIEWER NAME (LAST, FIRST, MI)

12. RANK/GRADE

15. SIGNATURE

16. LOSING FMTS OFFICE LOCATION

DD FORM X678-4 TEST, 20161011 DRAFT

13. TITLE/DISCIPLINE

14. PHONE
Commercial:
DSN:
17. DATE (YYYY/MM/DD)

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