DA Form 5192 Family Identification Sheet for a Child Receiving Service

DA Form 5192 - also known as the "Family Identification Sheet For A Child Receiving Service" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 5192 - was last revised on October 1, 2003. Download an up-to-date fillable PDF version of the DA 5192 down below or look it up on the Army Publishing Directorate website.

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CHILD'S CASE NUMBER
FAMILY IDENTIFICATION SHEET FOR A CHILD RECEIVING SERVICE
For use of this form, see AR 608-18; the proponent agency is OACSIM.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY:
5 U.S.C. 301, Department Regulations; 10 U.S.C. 3013, Secretary of the Army; 42 U.S.C. 10606 et seq.; Victims' Rights as implemented
by the Department of Defense Instruction 1030.2, Victim and Witness Assistance Program; DoD Directive 6400.1, Family Advocacy
Program (FAP); Army Regulation 608-18, The Family Advocacy Program; and E.O. 9397 (SSN)
To provide essential background information to develop a service plan for each child and family involved in emergency placement.
PRINCIPAL PURPOSE:
To federal, state, or local government agencies when it is deemed appropriate to use civilian resources in counseling and treating
ROUTINE USES:
individuals of families involved in child abuse or neglect or spouse abuse; or when appropriate or necessary to refer a case to civilian
authorities for civil or criminal law enforcement; or when a state, county, or municipal child protective service agency inquires about a
prior record of substantiated abuse for the purpose of investigating a suspected case of abuse.
Information may be disclosed to departments and agencies of the Executive Branch of government in performance of their official duties
relating to coordination of family advocacy programs, medical care and research concerning child abuse and neglect, and spouse abuse.
DISCLOSURE:
Voluntary. However, failure to provide the requested information may delay the provision of the appropriate services to the individual.
NAME (Child) (Last, First, Middle)
SOCIAL SECURITY NO.
BIRTHDATE (YYYYMMDD)
INFORMATION ON PARENTS
NATURAL FATHER
NATURAL MOTHER
NAME (Last, First, Middle, Nickname, Aliases)
NAME (Last, First, Middle, Maiden, Nickname, Aliases)
ADDRESS (Include ZIP Code)
ADDRESS (Include ZIP Code)
DATE OF BIRTH (YYYYMMDD)
DATE OF BIRTH (YYYYMMDD)
PLACE OF BIRTH (State, Country, town or city)
PLACE OF BIRTH (State, Country, town, or city)
RACE AND CITIZENSHIP
RACE AND CITIZENSHIP
PHYSICAL DESCRIPTION
PHYSICAL DESCRIPTION
HEIGHT
WEIGHT
COLOR HAIR
COLOR EYES SKIN
HEIGHT
WEIGHT
COLOR HAIR
COLOR EYES
SKIN
BIRTHMARKS, SCARS
BIRTHMARKS, SCARS
DISABILITIES
DISABILITIES
CHRONIC ILLNESS
WEARS GLASSES
CHRONIC ILLNESS
WEARS GLASSES
YES
NO
YES
NO
EDUCATION
EDUCATION
GRADE SCHOOL
HIGH SCHOOL
GRADE SCHOOL
HIGH SCHOOL
COLLEGE
COLLEGE
VOCATIONAL AND OTHER TRAINING
VOCATIONAL AND OTHER TRAINING
SOCIAL SECURITY NUMBER
EMPLOYED
SOCIAL SECURITY NUMBER
EMPLOYED
YES
NO
YES
NO
OCCUPATION(S)
OCCUPATION(S)
UNIT NUMBER AND NAME
UNIT NUMBER AND NAME
Page 1 of 3
DA FORM 5192-R, APR 1983 IS OBSOLETE.
DA FORM 5192, OCT 2003
APD LC v1.00
CHILD'S CASE NUMBER
FAMILY IDENTIFICATION SHEET FOR A CHILD RECEIVING SERVICE
For use of this form, see AR 608-18; the proponent agency is OACSIM.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY:
5 U.S.C. 301, Department Regulations; 10 U.S.C. 3013, Secretary of the Army; 42 U.S.C. 10606 et seq.; Victims' Rights as implemented
by the Department of Defense Instruction 1030.2, Victim and Witness Assistance Program; DoD Directive 6400.1, Family Advocacy
Program (FAP); Army Regulation 608-18, The Family Advocacy Program; and E.O. 9397 (SSN)
To provide essential background information to develop a service plan for each child and family involved in emergency placement.
PRINCIPAL PURPOSE:
To federal, state, or local government agencies when it is deemed appropriate to use civilian resources in counseling and treating
ROUTINE USES:
individuals of families involved in child abuse or neglect or spouse abuse; or when appropriate or necessary to refer a case to civilian
authorities for civil or criminal law enforcement; or when a state, county, or municipal child protective service agency inquires about a
prior record of substantiated abuse for the purpose of investigating a suspected case of abuse.
Information may be disclosed to departments and agencies of the Executive Branch of government in performance of their official duties
relating to coordination of family advocacy programs, medical care and research concerning child abuse and neglect, and spouse abuse.
DISCLOSURE:
Voluntary. However, failure to provide the requested information may delay the provision of the appropriate services to the individual.
NAME (Child) (Last, First, Middle)
SOCIAL SECURITY NO.
BIRTHDATE (YYYYMMDD)
INFORMATION ON PARENTS
NATURAL FATHER
NATURAL MOTHER
NAME (Last, First, Middle, Nickname, Aliases)
NAME (Last, First, Middle, Maiden, Nickname, Aliases)
ADDRESS (Include ZIP Code)
ADDRESS (Include ZIP Code)
DATE OF BIRTH (YYYYMMDD)
DATE OF BIRTH (YYYYMMDD)
PLACE OF BIRTH (State, Country, town or city)
PLACE OF BIRTH (State, Country, town, or city)
RACE AND CITIZENSHIP
RACE AND CITIZENSHIP
PHYSICAL DESCRIPTION
PHYSICAL DESCRIPTION
HEIGHT
WEIGHT
COLOR HAIR
COLOR EYES SKIN
HEIGHT
WEIGHT
COLOR HAIR
COLOR EYES
SKIN
BIRTHMARKS, SCARS
BIRTHMARKS, SCARS
DISABILITIES
DISABILITIES
CHRONIC ILLNESS
WEARS GLASSES
CHRONIC ILLNESS
WEARS GLASSES
YES
NO
YES
NO
EDUCATION
EDUCATION
GRADE SCHOOL
HIGH SCHOOL
GRADE SCHOOL
HIGH SCHOOL
COLLEGE
COLLEGE
VOCATIONAL AND OTHER TRAINING
VOCATIONAL AND OTHER TRAINING
SOCIAL SECURITY NUMBER
EMPLOYED
SOCIAL SECURITY NUMBER
EMPLOYED
YES
NO
YES
NO
OCCUPATION(S)
OCCUPATION(S)
UNIT NUMBER AND NAME
UNIT NUMBER AND NAME
Page 1 of 3
DA FORM 5192-R, APR 1983 IS OBSOLETE.
DA FORM 5192, OCT 2003
APD LC v1.00
INFORMATION ON PARENTS (cont'd)
NATURAL FATHER
NATURAL MOTHER
MILITARY SERVICE AND DATES
MILITARY SERVICE AND DATES
TYPE OF DISCHARGE
RANK/PAY GRADE
TYPE OF DISCHARGE
RANK/PAY GRADE
RELIGOUS PREFERENCE
RELIGOUS PREFERENCE
MARITAL STATUS OF NATURAL PARENTS
(How verified)
NEVER MARRIED
MARRIED TO EACH OTHER
(Date)
(Place)
(How verified)
NEVER
MAINTAINED A HOME TOGETHER
(State)
(County)
(City)
SEPARATED
DIVORCED
NOW,
LIVING TOGETHER
(Date)
(Place)
(How verified)
PATERNITY ESTABLISHED BY COURT ORDER
(Date)
(Court)
NAME OF LEGAL FATHER IF NOT NATURAL FATHER (Above)
FATHER (If deceased)
MOTHER (If deceased)
DATE AND PLACE OF DEATH
DATE AND PLACE OF DEATH
CAUSE OF DEATH
CAUSE OF DEATH
OTHER CHILDREN FROM EITHER OF NATURAL PARENTS
BIRTHDATE
NAME (Last, First, Middle)
OTHER INFORMATION
(YYYYMMDD)
Page 2 of 3
APD LC v1.00
DA FORM 5192, OCT 2003
NATURAL FATHER'S RELATIVES (Parents, siblings, children, other unions)
NAME
RELATIONSHIP
ADDRESS
NATURAL MOTHER'S RELATIVES (Parents, siblings, children, other unions)
NAME
RELATIONSHIP
ADDRESS
CHANGES IN WHEREABOUTS (Relatives listed above)
NATURAL FATHER
NATURAL MOTHER
DATE
NAME AND ADDRESS
DATE
NAME AND ADDRESS
Page 3 of 3
APD LC v1.00
DA FORM 5192, OCT 2003

Download DA Form 5192 Family Identification Sheet for a Child Receiving Service

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