APPENDIX I. FAMILY ASSISTANCE QUESTIONNAIRE: THE YELLOW RIBBON SPECIAL BULLETIN NO. 91-2

APPENDIX I

FAMILY ASSISTANCE QUESTIONNAIRE

PRIVACY ACT STATEMENTAUTHORITY: Title 10, USC, Section 3012. PRINCIPLE PURPOSE(S): To assist Army Agencies and Commands in their mission of providing care and assistance to families of Service members who are required to be away from their home station. ROUTINE USES: (1) To identify specific problems and service needs of soldiers and their families. (2) To gather data that will assist in the development of appropriate programs and services. (3) To serve as a record of services provided. MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Voluntary information is required to assist the individual and his/her family members. Failure to provide the required information could result in a delay in providing assistance to the individual and/or family members.

1.
SPONSOR INFORMATION

  

NAME:___________________________GRADE:__________SSN:____________

ADDRESS:________________________________________________________

         Street         City      State     County    Zip

HOME
PHONE NUMBER W/ AREA CODE:_________________________________



2.
MILITARY STATUS: ACTIVE__RESERVES__NATIONAL GUARD__IRR/RT-12__



UNIT:____________________UNIT
ADDRESS:__________________________





3.
MARITAL STATUS:  SINGLE________MARRIED________DIVORCED_______



4.
CHILDREN:  YES_____ NO_____



NAME(S)
            AGE(S)    NAME(S)             AGE(S)

__________________
 _____     __________________  _____

__________________
 _____     __________________  _____

__________________
 _____     __________________  _____



5.
PRIMARY NEXT OF KIN (PNOK)



NAME:____________________________RELATIONSHIP:___________________

ADDRESS__________________________________________________________

         Street         City      State     County    Zip

HOME
PHONE NUMBER W/ AREA CODE:__________________________________

NATIVE
LANGUAGE SPOKEN BY PNOK/SPOUSE:___________________________

NEAREST
MILITARY INSTALLATION TO YOUR PNOK/SPOUSE:_______________



6.
EVALUATE POTENTIAL FAMILY PROBLEMS/CONCERNS DURING YOUR

ABSENCE:



    a.  Medical.  Are there special medical needs in your       



        family?  Yes___ No___

        If yes, state problem and assistance needed_____________

        ________________________________________________________





    b.  Financial.  What arrangements have been make to provide

        financial support to spouse/children?  Check to bank    



        (Sure pay)___ Allotment___ Other, specify___



    c.  Housing.  Will your family (spouse/children) relocate as

        result of this deployment?  Yes___ No___  If yes,       



        relocation address:

        ________________________________________________________

         Street              City      State     County    Zip

        Phone number w/ area code:______________________________



        If no, are there any concerns about current housing     



        situations?  Specify____________________________________



    d.  Transportation.  Does your PNOK/spouse drive? Yes__ No__

        Will transportation be a problem during your absence? 

        No___  Yes, explain_____________________________________



    e.  Emotional.  How is your PNOK/spouse handling this       



        deployment?  Very Well___ OK___ Not Well___



    f.  Other problem areas, specify____________________________



7.
FAMILY DOCUMENTS CHECKLIST.  Do you or your family members

have
the following documents?  ID cards  Yes/No  Power of

Attorney
 Yes/No  Family Care Plan  Yes/No  (single parent, duel-

military
or pregnant soldiers)



SIGNATURE:________________________________DATE:__________________

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APPENDIX I

FAMILY ASSISTANCE QUESTIONNAIRE