Fillable Printable Exceptional Family Member Program Information Sheet

Exceptional Family Member Program Information Sheet

3. SPONSOR'S GRADE

1. SPONSOR'S NAME

(Last, first, MI)

2. SPONSOR'S TITLE

5. SPONSOR'S HOME PHONE

4.a. SPONSOR'S HOME ADDRESS

4.b. SPONSOR'S DUTY ADDRESS

EXCEPTIONAL FAMILY MEMBER PROGRAM INFORMATION SHEET

For use of this form, see AR 608-75; the proponent agency is OACSIM

PREVIOUS EDITIONS ARE OBSOLETE.

DA FORM 5863, JUN 2009

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE:

CONFIDENTIALITY:

PL 94-142

(Education for All Handicapped Children Act of 1975);

PL 95-561

(Defense Dependents' Education

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 .

DATA REQUIRED BY THE PRIVACY ACT OF 1974

The provision of requested information is mandatory. Failure to respond will preclude--

(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.

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.

PART B - FAMILY MEMBERS AUTHORIZED TRAVEL OUTSIDE THE UNITED STATES

7. NAME

(Last, first, MI)

8. RELATIONSHIP 9. DOB

(YYYYMMDD)

10. SEX

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6. SPONSOR'S DUTY PHONE

(Include area code)

a. DSN

b. COMMERCIAL

(Include area code)

To identify the special education and medical needs of dependent children and medical needs of adult 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.

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.

(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

in identifying special needs and in processing personnel for assignments outside the United States.

(a) SIGNATURE OF SPONSOR

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?

(b) DATE

(YYYYMMDD)

(b) DATE

(YYYYMMDD)

(b) DATE

(YYYYMMDD)

11. PLEASE READ ALL OF THE FOLLOWING QUESTIONS VERY CAREFULLY AND SIGN THE APPROPRIATE CERTIFICATION

STATEMENT IN k. BELOW.

SIGN ONE OF THE CERTIFICATIONS BELOW

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.)

DA FORM 5863, JUN 2009

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?

(1) I CERTIFY THAT I DO NOT HAVE FAMILY MEMBERS.

(2) I CERTIFY THAT MY ANSWER TO EACH OF THE ABOVE QUESTIONS IS NO FOR EACH OF THE FAMILY MEMBERS LISTED

(3) I CERTIFY THAT ONE OR MORE OF MY ANSWERS TO THE ABOVE QUESTIONS IS YES REGARDING A FAMILY MEMBER LISTED

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.

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?

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a. DO ANY OF THE ABOVE FAMILY MEMBERS HAVE A LONG TERM

(i.e., more than one year's duration)

PHYSICAL OR

EMOTIONAL ILLNESS?

ABOVE.

(Check appropriate block below)

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