DA Form 7246 Exceptional Family Member Program (EFMP) Screening Questionnaire

What Is DA Form 7246?

DA Form 7246, Exceptional Family Member Program Screening Questionnaire is a form filed by service members when enrolling a family member into the Exceptional Family Member Program - or EFMP. This form serves as a summary of the health condition and needs of that family member and later plays a role when selecting assignments for the service member. The EFMP is a program that works throughout all branches of the Military together with civilian agencies to provide a comprehensive and coordinated approach to medical, educational, housing, and personnel services for families with special needs. The Army EFMP includes both personal support and family support functions.

The latest version of the form - often incorrectly referred to as the DD Form 7246 - was released by the Department of the Army (DA) in June 2009. An up-to-date DA Form 7246 fillable version is available for digital filing and download below or can be found through the Army Publishing Directorate website.

DA 7246 related forms include the DA Form 5888 (Family Member Deployment Screening Sheet), the DA Form 5888-1 (Screening of Family Member in Remote OCONUS Areas), the DD Form 2792 (Family Member Medical Summary) and the DD Form 2792-1 (Special Education/Early Intervention Summary).

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NAME OF MEDICAL TREATMENT FACILITY
EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP)
SCREENING QUESTIONNAIRE
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 Act
AUTHORITY:
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 obtain information needed to evaluate and document the special education and medical needs of family members.
PRINCIPAL PURPOSE:
This will permit consideration of special education and medical needs of family members in the personnel
assignment process.
Information will be used by personnel of the Military Departments to evaluate and document special education and
ROUTINE USES:
medical needs of family members for consideration in personnel assignments.
The provision of requested information is mandatory. Failure to respond will preclude U.S. Total Personnel
DISCLOSURE:
Command from enrolling soldiers in the EFMP. Soldiers who knowingly refuse to enroll exceptional family members
will receive, at a minimum, a general officer letter of reprimand. Refusal to provide information may preclude
successful processing of an application for family travel/command sponsorship.
SERVICE MEMBER'S NAME/RANK
DATE (YYYYMMDD)
BRANCH
UNIT
DUTY PHONE
PROJECTED PCS ASSIGNMENT
DSN
HOME PHONE
HOME ADDRESS
DUTY ADDRESS
PROJECTED PCS DATE
FAMILY
CHECK IF
DATE OF BIRTH
LIST ALL FAMILY MEMBERS
MEMBER
SEX
ENROLLED
(YYYYMMDD)
PREFIX
IN EFMP
PLEASE ANSWER ALL QUESTIONS - FOR FAMILY MEMBERS ONLY
MEDICAL
YES
NO
1. Do any family members, excluding service member, have any medical records (civilian or military) other than the records
you have provided us to screen? If yes, please list conditions/services received and address of provider.
FAMILY MEMBER
CONDITIONS/SERVICES
NAME/ADDRESS OF PROVIDER
YES
NO
2. In the past five (5) years, have any members of your family, excluding service member, been hospitalized, excluding
hospitalization for normal uncomplicated childbirth? If yes, please explain.
NAME
REASON
YES
NO
3. Are any members of your family, excluding service member, currently receiving medical (includes mental health) or
educational services from any providers other than a general practitioner or family practice physician?
PREVIOUS EDITION IS OBSOLETE.
APD LC v1.00ES
DA FORM 7246, JUN 2009
NAME OF MEDICAL TREATMENT FACILITY
EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP)
SCREENING QUESTIONNAIRE
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 Act
AUTHORITY:
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 obtain information needed to evaluate and document the special education and medical needs of family members.
PRINCIPAL PURPOSE:
This will permit consideration of special education and medical needs of family members in the personnel
assignment process.
Information will be used by personnel of the Military Departments to evaluate and document special education and
ROUTINE USES:
medical needs of family members for consideration in personnel assignments.
The provision of requested information is mandatory. Failure to respond will preclude U.S. Total Personnel
DISCLOSURE:
Command from enrolling soldiers in the EFMP. Soldiers who knowingly refuse to enroll exceptional family members
will receive, at a minimum, a general officer letter of reprimand. Refusal to provide information may preclude
successful processing of an application for family travel/command sponsorship.
SERVICE MEMBER'S NAME/RANK
DATE (YYYYMMDD)
BRANCH
UNIT
DUTY PHONE
PROJECTED PCS ASSIGNMENT
DSN
HOME PHONE
HOME ADDRESS
DUTY ADDRESS
PROJECTED PCS DATE
FAMILY
CHECK IF
DATE OF BIRTH
LIST ALL FAMILY MEMBERS
MEMBER
SEX
ENROLLED
(YYYYMMDD)
PREFIX
IN EFMP
PLEASE ANSWER ALL QUESTIONS - FOR FAMILY MEMBERS ONLY
MEDICAL
YES
NO
1. Do any family members, excluding service member, have any medical records (civilian or military) other than the records
you have provided us to screen? If yes, please list conditions/services received and address of provider.
FAMILY MEMBER
CONDITIONS/SERVICES
NAME/ADDRESS OF PROVIDER
YES
NO
2. In the past five (5) years, have any members of your family, excluding service member, been hospitalized, excluding
hospitalization for normal uncomplicated childbirth? If yes, please explain.
NAME
REASON
YES
NO
3. Are any members of your family, excluding service member, currently receiving medical (includes mental health) or
educational services from any providers other than a general practitioner or family practice physician?
PREVIOUS EDITION IS OBSOLETE.
APD LC v1.00ES
DA FORM 7246, JUN 2009
YES
NO
4. Are any family members, excluding service member, taking any prescribed medication other than birth control pills on a
regular basis?
NAME
PRESCRIBED MEDICATION
5. In the past five (5) years, have any members of your family, excluding service member, been treated for, or had any problems related to any
of the following? (You will have an opportunity to discuss all "YES" answers with a screener.)
a.
Problems with sight (other than corrected by
YES
NO
YES
NO
g.
Asthma, allergies or other respiratory problems
glasses)
b.
Problems with hearing
h.
Cerebral Palsy
c.
Heart condition
i.
Delayed Speech
d.
Seizure disorder
j.
Sickle Cell Trait/Disease
e.
k.
Cancer
Loss of mobility (requiring use of a wheelchair/
walker or aid in mobility)
l.
High blood pressure
f.
Diabetes
m.
Other, if yes, explain
MENTAL HEALTH:
6. In the past five (5) years, have any members of your family, excluding service member, been treated for, or had any problems related to any
of the following? (You will have an opportunity to discuss all "YES" answers with a screener.)
a.
Referral to, diagnosed by, or therapy with a
YES
NO
YES
NO
Psychiatrist, Psychologist, or Social Worker
d.
Alcohol and drug use or abuse
in reference to a mental health problem
e.
Emotional problems
b.
Depression
f.
Behavioral problems/acting out behavior
g.
Received therapy (marital, family, individual or
c.
Suicidal thoughts/ideas, gestures, attempts
group counseling)
YES
NO
7. Have any members of your family, excluding service member, been in any of the following? Inpatient Psychiatric Facility,
Residential Treatment Center, Group Homes, Day Treatment Centers, Drug and Alcohol Treatment Rehabilitation Center. If
Yes, please explain:
EDUCATION
8. Do any of your children now have, or have they ever had, any of the following?
a.
YES
NO
YES
NO
Slow development (infants and preschoolers)
Counseling services for school-related problems
d.
b.
Learning problems (school)
c.
Special services (i.e., OT, PT, Speech, etc.)
e.
Mental retardation
for special education
YES
NO
9. Are any of your children receiving Special Education help in school (not in regular class placement and on an Individual
Education Plan (IEP))? If yes, who?
According to AR 608-75, Exceptional Family Member Program, soldiers will provide accurate information as required when requested to do so
by Army officials. Knowingly providing false information in this regard may be the basis for disciplinary or administrative action. For soldiers,
refusal to provide information may preclude successful processing of an application for family travel or command sponsorship.
Commanders will take appropriate action against soldiers who knowingly provide false information, or who knowingly fail or refuse to enroll
family members that meet the criteria for enrollment. (A false official statement is a violation of Article 107, Uniform Code of Military Justice
(UCMJ).) These actions will include, at a minimum, a general officer letter of reprimand.
All the above information is true and correct to the best of my knowledge. I understand that it is my responsibility to provide any information
about changes in medical or educational status for all members of my family, after the date indicated below, and prior to PCS move.
PRINTED NAME OF MILITARY SPONSOR OR
SIGNATURE OF MILITARY SPONSOR OR SPOUSE
DATE (YYYYMMDD)
COMPLETING THIS FORM
SPOUSE COMPLETING THIS FORM
SIGNATURE OF PHYSICIAN OR MEDICAL
PRINTED NAME OF PHYSICIAN OR MEDICAL
DATE (YYYYMMDD)
PRACTITIONER IF UNDER THE SUPERVISION OF A
PRACTITIONER IF UNDER THE SUPERVISION OF A
PHYSICIAN
PHYSICIAN
APD LC v1.00ES
PAGE 2, DA FORM 7246, JUN 2009

Download DA Form 7246 Exceptional Family Member Program (EFMP) Screening Questionnaire

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How to File DA Form 7246?

An overview of the form and filing guidelines can be found in the Army Regulation 608–75, Exceptional Family Member Program, released in January 2017. DA Form 7246 instructions are as follows:

  1. The first box at the top-right corner of the form requires the name of the medical treatment facility.
  2. The next section is for the service member's personal data. The required information requires their name, home address, home phone, rank, branch, unit, duty address, and duty phone along with the date of filing and the projected post, camp or station of assignment.
  3. The service member has to list the family members that they would like to enroll in the EFMP. The lists require the names, sexes, and dates of birth of those family members. The service member has to specify if any of them is already enrolled in the EFMP.
  4. Block 1 is for providing information on any family members with additional medical records other than the ones already provided. If yes, it is necessary to specify the family member, their condition and required services along with the name or address of the healthcare provider in the corresponding columns.
  5. Block 2 is for specifying if any of the listed family members have been hospitalized in the past five years. If yes, the name of that family member and the reason for hospitalization are provided in the corresponding columns of the table.
  6. The service member has to specify if any of the listed family members are currently receiving any medical or educational assistance from anyone other than a general practitioner or family practice physician.
  7. Block 4 is completed if any of the listed family members are currently taking prescription drugs other than birth control pills. If the answer is yes, the name of the family member and the prescribed drug must be specified in the corresponding boxes.
  8. Block 5 is completed if any of the listed family members have been treated for or had any problems connected with health issues from the list provided on the form in the last five years.
  9. Any prior treatment connected with mental health issues from the list provided on the form must be specified in Block 6.
  10. Block 7 is for specifying if any family members have ever stayed in inpatient psychiatric facilities, residential treatment centers, group homes, day treatment centers or drug and alcohol treatment rehabilitation centers.
  11. Block 8 is for providing information on any children of the service member that have any specific education-connected issues.
  12. Block 9 requires information on any dependent children receiving Special Education at school.
  13. The printed name of the service member - or "military sponsor" - or their spouse along with their signatures and the date of signing the form must be provided in the appropriate boxes on the second page of the DA 7246.
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