DA Form 7625-1 Army Child and Youth Services Health Screening Tool

DA Form 7625-1 or the "Army Child And Youth Services Health Screening Tool" is a Department of the Army-issued form used by and within the United States Military.

The form - often incorrectly referred to as the DD form 7625-1 - was last revised on May 1, 2009. Download an up-to-date fillable DA Form 7625-1 down below in PDF-format or look it up on the Army Publishing Directorate website.

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ARMY CHILD AND YOUTH SERVICES HEALTH SCREENING TOOL
For use of this form, see AR 608-75; the proponent agency is OACSIM.
PRIVACY ACT STATEMENT
10 U.S.C. 3013, Secretary of the Army; 29 U.S.C. 794, Nondiscrimination Under Federal Grants and
AUTHORITY:
Programs; DoDD 1342.17 Family Policy; AR 608-75, Exceptional Family Member Program; AR 608-10,
Child Development Services.
Information will be used to assist Army activities in their responsibilities in overall execution of the
PRINCIPAL PURPOSE:
Army's Exceptional Family Member Program (EFMP) and the Army Child and Youth Services Program.
The DoD "Blanket Routine Uses" that appear at the beginning of the Army's compilation of systems of
ROUTINE USES:
records apply to this system.
Disclosure of requested information is voluntary; however, if information is not provided individual may
DISCLOSURE:
not be able to participate in Army Child and Youth Services Program.
Part A - General Information
1. Child's Name
2. Date of birth (YYYYMMDD)
3. Family member prefix
4. Type of placement requested
5. Date (YYYYMMDD)
6. Sponsor name
7. Spouse name
8. Home phone
9. Duty phone
10. Cell phone
Part B - Identification of Child/Youth Condition/Restrictions
Child has any of the following conditions/restrictions: (Check yes or no)
1. Allergies
No
Yes (explain)
a. Life threatening reaction
No
Yes (explain)
b. Epi-pen required
No
Yes
c. Other allergic reations (hives, rash, diarrhea)
No
Yes
2. Asthma reactive airway disease
No
Yes (explain)
a. Triggers exist for child's asthma attacks (stress, environmental, exercise)
No
Yes (explain)
b. Child routinely (greater than 10 days per month/four months per year) uses inhaled anti-inflammatory agents and/or bronchodilators
No
Yes (explain)
c. Child has taken steroids during the past year (prednisone, prednisolone)
No
Yes (indicate number of days in past year)
Page 1 of 3
PREVIOUS EDITION IS OBSOLETE.
DA FORM 7625-1, MAY 2009
APD LC v1.00ES
ARMY CHILD AND YOUTH SERVICES HEALTH SCREENING TOOL
For use of this form, see AR 608-75; the proponent agency is OACSIM.
PRIVACY ACT STATEMENT
10 U.S.C. 3013, Secretary of the Army; 29 U.S.C. 794, Nondiscrimination Under Federal Grants and
AUTHORITY:
Programs; DoDD 1342.17 Family Policy; AR 608-75, Exceptional Family Member Program; AR 608-10,
Child Development Services.
Information will be used to assist Army activities in their responsibilities in overall execution of the
PRINCIPAL PURPOSE:
Army's Exceptional Family Member Program (EFMP) and the Army Child and Youth Services Program.
The DoD "Blanket Routine Uses" that appear at the beginning of the Army's compilation of systems of
ROUTINE USES:
records apply to this system.
Disclosure of requested information is voluntary; however, if information is not provided individual may
DISCLOSURE:
not be able to participate in Army Child and Youth Services Program.
Part A - General Information
1. Child's Name
2. Date of birth (YYYYMMDD)
3. Family member prefix
4. Type of placement requested
5. Date (YYYYMMDD)
6. Sponsor name
7. Spouse name
8. Home phone
9. Duty phone
10. Cell phone
Part B - Identification of Child/Youth Condition/Restrictions
Child has any of the following conditions/restrictions: (Check yes or no)
1. Allergies
No
Yes (explain)
a. Life threatening reaction
No
Yes (explain)
b. Epi-pen required
No
Yes
c. Other allergic reations (hives, rash, diarrhea)
No
Yes
2. Asthma reactive airway disease
No
Yes (explain)
a. Triggers exist for child's asthma attacks (stress, environmental, exercise)
No
Yes (explain)
b. Child routinely (greater than 10 days per month/four months per year) uses inhaled anti-inflammatory agents and/or bronchodilators
No
Yes (explain)
c. Child has taken steroids during the past year (prednisone, prednisolone)
No
Yes (indicate number of days in past year)
Page 1 of 3
PREVIOUS EDITION IS OBSOLETE.
DA FORM 7625-1, MAY 2009
APD LC v1.00ES
d. Child has experienced unconsciousness or seizures associated with asthma attacks
No
Yes (explain)
e. Child required an urgent visit to emergency room or clinic for acute asthma within the last 12 months
No
Yes (indicate number of visits in the past year)
f. Child has been hospitalized for asthma related condition in the past six months
No
Yes (explain)
3. Attention Deficit Disorder (ADD)
No
Yes
a. ADD with hyperactivity
No
Yes
b. Is not well controlled with medication
No
Yes (not well controlled)
c. Behavioral/conduct concerns
No
Yes (explain)
4. Autism
No
Yes
5. Behavioral/conduct concerns (for example, oppositional defiant disorder, anxiety disorder, school phobias)
No
Yes (explain)
6. Blindness/visual problems
No
Yes (explain)
7. Diabetes
No
Yes (explain)
8. Emotional problems that require care by a psychiatrist, psychologist or social worker
No
Yes (explain)
9. Epilepsy
No
Yes (explain)
10. Hearing problems
No
Yes (explain)
11. Heart problems
No
Yes (explain)
12. Kidney problems
No
Yes (explain)
13. Speech/language delay
No
Yes (explain)
14. Physical disability
No
Yes (explain)
15. Dietary restrictions
No
Yes (explain)
Page 2 of 3
DA FORM 7625-1, MAY 2009
APD LC v1.00ES
16. Assistance with activities of daily living
No
Yes (explain)
17. Other conditions
No
Yes (specify and explain)
Part C - Medications
Child is on medications on a regular basis
No
Yes (If yes, please list medications and indicate which require administration during child
care hours.)
Part D - Early Intervention and Special Education
Child has an Individualized Family Service Plan (IFSP), Individualized Education Plan (IEP) or 504 plan
No
Yes
Part E - Exceptional Family Member Program (EFMP) Enrollment
Child is enrolled in the EFMP
No
Yes (specify for what condition)
I authorize
(name of Medical Treatment Facility or physician's practice) to release any
medical information regarding my child
(name of child) to the
(name of installation) Child Youth Services (CYS)/Special Needs Accommodation
Process (SNAP) personnel and their staff that is necessary to conduct SNAP review. This authorization will remain in effect for one
year. I understand I may revoke this consent in writing at any time before expiration, but any action taken by the CYS/SNAP in reliance
on this authorization prior to revocation is valid and will remain in effect.
I understand that information disclosed pursuant to this authorization is For Official Use Only (FOUO) and may be subject to
redisclosure. I understand that information redisclosed is no longer protected by DoD 6025.18-R; however, confidentiality of this
information will remain protected by the Privacy Act of 1974, 5 U.S.C. section 552a.
The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs, payment by the
TRICARE Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan benefits on failure to obtain this
authorization.
Signature of Parent or Personal Representative of Child
Date (YYYYMMDD)
Page 3 of 3
DA FORM 7625-1, MAY 2009
APD LC v1.00ES

Download DA Form 7625-1 Army Child and Youth Services Health Screening Tool

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