DD Form 2792-1 Early Intervention/Special Education Summary

EARLY INTERVENTION / SPECIAL EDUCATION SUMMARY

OMB No. 0704-0411
OMB APPROVAL EXPIRES
XX/XX/XXXX

The public reporting burden for this collection of information, 0704-0411, is estimated to average 25 minutes per response, including 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington
Headquarters Services, at [email protected]. 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 U.S.C. 136; 20 U.S.C. 927; DoDI 1315.19: DoDI 1342.12
PRINCIPAL PURPOSE(S): Information will be used by DoD personnel to evaluate and document the early intervention/special education needs of family members. This information will enable: (1) sponsors
to enroll into the Exceptional Family Member Program (EFMP), (2) military assignment personnel to match the early intervention/special education needs of family members against the availability of early
intervention/special education services through the Family Member Travel Screening (FMTS) process, (3) EFMP Family Support staff to offer information on community support services, and (4) civilian
personnel offices to advise civilian employees about the availability of education services to meet the early intervention/special education needs of their family members. The personally identifiable
information collected on this form is covered by a number of system of records notices pertaining to Official Military Personnel Files, Exceptional Family Member or Special Needs files, Civilian Personnel
Files, and DoD Education Activity files.
The applicable SORNs and routine uses that apply can be found at: Air Force: F036 AF PC C: Military Personnel Records System at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORNArticle-View/Article/569821/f036-af-pc-c/; F044 AF SG U: Special Needs and Educational and Developmental Intervention Services at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORNArticle-View/Article/569875/f044-af-sg-u/; Army: A0600-8-104b AHRC - Official Military Personnel Record at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570054/
a0600-8-104-ahrc/; A0608b CFSC, Personnel Affairs: Army Community Service Assistance Files at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570084/a0608bcfsc/"
DHA: EDHA 07: Military Health Information System at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570672/edha-07/
OSD/JS: DMDC 02 DoD: Defense Enrollment Eligibility Reporting Systems (DEERS) at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/627618/dmdc-02-dod/
DPR 34 DoD: Defense Civilian Personnel Data System at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570697/dpr-34-dod/
EDHA 16 DoD: Special Needs Program Management Information System (SNPMIS) Records at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570679/edha-16-dod/
DoDEA 29: DoDEA Non-DoD Schools Program at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570576/dodea-29/
DoDEA 26: Department of Defense Education Activity Educational Records at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570573/dodea-26/
Navy and Marine Corps: "M01070-6: Marine Corps Official Military Personnel Files at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570626/m01070-6/
M01754-6: Exceptional Family Member Program Records at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570631/m01754-6/
N01070-3: Navy Military Personnel Records System at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570310/n01070-3/
N01301-2: On-Line Distribution Information System (ODIS) at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570320/n01301-2/
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 DoD Identification (DoD ID) number of the
sponsor (and sponsor's spouse if dual military) allows the Military Healthcare System and Service personnel offices to work together to ensure any early intervention/special education needs of your
dependent can be met at your next duty assignment. Dependent early intervention/special education needs are annotated in the official military personnel files which are retrieved by name and DoD ID
number.

INSTRUCTIONS FOR COMPLETING DD FORM 2792-1, EARLY INTERVENTION / SPECIAL EDUCATION SUMMARY
The DD Form 2792-1 is completed to identify a family
member with early intervention / special education needs.

EARLY INTERVENTION / SPECIAL EDUCATION SUMMARY.

DRAFT

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
Items 1 - 7. To be completed by sponsor, spouse, legal guardian, or student who has staff. Do not include medical information forms that may be used for
reached the age of majority.
family member travel screening or EFMP enrollment.
DEMOGRAPHICS.

Item 1

Request (X one):

• Exceptional Family Member Program (EFMP) Enrollment or Update - first
enrollment application for the family member or to update a previous
evaluation for the family member.
• Government Sponsored Travel.
• Change in EFMP Status.
Items 2.a. - h. Child / Student Information. Self-explanatory.
Items 3.a. - h. Sponsor Information. Self-explanatory.
Item 3.i. Child / student enrolled in Defense Enrollment Eligibility Reporting System
(DEERS) under another sponsor. Self-Explanatory.

Items 9.a. - d. Sponsor Information. Signature of sponsor, spouse, legal
guardian, or student who has reached the age of majority is REQUIRED to
authorize the school to release information.
Items 10.a. - d. Child / Student Information. Completed by sponsor, spouse, or
legal guardian. Self-explanatory.
Items 11.a. - e. Early Intervention Summary (EIS) Information. Completed
by EIS or school personnel. Mark (X) Yes or No for each item. Include
additional information as noted.
Items 12.a. - f. School Information. Completed by school personnel at the
school the child attends. Mark (X) Yes or No for each item. Include additional
information as noted.

Items 4a. - d. Self-explanatory.
Item 5. Completed for children age birth to 3.
Items 6.a. - c. Completed for children ages 3 to 21 only. Children who are ages 3 to
5 should have the DD Form 2792-1 completed at the school the child would normally
attend for kindergarten. High school graduates, students who have passed the
G.E.D., and college students are not required to complete the DD Form 2792-1.
NOTE: For 6.c., students that are home-schooled are eligible to receive some form of
special education services in the public school setting. Therefore they may have a
private school service plan. Include a copy of the service plan as applicable.
Items 7.a. - d. Signature of sponsor, spouse, legal guardian, or student
who has reached the age of majority and completed the form. Self-explanatory.
Items 8.a. - f. Administrative Review. Completed by EFMP Office or Family Member
Travel Screening (FMTS) Office responsible for enrollment or screening. NOTE: For
8.c., if child is entered into DEERS under a DoD ID number other than what is
provided in 8.a. and 8.b., list the additional ID in 8.c.

DD FORM 2792-1, JAN 2021

Item 13. Completed by school personnel. Mark (X) eligibility category. Mark
only one.
Item 14. Completed by school personnel. Mark (X) all related services provided
and indicate total time services are provided.
Items 15.a - c. Completed by EIS and school personnel. Self-explanatory.
Items 16.a - j. Completed by EIS provider / school official information
completing the form. Self-explanatory.
NOTE: If child is under 5 years of age, is not enrolled in school, a home school
program, or engaged with an Early Intervention Services program, and does not
have any identified needs, the parents or guardians can fill out and sign page 2
of the DD Form 2792-1 and return it to the requesting office. The completion of
Page 3 is not required in this case.

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EARLY INTERVENTION / SPECIAL EDUCATION SUMMARY
(Page 2, Items 1 - 7 to be completed by sponsor, parent, or legal guardian. Read Privacy Act Statement and Instructions before completing the form.)

DEMOGRAPHICS
1. REQUEST (Select One)
EFMP Enrollment or Update

Request Change in EFMP Status:

Request for Government Sponsored Travel

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

Divorce / change in custody*
Family member deceased

(*Provide documentation to change status)
2. CHILD / STUDENT INFORMATION (To be completed by sponsor, spouse, legal guardian, or student who has reached the age of majority.)
2a. CHILD / STUDENT NAME (Last, First, Middle Initial)
2b. SPONSOR NAME (Last, First, Middle Initial)
2c. CHILD / STUDENT CURRENT
MAILING ADDRESS (Street,
Apartment Number, City,State, ZIP
Code, APO / FPO)
2f. CHILD / STUDENT GENDER
2e. CHILD / STUDENT DATE OF
2d. FAMILY MEMBER PREFIX
(Select one)
BIRTH (YYYYMMDD)
Male
2g. FAMILY HOME E-MAIL ADDRESS

Female

2h. HOME TELEPHONE NUMBER (Include Country
Code / Area Code)

3a. SPONSOR RANK OR GRADE

3b. INSTALLATION OF SPONSOR'S CURRENT ASSIGNMENT (Include City, State, Country)

3c. SPONSOR'S OFFICIAL E-MAIL ADDRESS

3d. DUTY TELEPHONE NUMBER (Include Country
Code / Area Code)

3f. STATUS (Select One)

3e. MOBILE NUMBER (Include Country Code /
Area Code)

3g. BRANCH OF SERVICE (Military Only)

Regular Active Service Member

Active Reserve

Reserves

National Guard

Active Guard

Army

Navy

DRAFT
Civilian

Marine Corps

Air Force

Coast Guard

3h. DOES CHILD RESIDE WITH SPONSOR? (Select One. If No, Explain.)
Yes

No

3i. IS THE CHILD / STUDENT ENROLLED IN DEERS UNDER A SPONSOR OTHER THAN THE ONE LISTED ABOVE? (Select One. If Yes, provide
name of sponsor)
Yes

No

4a. ARE BOTH SPOUSES ON ACTIVE DUTY? (Military Only. Select One. If Yes, Complete 4b.- 4d. below)
4c. BRANCH OF SERVICE

4b. ACTIVE DUTY SPOUSE'S NAME (Last, First, Middle Initial)

Yes

No

4d. RANK / RATE

5. FOR CHILDREN FROM BIRTH TO AGE THREE ONLY:
Is your child being evaluated for, or eligible for early intervention services on an Individualized Family Service Plan (IFSP)?
Yes
No
(Select one. If No, sign Item 7 and return to the requesting office. If Yes, have early intervention professional complete page 3.)
6. EDUCATION SERVICES FOR DEPENDENTS 3 YEARS AND OLDER:
6a. Is your child being home-schooled full-time or part-time? (Select one)

Yes, Part-Time

Yes, Full-Time

No (If Yes, complete 6a(1) and 6a(2))

6a(1). When did you start home-schooling? (YYYYMMDD)
6a(2). Name of home school program/title of courses:
6b. Is your child being evaluated for, or receiving, special education services on an IEP?
If Yes, have the child's school (or primary care provider if school is not in session) complete page 3.

Yes

No

6c. List any special education-related services received in the last 3 years: (include a copy of the service plan as applicable)

7. RELEASE OF INFORMATION (To be completed by sponsor, spouse, legal guardian, 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 appropriate personnel of the Department of Defense. This information will be used
to evaluate and document my child / student's needs for educational services for the purpose of assignment coordination, EFMP enrollment, or eligibility for
other educationally related benefits.
7a. SIGNATURE
7b. PRINTED NAME
7c. RELATIONSHIP TO CHILD / STUDENT 7d. DATE (YYYYMMDD)

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

8b. SPOUSE DoD ID # (If dual military)

8d. MTF OR OFFICE RECEIVING COMPLETED FORM

DD FORM 2792-1, JAN 2021

8c. DoD ID # USED IN DEERS (If different from sponsor's) 8f. STAMP
8e. DATE (YYYYMMDD)

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EARLY INTERVENTION / SPECIAL EDUCATION SUMMARY
NOTE TO EDUCATIONAL AUTHORITY COMPLETING THIS FORM: It is important to the military and to the family that the service member 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) to this page.)

9. RELEASE OF INFORMATION (To be completed by sponsor, spouse, legal guardian, 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 enrollment or eligibility for other educationally related benefits.

9a. PRINTED NAME

9b. SIGNATURE

9c. RELATIONSHIP TO CHILD / STUDENT

9d. DATE (YYYYMMDD)

10. CHILD / STUDENT INFORMATION (To be completed by sponsor, spouse, or legal guardian)
10a. NAME OF CHILD / STUDENT (Last, First, Middle Initial)

10b. CURRENT GRADE LEVEL (if school age) 10c. DATE OF BIRTH (YYYYMMDD) 10d. GENDER (Select one)
Male

Female

11. EARLY INTERVENTION SERVICES (EIS) - FOR CHILDREN UNDER 3 YEARS OF AGE (To be completed by EIS representative)
YES NO
11a. Is the child currently being evaluated for early intervention services?
11b. Does this child receive early intervention services under a current Individualized Family Service Plan (IFSP)? (If Yes, please attach current IFSP).
Date of next annual review (YYYYMMDD)
11c. Has the child been found eligible but the family declined IFSP services?
11d. Basis for eligibility:
Developmental Delay
Diagnosed physical or mental condition that has a high probability of resulting in a Developmental Delay
11e. Is there an identified disability? (If known, please specify)
12. SCHOOL INFORMATION - FOR STUDENTS AGES 3 - 21 (To be completed by school representative - answer all questions)
YES NO
12a. Is this student currently being evaluated for special education services?
12b. Has the child been found eligible for special education services? (If Yes, complete Item 13.)
12c. 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 13 and proceed to Item 16)
12d. Does this child / student receive special education services under a current Individualized Education Program (IEP)?
(If Yes, complete Items 13 and following and attach a copy of the current IEP.)
Date of next annual review (YYYYMMDD)
12e. Were IEP services terminated by the IEP team due to ineligibility within the last 2 years? Date of IEP termination (YYYYMMDD)
12f. Was the IEP terminated at the request of the parents within the last year (parents withdrew student from special education)? (If Yes, complete
Items 13 and following). Date of IEP termination (YYYYMMDD)
13. ELIGIBILITY CATEGORY FOR CHILDREN 3 TO 21 YEARS OF AGE (Select only one)
N/A

DRAFT
Communication Impaired

Autism Spectrum Disorder
Deaf

Articulation

Blind
Deaf / Blind
Visually Impaired

Behavioral / Conduct Disorder
Intellectual Disability

Dysfluency

Mild

Voice

Moderate

Language / Phonology

Traumatic Brain Injury

Developmental Delay

Hearing Impaired

Specific Learning Disability

Severe / Profound
Other Health Impaired (Specify)

Orthopedically Impaired
Emotionally Impaired
14. RELATED SERVICES ON IEP (Select 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: 20 M per W)
Counseling
Occupational Therapy
Physical Therapy
Speech Therapy
Intensive Behavioral Intervention (such as ABA)

per
per
per
per
per

15. BEHAVIOR / COMMUNICATION (Select all that apply and specify in comments section)
YES NO
15a. Child exhibits high risk or dangerous behavior
15b. Child is verbal (If No, answer 15b(1)-15b(4) The student uses:)

N/A

Special Transportation (Describe)

Other (Describe)

15c. COMMENTS

15b(1). Signing
15b(2). Picture Exchange Communication System (PECS)
15b(3). Communication Device
15b(4). Other
16. PROVIDER / SCHOOL INFORMATION
16a. NAME OF EARLY INTERVENTION PROGRAM OR SCHOOL
16c. CITY, STATE, COUNTRY

16d. TELEPHONE NUMBER (Include Country Code / Area code) 16e. FAX NUMBER (Include Country Code / Area Code)

16f. E-MAIL ADDRESS
16h. SIGNATURE

DD FORM 2792-1, JAN 2021

16b. SCHOOL DISTRICT

16g. NAME OF INDIVIDUAL COMPLETING THIS SECTION
16i. TITLE

16j. DATE (YYYYMMDD)

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