Blank Af 4380 PDF Template

1. What is the purpose of the AF Form 4380?

The AF Form 4380 serves a critical function in ensuring the health care needs of Air Force families are adequately met during relocation. It is used to document, plan, and coordinate health care for family members. Additionally, the form determines eligibility for various programs and compiles statistical data to improve service delivery. By identifying any special medical and/or educational needs a family member might have, the Air Force can better facilitate the availability of specialized services.

2. Who is required to complete the AF Form 4380?

Any sponsor with family members, regardless of whether they currently live with the sponsor, is required to complete the AF Form 4380. This is a necessary step in the relocation processing to ensure that the Air Force can provide the necessary support and services to all military family members with special needs.

3. What happens if I do not provide the information requested on the AF Form 4380?

Disclosure of the information requested on the AF Form 4380 is voluntary. However, not providing the Social Security Number (SSN) or other requested information can delay the screening process for your family member’s suitability for relocation at government expense. This delay may also affect the issuance of Permanent Change of Station (PCS) orders, which could impact your family’s relocation timeline.

4. Are there any privacy protections in place for the information provided on the AF Form 4380?

Yes, the AF Form 4380 is protected under the Privacy Act of 1974. It employs a blanket Personnel Authorization System (PAS) as outlined in DD Form 2005. These protections ensure that the personal information provided is handled with confidentiality and is only used for the intended purposes: to coordinate health care, determine benefit eligibility, and for statistical compilation.

5. What should I do if I answer "Yes" to any questions numbered 2 - 8 on the form?

If you answer "Yes" to any questions numbered 2 through 8, you are advised to contact the Exceptional Family Member Program (EFMP-M) Office at the Military Treatment Facility for assistance. It is important to do this prior to pursuing any further relocation actions to ensure that all special needs can be adequately addressed.

6. What are the consequences of providing false information on the AF Form 4380?

Providing false information on the AF Form 4380 is a serious offense. It is subject to legal action which can include fines or imprisonment as outlined in the U.S. Code, Title 18, Section 1001, Title 10, Section 907, and Article 107 of the Uniform Code of Military Justice (UCMJ). Accurate and truthful information is essential to ensure the well-being of your family members during the relocation process.

7. What authority requires the completion of the AF Form 4380?

The completion of the AF Form 4380 is mandated by 10 U.S.C. 55, 10 U.S.C. 8013, and Executive Order 9397 (SSN), as amended. These authorities grant the form its legal basis for collecting personal information necessary for the relocation process and for facilitating the special needs of military family members.

8. How is the information on the AF Form 4380 used?

The information provided on the AF Form 4380 is used to ensure that family members with special needs receive the necessary medical and educational services. It aids in the health care documentation, planning, and coordination process and assists in determining eligibility for various benefits. Moreover, the data collected through this form are utilized to compile statistical information to enhance support programs for military families.

When filling out the AF Form 4380, individuals frequently make several critical errors. Recognizing and avoiding these mistakes can ensure a smoother process for military families during times of relocation. Below are the common pitfalls to be aware of:

1. Not providing the last four digits of the Social Security Number (SSN): Despite its voluntary disclosure, failing to include this information can delay the screening process and the issuance of PCS orders.
2. Omitting sponsor's duty telephone number and projected departure date: This essential information facilitates communication and planning for the relocation process.
3. Skipping questions related to family members’ special needs: It is crucial to answer all questions accurately to ensure that the family receives the appropriate support and resources.
4. Ignoring the instruction to stop and contact the Exceptional Family Member Program (EFMP-M) Office if answering "Yes" to questions 2-8: This step is vital for obtaining necessary assistance and should not be overlooked.
5. Forgetting to indicate whether enrolled in any Service's Exceptional Family Member Program (EFMP): This information is important for continuity of care and support services.
6. Failing to accurately report on the receipt of special education, early intervention, or any therapy services: Accurate reporting is essential for the AFPC to provide appropriate resources and support.
7. Glossing over the need for specialized equipment or modified housing: This question directly impacts the suitability of future housing arrangements and must be answered thoroughly.
8. Signing the form without verifying the completeness and accuracy of the information: The certification statement at the end of the form highlights the importance of the provided information’s integrity, which can have legal implications.

Individuals who take the time to carefully complete the AF Form 4380, avoiding these common errors, contribute significantly to a smoother and more efficient relocation process for themselves and their families. This attention to detail ensures that the needs of all family members are considered and met appropriately.

When processing or completing the AF Form 4380, Air Force Special Needs Screener, several other forms and documents often accompany it to ensure comprehensive support for military families. These documents play a crucial role in the coordination and delivery of services to meet the unique needs of family members, enhancing their well-being and quality of life during relocations.

• DD Form 2005, Privacy Act Statement - Health Care Records: This form serves as a Privacy Act Statement for individuals receiving healthcare services. It ensures that patients are aware of their rights concerning personal health information, aligning with the privacy requirements mentioned in the AF Form 4380.
• DD Form 2792, Exceptional Family Member Program (EFMP) Medical Summary: Required for family members with long-term health conditions, this form documents medical needs and is used to coordinate appropriate care and services. It supports the AF Form 4380's purpose of determining suitability for relocation and benefits.
• DD Form 2792-1, Exceptional Family Member Program (EFMP) Special Education/Early Intervention Summary: For children receiving special education or early intervention services, this form captures educational requirements and support needs. It complements the AF Form 4380 by providing detailed educational information pertinent to relocation planning.
• PCS Orders: While not a form, Permanent Change of Station (PCS) orders are essential documents associated with the AF Form 4380. They detail the service member's relocation assignment and are crucial for planning and coordinating special needs services at the new location.

Together, these forms and documents work in tandem with the AF Form 4380 to ensure a smooth transition for military families, especially those with special needs. By meticulously documenting healthcare and educational needs, the Air Force can provide targeted support, making relocations as seamless as possible for all family members.

The AF Form 4380, designed for the screening of Air Force members' family special needs, shares similarities with several other forms and documents across various sectors. Each of these documents facilitates crucial information gathering for decision-making, benefits eligibility determinations, and coordinating care or assistance.

• DD Form 2005 (Privacy Act Statement - Health Care Records): Similar to the AF Form 4380's use of the Privacy Act of 1974 notice, this form informs service members about their privacy rights concerning health care records.
• DD Form 2792 (Exceptional Family Member Program - Medical Summary): This form, like the AF Form 4380, collects medical information for family members to ensure appropriate medical and educational support is available, particularly during relocations.
• Individualized Education Program (IEP) Documents: Used to outline special education services for students with disabilities, these documents, similar to questions on the AF Form 4380, aim at identifying and planning for special educational needs.
• 504 Plan: A 504 Plan outlines accommodations for students with disabilities in public schools, similar to how the AF Form 4380 identifies children who may require special educational services.
• SSA-827 (Authorization to Disclose Information to the Social Security Administration): Like the AF Form 4380, this document allows for the sharing of medical or other sensitive information, albeit for determining eligibility for Social Security benefits.
• VA Form 10-10EZ (Application for Health Benefits): This Veterans Affairs form is used to determine eligibility for health benefits, similar to how AF Form 4380 identifies eligibility for special programs within the military community.
• Health Insurance Portability and Accountability Act (HIPAA) Authorization Form: Similar in purpose to the AF Form 4380's adherence to the Privacy Act, this form authorizes the release of an individual's health information, ensuring a patient's data protection while allowing necessary information flow for care coordination.
• HUD Section 504 Self-Evaluation Form: This form, used in housing, identifies needs for accommodations, akin to how AF Form 4380 might flag the necessity for modified housing due to a family member's condition.
• Consent for Release of Information (FERPA Form): Similar to how the AF Form 4380 collects educational services information, FERPA forms allow schools to release or exchange a student's educational records.
• Medical Release Forms (General): These forms are commonly used throughout the healthcare industry to permit the sharing of healthcare information, similar to parts of AF Form 4380 that pertain to the release and sharing of medical conditions and therapy needs.

When filling out the AF 4380 form for Air Force Special Needs Screener, there are several important do's and don'ts to ensure that the process goes smoothly and accurately. This form is crucial for documenting, planning, and coordinating the health care of family members during relocation. Here are some guidelines:

• Review each question carefully. Make sure you understand what is being asked before you answer. If you have doubts, seek clarification.
• Answer all questions honestly. Provide accurate information to ensure that your family members receive the appropriate support and services.
• Use only the last 4 digits of the Social Security Number (SSN). This is a precaution to protect your privacy, in line with the Privacy Act of 1974.
• Contact the Exceptional Family Member Program (EFMP-M) Office if you answer "Yes" to any questions numbered 2 through 8. This is crucial for receiving the necessary assistance before proceeding with any relocation actions.
• Sign and date the form. Your signature certifies that the information provided is complete and accurate to the best of your knowledge.

• Skip questions. Even if you believe a question does not apply to your situation, indicate this appropriately rather than leaving it blank.
• Provide incomplete information. Incomplete information may delay screening for your family member’s suitability for relocation or delay the issuance of Permanent Change of Station (PCS) orders.
• Guess answers if you are unsure about specific details. It's better to verify the correct information than to provide guesses that may lead to inaccuracies.
• Include the full SSN. For your protection and to comply with privacy regulations, only the last four digits of your SSN should be used on this form.
• Postpone completing the form. Delaying the completion of this form can delay your relocation process. Fill it out as soon as possible to avoid any inconvenience.

When it comes to understanding the AF Form 4380, or the Airforce Special Needs Screener, there are several misconceptions that can lead to confusion for military families. This form is crucial for the planning and coordination of healthcare for family members during relocation. Let's address and clarify some of these misunderstandings.

• Misconception 1: The form is only for those with severe disabilities. In reality, the AF Form 4380 is designed to identify any special medical and/or educational needs that might affect relocation. This includes a wide range of needs, not just severe disabilities.

• Misconception 2: Completing the form will delay the relocation process. Although it might seem like an additional step, the form is intended to ensure that families receive the appropriate support and resources at their new location. In the long run, it aids in the smooth transition of the family.

• Misconception 3: Personal information will be shared widely. Despite the form being subject to the Privacy Act of 1974, the information provided is used strictly for determining eligibility and suitability for benefits and coordinating care. It is handled with the utmost confidentiality and shared only with necessary personnel.

• Misconception 4: All sections of the form must be completed by the sponsor. While the sponsor’s information is crucial, not all sections may apply to every family. It’s important to read and answer all questions truthfully, but only those relevant to your family's situation.

• Misconception 5: Submission of the form is optional. Disclosure may be voluntary, but failure to provide the requested information can delay or affect the screening process for relocation at government expense or the issuance of Permanent Change of Station (PCS) orders.

• Misconception 6: The form only covers medical needs. Apart from medical requirements, the AF Form 4380 also addresses educational needs, ensuring that children receive the appropriate support and services in their new environment.

• Misconception 7: Once submitted, no further action is required. If you answer "Yes" to questions concerning special education services, chronic conditions, or the need for specialized equipment, you are encouraged to contact the Exceptional Family Member Program (EFMP-M) Office at the Military Treatment Facility for further assistance.

Understanding these points clarifies the importance and purpose of the AF Form 4380. It's designed to help military families get the support they need during significant transitions. If you have any concerns or need assistance completing the form, reaching out to a legal advisor or the designated special needs coordinator can provide guidance and support throughout the process.

Filling out the AF Form 4380 is an essential step for Air Force sponsors with family members, especially during relocation. Understanding how to properly complete and use this form ensures the needs of family members are identified and met. Here are four key takeaways regarding the completion and use of the AF Form 4380:

• Completion Is Mandatory for Relocation Processing: Sponsors are required to fill out the AF Form 4380 as part of the relocation process if they have family members, regardless of whether these family members live with the sponsor. This step helps the Air Force coordinate and plan for the health care and educational needs of all military family members.
• Disclosure Is Voluntary but Critical: While providing information on the form is voluntary, failure to supply the requested information, such as the last four digits of the Social Security Number (SSN) or details about family members' special needs, may delay the screening process. This delay can affect the family's eligibility and suitability for various programs and benefits, including relocation at government expense.
• It Helps in Identifying Special Needs: The form is designed to identify any medical, educational, or other special needs that family members may have. Accurately reporting issues such as chronic medical conditions, the requirement for special education services, or the need for specialized equipment ensures that appropriate resources and accommodations can be provided to support family members.
• Contact the Exceptional Family Member Program (EFMP) for Assistance: If any questions numbered 2 through 8 on the form are answered "Yes," sponsors should contact the Exceptional Family Member Program (EFMP-M) Office at their Military Treatment Facility. The EFMP-M provides assistance in coordinating care and resources for family members with special needs, ensuring they receive necessary support during relocation and beyond.

Understanding and accurately completing the AF Form 4380 ensures support for Air Force family members with special needs, facilitating a smoother relocation process and access to essential resources and benefits.