Fillable Printable Family Member Deployment Screening Sheet

Family Member Deployment Screening Sheet

FAMILY MEMBER DEPLOYMENT SCREENING SHEET

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

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Title 10, USC Section 3013.

Personnel support.

AUTHORITY:

PRINCIPAL PURPOSE:

To validate family member deployment screening, and to provide gaining command with data to assist in

making an assignment decision.

ROUTINE USES:

The provision of requested information is mandatory. Failure to respond may preclude successful

processing of an application for family member travel/command sponsorship and may lead to

appropriate administrative or disciplinary action against the soldier.

DISCLOSURE:

PART A - SOLDIER/FAMILY MEMBER DATA

(Last, first, MI)

1. NAME OF SOLDIER

2. SOCIAL SECURITY NUMBER 3a. RANK 3b. MOS/BRANCH

4a. HOME ADDRESS 5a. DUTY ADDRESS

6. DATE OF EDAS

CYCLE OR RFO

(0FF)

DATE

(Include Area Code)

4b. HOME PHONE NO.

5b. DUTY PHONE NO. a. DSN

(Include area code)

b. COMMERCIAL

FAMILY MEMBERS

(YYYYMMDD)

a. NAME b. RELATIONSHIP c. DOB d. HOME ADDRESS

AUTHENTICATION

(Grade )

a. MILITARY PERSONNEL DIVISION/PERSONNEL

SERVICE COMPANY REPRESENTATIVE'S NAME

d. SIGNATURE

c. RANK

b. TITLE

(YYYYMMDD )

e. DATE

PART B - FAMILY MEMBER SCREENING RESULTS

(EFMP)

(Check one)

EXCEPTIONAL FAMILY MEMBER PROGRAM ENROLLMENT

b. CONSIDERATION

9. NAME

a. NOT

WARRANTED

c. SUBSTANTIAL CHANGE SINCE ENROLLMENT

(Date

WARRANTED

sent for Coding)

NO YES DATE SENT FOR CODING

10.

ARMY MEDICAL TREATMENT FACILITY (MTF) EFMP MEDICAL PRACTITIONER COMPLETING THIS FORM

a. PRINTED NAME OF MEDICAL PRACTITIONER

b. SIGNATURE

(YYYYMMDD )

c. DATE

d. ADDRESS

(Include Commercial and DSN)

e. PHONE NUMBER

(To be signed when a medical practitioner other than a physician completes this form.)

11.

ARMY MTF EFMP PHYSICIAN'S AUTHENTICATION

a. TYPED OR PRINTED NAME OF PHYSICIAN b. TITLE c. RANK

(YYYYMMDD )

e. DATE

d. SIGNATURE

APD LC v1.00ES

EDITION OF AUG 1995 IS OBSOLETE

DA FORM 5888, SEP 2002