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.

ADVERTISEMENT
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
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
11. PLEASE READ ALL OF THE FOLLOWING QUESTIONS VERY CAREFULLY AND SIGN THE APPROPRIATE CERTIFICATION
STATEMENT IN k. BELOW.
a. DO ANY OF THE ABOVE FAMILY MEMBERS HAVE A LONG TERM (i.e., more than one year's duration) PHYSICAL OR
EMOTIONAL ILLNESS?
b. ARE ANY OF THE ABOVE FAMILY MEMBERS BEING SEEN AT A HOSPITAL OR CLINIC REGULARLY? ("Regularly" means about
every 2 months or more often and 4 or 5 times a year or more often.)
c. WILL ANY OF THE ABOVE FAMILY MEMBERS NEED TO BE SEEN AT A HOSPITAL OR CLINIC OUTSIDE THE UNITED STATES
REGULARLY BASED ON THEIR PRESENT MEDICAL CONDITION?
d. HAVE ANY OF THE ABOVE FAMILY MEMBERS BEEN TOLD THEY SHOULD BE SEEN REGULARLY AT A HOSPITAL OR CLINIC
BUT ARE NOT BEING SEEN?
e. ARE ANY OF THE ABOVE FAMILY MEMBERS ENROLLED IN A SPECIAL EDUCATION PROGRAM?
f. DO ANY OF THE ABOVE FAMILY MEMBERS HAVE A LEARNING DISABILITY?
g. ARE ANY OF THE ABOVE FAMILY MEMBERS BLIND, DEAF, OR HARD OF HEARING?
h. DO ANY OF THE ABOVE FAMILY MEMBERS HAVE A SPEECH PROBLEM THAT REQUIRES THE SERVICES OF A SPEECH
THERAPIST?
i. DO ANY OF THE ABOVE FAMILY MEMBERS HAVE A PHYSICAL DISABILITY THAT COULD AFFECT THEIR LEARNING?
j . DO ANY OF THE ABOVE FAMILY MEMBERS REQUIRE PROFESSIONAL COUNSELING REGARDING PROBLEM BEHAVIOR, SUCH
AS ABUSE OF ALCOHOL OR DRUGS, RUNNING AWAY, SKIPPING SCHOOL, OR OTHER DELINQUENT-TYPE ACTS?
k. SIGN ONE OF THE CERTIFICATIONS BELOW
(1) I CERTIFY THAT I DO NOT HAVE FAMILY MEMBERS.
(a) SIGNATURE OF SPONSOR
(b) DATE (YYYYMMDD)
(2) I CERTIFY THAT MY ANSWER TO EACH OF THE ABOVE QUESTIONS IS NO FOR EACH OF THE FAMILY MEMBERS LISTED
ABOVE.
(a) SIGNATURE OF SPONSOR
(b) DATE (YYYYMMDD)
(3) I CERTIFY THAT ONE OR MORE OF MY ANSWERS TO THE ABOVE QUESTIONS IS YES REGARDING A FAMILY MEMBER LISTED
ABOVE. (Check appropriate block below)
I INTEND THAT THE FAMILY MEMBER OR FAMILY MEMBERS WILL TRAVEL WITH ME CONCURRENTLY.
I INTEND THAT THE FAMILY MEMBER OR FAMILY MEMBERS WILL TRAVEL ON A DELAYED BASIS.
I DO NOT INTEND THAT THE FAMILY MEMBER OR FAMILY MEMBERS WILL TRAVEL TO MY NEW DUTY LOCATION
OUTSIDE THE UNITED STATES. I UNDERSTAND THAT A DA FORM 5862-R (ARMY EXCEPTIONAL FAMILY MEMBER
PROGRAM MEDICAL SUMMARY) AND DA FORM 5291-R (ARMY EXCEPTIONAL FAMILY MEMBER PROGRAM
EDUCATIONAL SUMMARY) (WHEN APPLICABLE) MUST BE COMPLETED ON THE FAMILY MEMBER OR FAMILY
MEMBERS AND PROVIDED TO THE CIVILIAN PERSONNEL OFFICE SHOULD I, AT A LATER DATE, DECIDE TO HAVE THE
FAMILY MEMBER OR FAMILY MEMBERS JOIN ME AND THIS MUST BE ACCOMPLISHED PRIOR TO THEIR ARRIVAL AT
THE LOCATION OUTSIDE THE UNITED STATES.
(a) SIGNATURE OF SPONSOR
(b) DATE (YYYYMMDD)
Page 2 of 2
DA FORM 5863, JUN 2009
APD LC v1.00ES

Download DA Form 5863 Exceptional Family Member Program Information Sheet

748 times
Rate
4.5(4.5 / 5) 98 votes
ADVERTISEMENT
Page of 2