Submit the completed form to your Special Needs Coordinator at your current base of assignment. Ensure all sections are accurately filled and all necessary attachments are included. You can submit the form via email, fax, or physical delivery to the appropriate office. Make sure to keep copies of all submitted documents for your records. For email submissions, get the email address from your local base office. For fax submissions, use the fax number provided by your base. For physical submissions, deliver it to the office of the Special Needs Coordinator at your current base of assignment.

The purpose of this form is to request medical and educational clearance for family members who will be accompanying a military sponsor to a new duty station. Accurate completion of this form ensures that all necessary medical and educational needs are addressed before travel. It is important to provide detailed information to avoid delays in the clearance process.

• 1. A. NAME: The last, first, and middle initial of the sponsor.
• 2. B. GRADE: The sponsor's military grade.
• 3. C. SSN: The sponsor's social security number.
• 4. D. DUTY / HOME PHONE: The sponsor's duty or home phone number.
• 5. E. PRESENT UNIT/LOCATION: The sponsor's present unit and location.
• 6. H. PROJECTED UNIT / LOCATION: The sponsor's projected unit and location.
• 7. I. JOIN SPOUSE ASSIGNMENT: Indicate if this is a join spouse assignment, yes or no.
• 8. F. LOSING MPF LOCATION: The location of the losing Military Personnel Flight.
• 9. J. GAINING MAJCOM: The gaining Major Command.
• 10. K. PROJECTED AFSC: The sponsor's projected Air Force Specialty Code.
• 11. G. MO/YR OF SPONSOR TRAVEL: The month and year of the sponsor's travel.
• 12. L. PREVIOUSLY Q-CODED: Indicate if the sponsor has been previously Q-coded, yes or no.
• 13. M. Name and SSN of spouse if active duty: The name and social security number of the spouse if they are active duty.
• 14. SECTION II - STATE DEPARTMENT DUTY: Indicate if the member is being assigned to State Department duties, yes or no.
• 15. Family Member's Name: The last, first, and middle initial of the family member.
• 16. Relationship: The relationship of the family member to the sponsor.
• 17. Age: The age of the family member.
• 18. SECTION III - FAMILY MEMBERS NOT TRAVELING: Certify which family members will not accompany the sponsor during the assignment.
• 19. Sponsor's Signature: The sponsor's signature to certify the form.
• 20. SECTION IV - FAMILY MEMBERS REQUESTING COMMAND SPONSORSHIP TO TRAVEL: List all family members requesting command sponsorship and complete page 2 for each member.
• 21. Medical: Indicate any medical conditions.
• 22. Emotional/Behavioral: Indicate any emotional or behavioral conditions.
• 23. Educational: Indicate any educational needs.
• 24. Dental: Indicate any dental needs.
• 25. Modified Housing: Indicate any modified housing needs.
• 26. None: Indicate if no special conditions are present.
• 27. Location of Medical Records: Indicate the location of stored medical records.
• 28. Copies Provided: Check if copies of medical records are provided.
• 29. Month and Year of Travel: Submit dates of travel for family members if different than the sponsor.
• 30. SECTION V - CERTIFICATION OF APPLICANT: Certification by the applicant that the information is true and complete.
• 31. Printed Name and Grade of Sponsor: The sponsor's printed name and grade.
• 32. Signature: The sponsor's signature to certify the form.
• 33. SECTION VI - MEDICAL PROVIDER EVALUATION: Evaluation and certification by a medical provider.
• 34. YES/NO: Indicate yes or no for each query in the medical provider evaluation.
• 35. Comments: Provide comments on the evaluation.
• 36. Type/Print Name and Grade of Medical Provider: The medical provider's printed name and grade.
• 37. Signature: The medical provider's signature to certify the evaluation.
• 38. SECTION VII - SPECIAL NEEDS COORDINATOR ENDORSEMENT: Endorsement by the Special Needs Coordinator.
• 39. YES/NO: Indicate yes or no for each query in the endorsement.
• 40. Date: The date of the endorsement.
• 41. Type/Print Name and Grade of Special Needs Coordinator: The Special Needs Coordinator's printed name and grade.
• 42. Signature: The Special Needs Coordinator's signature to certify the endorsement.

Failing to submit this form can result in delays or denial of travel for the sponsor and their family members. Incomplete or inaccurate information may lead to further complications.

• Travel Delays: Incomplete submission may cause delays in the travel clearance process.
• Denial of Command Sponsorship: Failure to provide accurate information can lead to denial of command sponsorship for family members.
• Complications in Medical Care: Incomplete medical information may result in complications in arranging necessary medical care.

• 1. Request Command Sponsorship: To request command sponsorship for family members accompanying the sponsor.
• 2. Ensure Medical Clearance: To ensure that all medical needs are addressed before travel.
• 3. Educational Needs Evaluation: To evaluate and document any special educational needs.
• 4. Dental Clearance: To confirm that dental needs are met before travel.
• 5. Special Housing Needs: To document any special housing requirements for family members.