DD Form 2792-1 Special Education/Early Intervention Summary

DD Form 2792-1, Special Education/Early Intervention Summary is a United States Military form used to enroll in EFMP and to record special educational needs of a dependent child from birth through the age of 21 whose health condition requires special educational services.

The latest revision of the DD 2792-1 was last issued by the Department of Defense (DoD) in August 2014. An up-to-date fillable version of the form is available for download below or can be found on the DoD Documentation website.

What Is DD Form 2792-1?

The DD Form 2792-1 is used to compile the information required to help the military assignment personnel match the child's special needs to the available educational service-related resources at a particular duty station.

The Special Education/Early Intervention Summary is a part of a package of forms necessary for enrolling in the Exceptional Family Member Program - or EFMP for short - and for the Family Member Travel Screening Process along with the DD Form 2792, Family Member Medical Summary.

Despite being issued by the Department of Defense, DD 2792 and DD 2792-1 are required for EFMP enrollment for individuals serving in the Army, Navy, Marine Corps and Air Force.

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The Exceptional Family Member Program (EFMP)

The EFMP is a program run by the U.S. Department of Defense. The program was designed to provide support and services to United States military family members with special needs including spouses, children, and dependent adults. Service members may enroll in the EFMP if they have a family member or family members with a diagnosed physical, developmental, intellectual, emotional or psychological condition that requires specialized medical attention or educational services.

Individuals need a completed the DD 2792 and DD 2792-1 forms to enroll in the program. The forms should be completed by a spouse, primary care provider, or sponsor. Participation in the EFMP and access to the wide range of medical, educational, and family support functions it provides is available for servicemen of every military branch.

The completed forms are submitted to an Army Medical Treatment Facility (MTF) with all necessary attachments. The EFMP Case Coordinator reviews the provided data and forwards the forms to the appropriate Regional Health Command (RHC) who will then determine eligibility.

If the application is approved, the RHC downloads the data into the EFMP database on the Army Personnel Network and the Case Coordinator informs the Soldier of the success of the application.

DD Form 2792-1 Instructions

The first page of the form provides step-by-step instructions on how to correctly file the DD Form 2792-1.

The Special Education/Early Intervention Summary is completed by the parents or sponsors of the dependent and by school personnel or early intervention staff.

Items 1 through 7 are to be filled by a spouse or a sponsor and provide the type of request and all of the necessary personal information on both the enrolled family member and the sponsor or spouse, along with the current military status, phone number and email address.

Provide details about DEERS enrollment, the other spouse's military status, elementary or secondary education eligibility and intervention service participation in Boxes H and I of Item 3 and Items 4, 5 and 6.

The person filling the form should date the form and certify it with their signature. The rest of the form should be completed by an EIS provider or school representatives.

EFMP Enrollment Forms

Army Forms for Family Member Travel Screening:

Air Force Enrollment Form:

  • AF Form 2523, Exceptional Family Member Program-Medical Information Form (EFMP-M).

Air Force Family Member Travel Screening Forms:

Navy Forms and Marine Corps Family Member Travel Screening Forms:

  • NAVMED Form 13001, Medical, Dental and Educational Suitability Screening for Service and Family Members;
  • NAVMED Form 13002, Medical, Dental and Educational Suitability Screening Checklist and Worksheet;
  • NAVPERS Form 130016, Report of Suitability for Overseas Assignment.
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 (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://dpclo.defense.gov/Privacy/SORNsIndex/DODComponentNotices.aspx.
ROUTINE USE(S): DoD Blanket Routine Uses 1, 4, 6, 8, 9, 12, and 15 found at http://dpclo.defense.gov/Privacy/SORNSIndex/
BlanketRoutineUses.aspx may 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 or a school in which DoD is responsible for paying
the tuition for a space-required family member. 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 annotated in the official military personnel files which are retrieved by name and Social
Security Number.
INSTRUCTIONS
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 enrollment
Items 1.a. - d. Sponsor Information. Signature of sponsor,
application for the family member or to update a previous
spouse, legal guardian, or student who has reached the age of
evaluation for the family member.
majority is REQUIRED to authorize the school to release
- Government Sponsored Travel.
- Change in EFMP Status.
information.
Items 2.a. - h. Child/Student Information. Self-explanatory.
Items 2.a. - d. Child/Student Information. Completed by
sponsor, spouse, or legal guardian. Self-explanatory.
Items 3.a. - h. Sponsor Information. Self-explanatory.
Items 3.a. - d. EIS Information. Completed by EIS or school
Item 3.i. Child/student enrolled in DEERS under another
personnel. Mark (X) Yes or No for each item. Include
sponsor. Self-explanatory.
additional information as noted.
Items 4.a. - d. Self-explanatory.
Items 4.a. - f. School Information. Completed by school
personnel at the public school the child attends or would attend.
Item 5. Completed for children age birth to 3 who have or
require an IFSP.
Mark (X) Yes or No for each item. Include additional
information as noted.
Item 6.a. - e. Completed for children ages 3 to 21 only who
have or require an IEP. Children who have IEPs and are ages
Item 5. Completed by school personnel. Mark (X) eligibility
3 to 5 should have the DD 2792-1 completed at the school the
category. Mark only one. (Codes are for Army coding only.)
child would normally attend for kindergarten. High School
graduates, students who have passed the G.E.D. and college
Item 6. Completed by school personnel. Mark (X) all related
students are not required to complete the DD 2792-1.
services provided and indicate total time services are provided.
Items 7.a. - c. Signature of sponsor or spouse who completed
Item 7. Completed by EIS and school personnel. Self-
the form. Self-explanatory.
explanatory.
Items 8.a. - f. Administrative Review. Completed by EFMP
responsible for screening or enrollment in the MTF.
Item 8. Completed by EIS provider/school official information
completing form. Self-explanatory.
DD FORM 2792-1, AUG 2014
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 3 Pages
Adobe Designer 9.0
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 (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://dpclo.defense.gov/Privacy/SORNsIndex/DODComponentNotices.aspx.
ROUTINE USE(S): DoD Blanket Routine Uses 1, 4, 6, 8, 9, 12, and 15 found at http://dpclo.defense.gov/Privacy/SORNSIndex/
BlanketRoutineUses.aspx may 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 or a school in which DoD is responsible for paying
the tuition for a space-required family member. 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 annotated in the official military personnel files which are retrieved by name and Social
Security Number.
INSTRUCTIONS
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 enrollment
Items 1.a. - d. Sponsor Information. Signature of sponsor,
application for the family member or to update a previous
spouse, legal guardian, or student who has reached the age of
evaluation for the family member.
majority is REQUIRED to authorize the school to release
- Government Sponsored Travel.
- Change in EFMP Status.
information.
Items 2.a. - h. Child/Student Information. Self-explanatory.
Items 2.a. - d. Child/Student Information. Completed by
sponsor, spouse, or legal guardian. Self-explanatory.
Items 3.a. - h. Sponsor Information. Self-explanatory.
Items 3.a. - d. EIS Information. Completed by EIS or school
Item 3.i. Child/student enrolled in DEERS under another
personnel. Mark (X) Yes or No for each item. Include
sponsor. Self-explanatory.
additional information as noted.
Items 4.a. - d. Self-explanatory.
Items 4.a. - f. School Information. Completed by school
personnel at the public school the child attends or would attend.
Item 5. Completed for children age birth to 3 who have or
require an IFSP.
Mark (X) Yes or No for each item. Include additional
information as noted.
Item 6.a. - e. Completed for children ages 3 to 21 only who
have or require an IEP. Children who have IEPs and are ages
Item 5. Completed by school personnel. Mark (X) eligibility
3 to 5 should have the DD 2792-1 completed at the school the
category. Mark only one. (Codes are for Army coding only.)
child would normally attend for kindergarten. High School
graduates, students who have passed the G.E.D. and college
Item 6. Completed by school personnel. Mark (X) all related
students are not required to complete the DD 2792-1.
services provided and indicate total time services are provided.
Items 7.a. - c. Signature of sponsor or spouse who completed
Item 7. Completed by EIS and school personnel. Self-
the form. Self-explanatory.
explanatory.
Items 8.a. - f. Administrative Review. Completed by EFMP
responsible for screening or enrollment in the MTF.
Item 8. Completed by EIS provider/school official information
completing form. Self-explanatory.
DD FORM 2792-1, AUG 2014
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 3 Pages
Adobe Designer 9.0
OMB No. 0704-0411
SPECIAL EDUCATION/EARLY INTERVENTION SUMMARY
OMB approval expires
(Page 1, Items 1 - 7 to be completed by sponsor, parent or legal guardian.)
Jul 31, 2017
(Read Privacy Act Statement and 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, Directives Division, 4800 Mark Center Drive,
Alexandria, VA 22350-3100 (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
No longer requires IEP/IFSP services
No longer qualifies as a dependent*
(*Provide documentation for change in status)
Divorce/change in custody*
2. CHILD/STUDENT INFORMATION
(To be completed by sponsor, spouse or legal guardian)
c. CHILD/STUDENT CURRENT MAILING
a. CHILD/STUDENT NAME (Last, First, Middle Initial)
b. SPONSOR NAME (Last, First, Middle Initial)
ADDRESS (Street, Apartment Number, City,
State, ZIP Code, APO/FPO)
d. FAMILY MEMBER
e. CHILD/STUDENT DATE
f. CHILD/STUDENT GENDER (X one)
PREFIX
OF BIRTH (YYYYMMDD)
MALE
FEMALE
h. HOME TELEPHONE NUMBER
g. FAMILY HOME E-MAIL ADDRESS
(Include Area Code/Country Code)
3.
a. SPONSOR RANK OR GRADE
b. INSTALLATION OF CURRENT ASSIGNMENT (Include City, State, Country)
d. DUTY TELEPHONE NUMBER
e. MOBILE NUMBER
c. SPONSOR'S OFFICIAL E-MAIL ADDRESS
(Include Area Code/Country Code)
(Include Area Code/Country Code)
f. STATUS (X one)
g. BRANCH OF SERVICE (Military only)
Active Guard
Regular Active Service Member
Active Reserve
Army
Navy
Air Force
Reserves
National Guard
Civilian
Marine Corps
Coast Guard
h. DOES CHILD RESIDE WITH SPONSOR? (X one. If No, explain.)
YES
NO
i. 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:
Is your child being evaluated for, or receiving, early intervention services on an Individualized Family Service Plan (IFSP)? (X one. If No, sign
YES
NO
Item 7 and return to the requesting office. If Yes, have early intervention professional complete Page 3.)
6. FOR STUDENTS AGES 3 - 21 WHO ARE ELIGIBLE FOR ELEMENTARY AND SECONDARY EDUCATION
:
(Includes preschool-aged children)
a. Is your child being home-schooled? (X one. If No, sign Item 7 and take Page 3 to your child's school. If Yes, complete the following and
YES
NO
sign Item 7.)
b. Is your child being home-schooled part-time or full-time? (X one)
Part-time
Full-time
c. When did you start home-schooling? (YYYYMMDD)
d. Name/title home school program, if known:
e. List any special education-related services received in the last 3 years:
7.
a. SIGNATURE
b. PRINTED NAME (Last, First, Middle Initial)
c. DATE (YYYYMMDD)
f. STAMP
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)
c. SSN USED IN DEERS (If different from sponsor's)
d. MILITARY MTF OR OFFICE RECEIVING COMPLETED FORM
e. DATE (YYYYMMDD)
DD FORM 2792-1, AUG 2014
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 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.)
1. 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 registration or eligibility for other educationally
related benefits.
c. RELATIONSHIP TO CHILD/
d. DATE
a. SIGNATURE
b. PRINTED NAME
STUDENT
(YYYYMMDD)
2. CHILD/STUDENT INFORMATION
(To be completed by sponsor, spouse, or legal guardian)
b. CURRENT GRADE LEVEL
a. NAME OF CHILD/STUDENT (Last, First, Middle Initial)
c. DATE OF BIRTH (YYYYMMDD)
d. GENDER (X one)
(If school age)
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 Service Plan (IFSP)?
(If Yes, please attach current IFSP.)
Date of next annual review (YYYYMMDD)
c. Basis for eligibility:
Developmental Delay
Diagnosed physical or mental condition that has a high probability of resulting in a Developmental Delay
d. Is there an identified disability? (If known, please specify):
4. SCHOOL INFORMATION - FOR STUDENTS AGES 3 - 21
(To be completed by school representative)
YES
NO
a. Has this child ever been evaluated for, or been offered, special education services by your school? (If No, skip to Item 8.)
b. Is this student currently being evaluated for special education services? If Yes, what disability category?
(Skip to Item 8)
c. 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.)
d. 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)
e. Were IEP services terminated by the IEP team within the last 2 years? (If Yes, skip to Item 8.) Date of IEP termination (YYYYMMDD)
f. 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)
N09 Communication Impaired:
N07 Autism Spectrum Disorder:
N16 Behavioral/Conduct Disorder
N01 Deaf
Articulation
N04 Intellectual Disability
:
(Mental Retardation)
N02 Blind
Dysfluency
Mild
N13 Deaf/Blind
Voice
Moderate
N11 Visually Impaired
Language/Phonology
Severe/Profound
N05 Traumatic Brain Injury
N15 Developmental Delay
N08 Other Health Impaired (Specify)
N03 Hearing Impaired
N12 Specific Learning Disability
N06 Orthopedically Impaired
N10 Emotionally 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
20
M
per
W
(Example:)
R01 Counseling
R06 Special Transportation (Describe)
per
R02 Occupational Therapy
per
R03 Physical Therapy
per
R04 Speech Therapy
per
R07 Other (Describe):
Intensive Behavioral Intervention
R05
per
(Such as ABA)
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. CITY, STATE, COUNTRY
d. TELEPHONE NUMBER (Include Area Code/
e. FAX NUMBER (Include Area Code/
Country Code)
Country Code)
f. E-MAIL ADDRESS
g. NAME OF INDIVIDUAL COMPLETING THIS SECTION
h. SIGNATURE
i. TITLE
j. DATE SIGNED
(YYYYMMDD)
DD FORM 2792-1, AUG 2014
Page 3 of 3 Pages

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