DA Form 7625-3 Special Needs Accommodation Process (Snap) Team Care Plan

DA Form 7625-3 - also known as the "Special Needs Accommodation Process (snap) Team Care Plan" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 7625-3 - was last revised on November 1, 2006. Download an up-to-date fillable PDF version of the DA 7625-3 down below or look it up on the Army Publishing Directorate website.

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SPECIAL NEEDS ACCOMMODATION PROCESS (SNAP) TEAM CARE PLAN
For use of this form, see AR 608-75; the proponent agency is OACSIM.
Part A - Demographic Information
1. Name of child
2. Date of birth (YYYYMMDD)
3. Type of placement
4. Date of placement (YYYYMMDD)
5. Sponsor name
6. Spouse name
7. Home phone
8. Duty phone
9. Cell phone
10. Emergency point of contact (POC) name
11. Emergency POC phone number
Part B - Medical Requirements
Below are medical requirements for reasonably accommodating the above named child in a Child and Youth Services Program.
1. Medications
No
Yes (list each medication separately)
Name
Dosage
Frequency
Special Instructions (e.g., refrigeration)
Individuals authorized to administer medications to child or youth while attending CYS programs (for example, nurse, family child care provider,
child and youth program assistant, self). NOTE: Self administration of medication will be determined by age and maturity of child or youth.
Names:
2. Physical accommodations
Facility accessibility (e.g., ramps; widen doors)
Assistive devices and/or technology (e.g., Braille computer; canes)
Transportation (where applicable/feasible)
Other (explain)
3. Dietary restrictions
Food allergies (e.g., peanut butter)
Special diet
Other (explain)
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DA FORM 7625-3, NOV 2006
APD LC v1.01ES
SPECIAL NEEDS ACCOMMODATION PROCESS (SNAP) TEAM CARE PLAN
For use of this form, see AR 608-75; the proponent agency is OACSIM.
Part A - Demographic Information
1. Name of child
2. Date of birth (YYYYMMDD)
3. Type of placement
4. Date of placement (YYYYMMDD)
5. Sponsor name
6. Spouse name
7. Home phone
8. Duty phone
9. Cell phone
10. Emergency point of contact (POC) name
11. Emergency POC phone number
Part B - Medical Requirements
Below are medical requirements for reasonably accommodating the above named child in a Child and Youth Services Program.
1. Medications
No
Yes (list each medication separately)
Name
Dosage
Frequency
Special Instructions (e.g., refrigeration)
Individuals authorized to administer medications to child or youth while attending CYS programs (for example, nurse, family child care provider,
child and youth program assistant, self). NOTE: Self administration of medication will be determined by age and maturity of child or youth.
Names:
2. Physical accommodations
Facility accessibility (e.g., ramps; widen doors)
Assistive devices and/or technology (e.g., Braille computer; canes)
Transportation (where applicable/feasible)
Other (explain)
3. Dietary restrictions
Food allergies (e.g., peanut butter)
Special diet
Other (explain)
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DA FORM 7625-3, NOV 2006
APD LC v1.01ES
4. Routine or "as needed" medical procedures
Glucose monitoring
Use of hand held or powered nebulizers
Catherization
Gastrostomy tube feeding
Other (explain)
Part C - Program Accommodations
1. Specific plans or accommodations reflected in child's Individualized Family Service Plan (IFSP), Individualized Education Program (IEP) or
504 plan that impact on child care setting.
2. Management techniques used in home setting
Behavior modification
Time out
Other (explain)
3. Child can be accommodated within CYS established staff/child ratios
No
Yes
4. Assistance with activities for daily participation in CYS settings
Dressing
Eating
Toileting/diapering
Small motor
Large motor
Supervision (adult/child ratio)
Play/work in large groups
Play/work in small groups
Field trips (walking)
Field trips (transported)
Special events (usually large groups)
Other (explain)
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DA FORM 7625-3, NOV 2006
APD LC v1.01ES
5. Assistance with activities for occasional participation in CYS settings
Dressing
Eating
Toileting/diapering
Small motor
Large motor
Supervision (adult/child ratio)
Play/work in large groups
Play/work in small groups
Field trips (walking)
Field trips (transported)
Special events (usually large groups)
Other (explain)
Part D - Child and Youth Services Staff Training
1. Type of training required
2. Trainer
3. Projected training date (YYYYMMDD)
4. Frequency
5. Location
Signature of Chair, SNAP Team
Date (YYYYMMDD)
Signature of Child and Youth Services Coordinator
Date (YYYYMMDD)
Signature of Army Public Health Nurse
Date (YYYYMMDD)
Signature of Parent
Date (YYYYMMDD)
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DA FORM 7625-3, NOV 2006
APD LC v1.01ES

Download DA Form 7625-3 Special Needs Accommodation Process (Snap) Team Care Plan

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