DA Form 5224-R Child Development Services (Cds) Child and Family Profile

DA Form 5224-R - also known as the "Child Development Services (cds) Child And Family Profile" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 5224-R - was last revised on July 1, 1989. Download an up-to-date fillable PDF version of the DA 5224-R below or request a copy through the chain of command.

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CHILD DEVELOPMENT SERVICES (CDS) CHILD AND FAMILY PROFILE
For use of this form, see AR 608-10; the proponent agency is DCSPER
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Title 10, United States Code, Section 3013
AUTHORITY:
Information is used by DA personnel to: (1) develop programs meeting needs of child and
PRINCIPAL PURPOSE:
family, (2) ensure appropriate placement of child, (3) identify contingency plan for child
illness, (4) verify Family Care Plan, and (5) identification of potential program volunteers.
Information provided may be released IAW the Army's blanket routine uses contained in AR
ROUTINE USES:
340-21.
Disclosure of requested information is voluntary; however, if information is not provided,
DISCLOSURE:
individuals may not be able to participate in CDS programs.
NAME OF SPONSOR (Last, first, MI)
DATE
ADDRESS (Include ZIP Code)
TELEPHONE
DUTY ADDRESS (Include ZIP Code)
TELEPHONE
CHILD DATA
NAME (Last, first, MI)
NICKNAME
BIRTH DATE
DEVELOPMENTAL TASKS/ACCOMPLISHMENTS FOR INFANTS AND TODDLERS (Check appropriate blocks)
SITS
WITH SUPPORT
INDEPENDENTLY
WALKS
WITH SUPPORT
INDEPENDENTLY
SPEECH
SENTENCES
SINGLE WORDS
PHRASES
TOILET TRAINED
DAY
NIGHT
SELF-HELP SKILLS
DRESSES
FEEDS
TOILETS
BUTTONS/SNAPS
TIES
ZIPS
READINESS SKILLS
CUTS
COLORS
PRINTS NAME
ATTENTION SPAN
SUSTAINED
SPORADIC
MODERATE
ACTIVITY LEVEL
HIGH
LOW
MODERATE
PLAYS
WITH OTHERS
ALONE
NEAR OTHERS
INFANTS/TODDLER UNIQUE VOCABULARY (List child's special words and what they actually mean)
CHILD'S WORDS
MEANING
CHILD'S WORDS
MEANING
DRINK
BATHROOM
BOWEL MOVEMENT
URINATION
SPECIAL TOY(S)
CHILD'S PREFERENCES
FOODS
TOYS
PASTIMES
SPECIAL CONSIDERATIONS
FEARS/DISLIKES
PERSONALITY CHARACTERISTICS
SPECIAL NEEDS
RESPONSE TO NEW/STRANGE SITUATION
PREVIOUS GROUP EXPERIENCES
NAP (Comments)
BEDTIME (Time, etc.)
YES
NO
APD LC v2.00
DA FORM 5224-R, JUL 1989
EDITION OF AUG 83 IS OBSOLETE
CHILD DEVELOPMENT SERVICES (CDS) CHILD AND FAMILY PROFILE
For use of this form, see AR 608-10; the proponent agency is DCSPER
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Title 10, United States Code, Section 3013
AUTHORITY:
Information is used by DA personnel to: (1) develop programs meeting needs of child and
PRINCIPAL PURPOSE:
family, (2) ensure appropriate placement of child, (3) identify contingency plan for child
illness, (4) verify Family Care Plan, and (5) identification of potential program volunteers.
Information provided may be released IAW the Army's blanket routine uses contained in AR
ROUTINE USES:
340-21.
Disclosure of requested information is voluntary; however, if information is not provided,
DISCLOSURE:
individuals may not be able to participate in CDS programs.
NAME OF SPONSOR (Last, first, MI)
DATE
ADDRESS (Include ZIP Code)
TELEPHONE
DUTY ADDRESS (Include ZIP Code)
TELEPHONE
CHILD DATA
NAME (Last, first, MI)
NICKNAME
BIRTH DATE
DEVELOPMENTAL TASKS/ACCOMPLISHMENTS FOR INFANTS AND TODDLERS (Check appropriate blocks)
SITS
WITH SUPPORT
INDEPENDENTLY
WALKS
WITH SUPPORT
INDEPENDENTLY
SPEECH
SENTENCES
SINGLE WORDS
PHRASES
TOILET TRAINED
DAY
NIGHT
SELF-HELP SKILLS
DRESSES
FEEDS
TOILETS
BUTTONS/SNAPS
TIES
ZIPS
READINESS SKILLS
CUTS
COLORS
PRINTS NAME
ATTENTION SPAN
SUSTAINED
SPORADIC
MODERATE
ACTIVITY LEVEL
HIGH
LOW
MODERATE
PLAYS
WITH OTHERS
ALONE
NEAR OTHERS
INFANTS/TODDLER UNIQUE VOCABULARY (List child's special words and what they actually mean)
CHILD'S WORDS
MEANING
CHILD'S WORDS
MEANING
DRINK
BATHROOM
BOWEL MOVEMENT
URINATION
SPECIAL TOY(S)
CHILD'S PREFERENCES
FOODS
TOYS
PASTIMES
SPECIAL CONSIDERATIONS
FEARS/DISLIKES
PERSONALITY CHARACTERISTICS
SPECIAL NEEDS
RESPONSE TO NEW/STRANGE SITUATION
PREVIOUS GROUP EXPERIENCES
NAP (Comments)
BEDTIME (Time, etc.)
YES
NO
APD LC v2.00
DA FORM 5224-R, JUL 1989
EDITION OF AUG 83 IS OBSOLETE
FAMILY DATA
HOUSEHOLD MEMBERS
PETS
NAME
AGE
RELATIONSHIP TO CHILD
TYPE
NAME
REASONS(s) FOR USE OF CDS PROGRAM(s)
CONTINGENCY CARE PLAN FOR CHILD ILLNESS
CAR POOL/TRANSPORTATION ARRANGEMENTS
FAMILY CARE PLAN (Sole Parent/Dual Sponsors)
VOLUNTEER AVAILABILITY (Check appropriate blocks)
FIELD TRIPS AIDE
HOLIDAY ACTIVITIES
AT HOME PROJECTS
ON SITE ADMINISTRATIVE/CURRICULUM PROJECTS
TOY/EQUIPMENT REPAIR
CLASSROOM AIDE
OTHER
EMERGENCY NOTIFICATION DESIGNEE
HOME PHONE
DUTY PHONE
CHILD RELEASE DESIGNEE
EMERGENCY NOTIFICATION DESIGNEE
HOME PHONE
DUTY PHONE
CHILD RELEASE DESIGNEE
CHILD RELEASE DESIGNEE
EMERGENCY NOTIFICATION DESIGNEE
HOME PHONE
DUTY PHONE
REMARKS
APD LC v2.00
REVERSE OF DA FORM 5224-R, JUL 1989

Download DA Form 5224-R Child Development Services (Cds) Child and Family Profile

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