DA Form 5863 Exceptional Family Member Program Information Sheet

DA Form 5863 or the "Exceptional Family Member Program Information Sheet" 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 5863 - was last revised on June 1, 2009. Download an up-to-date fillable DA Form 5863 down below in PDF-format or look it up on the Army Publishing Directorate website.

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EXCEPTIONAL FAMILY MEMBER PROGRAM INFORMATION SHEET
For use of this form, see AR 608-75; the proponent agency is OACSIM
DATA REQUIRED BY THE PRIVACY ACT OF 1974
PL 94-142 (Education for All Handicapped Children Act of 1975); PL 95-561 (Defense Dependents' Education
AUTHORITY:
Act of 1978); DODI 1342-12 (Education of Handicapped Children in DODDS),
17 December 1981; DODI 1010.13 (Provision of Medically Related Services to Children Receiving or Eligible
to Receive Special Education in DOD Dependents Schools Outside the United States), 28 August 1986, 10
USC 3013; 20 USC 921-932 and 1401 et . seq .
To identify the special education and medical needs of dependent children and medical needs of adult family
PRINCIPAL PURPOSE:
members of Department of the Army civilian employees processing for an assignment to a location outside the
United States where dependent family member travel is authorized at Government expense.
ROUTINE USES:
Information will be used by civilian personnel offices to determine the need for coordinating the availability of
medically related services to meet the special needs of dependent children and medical needs of family members
of Department of the Army civilian employees processing for an assignment to a location outside the United States
where dependent family member travel is authorized at Government expense.
The provision of requested information is mandatory. Failure to respond will preclude--
DISCLOSURE:
(1) Civilian personnel offices from performing required EFMP aspects of overseas processing of Department
of the Army civilian employees with family members with special needs.
(2) Transportation of family members of Department of the Army civilian employees to duty assignments outside the
United States at Government expense.
Information obtained will be maintained in strict confidence and provided only to those with an official need to know
CONFIDENTIALITY:
in identifying special needs and in processing personnel for assignments outside the United States.
PART A - GENERAL INFORMATION
ALL EMPLOYEES TAKING AN ASSIGNMENT IN A LOCATION OUTSIDE THE UNITED STATES WHERE FAMILY MEMBER TRAVEL IS
AUTHORIZED AT GOVERNMENT EXPENSE MUST COMPLETE THIS FORM. EMPLOYEES WHO DO NOT HAVE FAMILY MEMBERS
MUST COMPLETE BLOCKS 1-7 AND SIGN THE APPROPRIATE CERTIFICATION STATEMENT BELOW.
1. SPONSOR'S NAME (Last, first, MI)
2. SPONSOR'S TITLE
3. SPONSOR'S GRADE
5. SPONSOR'S HOME PHONE
4.a. SPONSOR'S HOME ADDRESS
(Include area code)
4.b. SPONSOR'S DUTY ADDRESS
6. SPONSOR'S DUTY PHONE
a. DSN
b. COMMERCIAL (Include area code)
PART B - FAMILY MEMBERS AUTHORIZED TRAVEL OUTSIDE THE UNITED STATES
7. NAME (Last, first, MI)
8. RELATIONSHIP
9. DOB
(YYYYMMDD)
10. SEX
a.
b.
c.
d.
e.
DA FORM 5863, JUN 2009
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.00ES

Download DA Form 5863 Exceptional Family Member Program Information Sheet

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