ARMY CHILD AND YOUTH SERVICES PROGRAM PLACEMENT CHECKLIST
For use of this form, see AR 608-75; the proponent agency is OACSIM.
Part A - General Information
1. Child's name
2. Date of birth (YYYYMMDD)
3. Type of placement requested
4. Date of review (YYYYMMDD)
Part B - Medical Factors
1. Medications
Type
Dosage
Frequency
None
2. Physical accommodations
Facility accessibility assessment
Assistive devices and/or technology
Other (Explain)
3. Assistance with activities of daily living
Dressing
Eating
Toileting/diapering
Other (Explain)
4. Dietary restrictions
Food allergies
Special diet
Other (Explain)
5. Routine or "as needed" medical procedures
Glucose monitoring
Use of hand held or powered nebulizers
Catherization
Gastrostomy tube feeding
Other (Explain)
NOTE: Medical factors are one consideration in determining placement.
DA FORM 7625-2, NOV 2006
Page 1 of 2
APD LC v1.01ES
ARMY CHILD AND YOUTH SERVICES PROGRAM PLACEMENT CHECKLIST
For use of this form, see AR 608-75; the proponent agency is OACSIM.
Part A - General Information
1. Child's name
2. Date of birth (YYYYMMDD)
3. Type of placement requested
4. Date of review (YYYYMMDD)
Part B - Medical Factors
1. Medications
Type
Dosage
Frequency
None
2. Physical accommodations
Facility accessibility assessment
Assistive devices and/or technology
Other (Explain)
3. Assistance with activities of daily living
Dressing
Eating
Toileting/diapering
Other (Explain)
4. Dietary restrictions
Food allergies
Special diet
Other (Explain)
5. Routine or "as needed" medical procedures
Glucose monitoring
Use of hand held or powered nebulizers
Catherization
Gastrostomy tube feeding
Other (Explain)
NOTE: Medical factors are one consideration in determining placement.
DA FORM 7625-2, NOV 2006
Page 1 of 2
APD LC v1.01ES
6. Potential for life threatening event (for example, allergic reaction, seizure, heat exhaustion)
7. Other
Part C - Staff Training
1. Type of training required
3. Projected training date (YYYYMMDD)
2. Trainer
4. Frequency
5. Location
Date (YYYYMMDD)
Signature of Army Public Health Nurse
Page 2 of 2
DA FORM 7625-2, NOV 2006
APD LC v1.01ES
ADVERTISEMENT