Dd Form 2792 1 – Fill Out and Use This PDF

SPECIAL EDUCATION/EARLY INTERVENTION SUMMARY

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 136; 20 U.S.C. 927; DoDI 1315.19: DoDI 1342.12; and E.O. 9397 (SSN) as amended.

PRINCIPAL PURPOSE(S): Information will be used by DoD personnel to evaluate and document the special education needs of family members.

This information will enable: (1) Military assignment personnel to match the special education needs of family members against the availability of educational services, and (2) Civilian personnel officers to advise civilian employees about the availability of education services to meet the 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 SORNs may be found at http://privacy.defense.gov/notices.

ROUTINE USE(S): The DoD "Blanket Routine Uses" found at http://privacy.defense.gov/blanket_uses.shtml apply.

DISCLOSURE: Voluntary for civilian employees and applicants for civilian employment; however, the information must be provided if you intend to enroll your child with special education needs in a school funded by the Department of Defense.

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 sponsor's spouse if dual military) allows the DoD Education Activity and Service personnel offices to work together to ensure any special education needs of your dependent can be met at your next duty assignment. Dependent special education needs are noted in the official military personnel files which are retrieved by name and Social Security Number.

INSTRUCTIONS

DD FORM 2792-1, APR 2011

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 3 Pages

Adobe Professional 8.0

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.

DEMOGRAPHICS

1. REQUEST (X one)

	EFMP Registration/Enrollment Update		Change in EFMP Status:						Other (Explain):
	Government Sponsored Travel and/or Command			No longer requires IEP/IFSP services
	Sponsorship			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)						c. CHILD/STUDENT CURRENT MAILING
								ADDRESS (Street, Apartment Number, City,
								State, ZIP Code, APO/FPO)
d. CHILD/STUDENT DATE OF BIRTH (YYYYMMDD)		e. CHILD/STUDENT GENDER (X one)
			MALE				FEMALE
f. FAMILY HOME E-MAIL ADDRESS				g. HOME TELEPHONE NUMBER
					(Include Area Code/Country Code)

d. SPONSOR'S OFFICIAL E-MAIL ADDRESS

e. DUTY TELEPHONE NUMBER

f. MOBILE NUMBER

(Include Area Code/Country Code)

(Include Area Code/Country Code)

g. SPONSOR'S CURRENT UNIT MAILING ADDRESS

h. STATUS (X one)

d. BRANCH OF SERVICE (Military only)

Regular Active Service

Reservist

Army

Air Force

Member

National Guard

Active Guard/Reserve

Navy

Marine Corps

Civilian

Program (AGR)

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, provide 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)	c. BRANCH OF SERVICE	d. RANK/RATE
	YES		NO

5. FOR CHILDREN FROM BIRTH TO AGE THREE ONLY:

6. FOR STUDENTS AGES 3 - 21 WHO ARE ELIGIBLE FOR ELEMENTARY AND SECONDARY EDUCATION:

YES		NO 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)

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)	c. DATE (YYYYMMDD)
8. ADMINISTRATIVE REVIEW (Completed after review of entire form by local military MTF or office receiving form)			STAMP
a. SPONSOR SSN	b. SPOUSE SSN (If dual military)	c. SSN USED IN DEERS (If different from sponsor's)

DD FORM 2792-1, APR 2011

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.

2.CHILD/STUDENT INFORMATION (To be completed by sponsor or spouse)

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: Developmental delay High probability for 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:		N09	Communication Impaired:		N12	Specific Learning Disability
		Autism			Articulation		N10	Emotionally Impaired
		PDD-NOS			Dysfluency		N16	Behavioral/Conduct Disorder
		Asperger's Syndrome			Voice		N04	Mental Retardation:
	N01	Deaf			Language/Phonology			Mild/Moderate
	N02	Blind		N05	Traumatic Brain Injury			Moderate/Severe
	N13	Deaf/Blind		N03	Hearing Impaired			Severe/Profound
	N11	Visually Impaired		N06	Orthopedically Impaired		N08	Other Health Impaired (Specify)

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:			20	M	per	W
	R01	Counseling			per				R06	Special Transportation (Describe):
	R02	Occupational Therapy			per
	R03	Physical Therapy			per				R07	Other (Describe):
	R04	Speech Therapy			per
	R05	Intensive Behavioral Intervention (Such as ABA)			per

7.BEHAVIOR/COMMUNICATION (X all that apply and explain in comments section.)

8. PROVIDER/SCHOOL INFORMATION

a.NAME OF EARLY INTERVENTION PROGRAM OR SCHOOL

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

DD FORM 2792-1, APR 2011

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