CONFIDENTIAL
DODDS PACIFIC COMPASSIONATE REASSIGNMENT PROGRAM APPLICATION

Submit to:	DoDDS-Pacific
		ATTN: Personnel Division
		Unit 35007
		APO AP 96376-5007

Commercial Fax Number:  011-81-98-957-4523 

1.  PERSONAL DATA:
A.  Last Name:					 First Name:					 MI:		
B.  Social Security Number:											
C.  Current Duty Station (School Name): 									
D.  Current Teaching Assignment: 										
E.  Service Computation Date:  Month:		 Day:		 Year:		

2.  LIST CATEGORIES IN ORDER OF PLACEMENT PREFERENCE: (See attachment 1- Category List.) You must be currently certified in each category that you list below.
1)		 2)		 3)		 4)		 5)		 6)		 7)		
8)		 9)		 10)		 11)		 12)		 13)		 14)		

3. REQUEST FOR JOINT CONSIDERATION WITH TEACHER SPOUSE:      Yes 	  No 		
Spouse’s Name							 Spouse’s SSN					
Spouse’s Current Duty Station  (School Name)									
Current Teaching Assignment: ________________

4.  LIST SPOUSE’S CATEGORIES IN ORDER OF PLACEMENT PREFERENCE: (See attachment 1 - Category List.) Your spouse must be currently certified in each category listed below.
1)		 2)		 3)		 4)		 5)		 6)		 7)		
8)		 9)		 10)		 11)		 12)		 13)		 14)		

5. BASIS FOR REQUEST (check appropriate block):

__ Medical (Physician’s statement must be completed).

     a. Documentation required:
     
     (1) Physician’s statement (attachment 2) must be completed in English and provide diagnosis, prognosis, the medical basis for inability to remain in current location, and the medical basis for the ability to work at new location, the type of medical care, climate or environment needed to relieve or improve the medical condition.  Physician should identify locations that can meet the medical needs. Include in documentation a statement from your doctor regarding ability to treat medical condition on the economy, either at current duty location, or another geographic location identified by the physician. This statement must be attached to your application.  

    (2) If applicable, attach completed DA Form 5862 (Army Exceptional Family Member Program Medical Summary) and DA form 7246 (Exceptional Family Member Program Screening Questionnaire). These forms should be submitted for individuals receiving treatment/evaluation by military medical facilities. Forms may be downloaded from the internet address: www.usapa.army.mil/USAPA_PUB formnum_f.asp.

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__ Reunite DoDDS Teacher Couples.

    Submit a copy of your or your spouse’s excess notification and reassignment letter.

__ Other reasons.  

     Submit all documentation supporting unique circumstances.
  	
6.  EMPLOYEE VERIFICATION:
By signing below, I verify the above information is correct. I understand that failure to accept an assignment will result in removal from consideration for compassionate reassignment for one year. I understand that I am required to submit an annual update to my application. However, updates may be submitted at any time if medical conditions or circumstances change. Failure to do so may result in removal from consideration for a compassionate reassignment. 


Signature:									  Date:				


7. SUPERVISORY VERIFICATION:


If employee is transferred, the vacated position will be:  Abolished: __________    Filled As: __________


PRINCIPAL’S SIGNATURE:  							  Date:				

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      PHYSICIAN’S STATEMENT
       
        
MEDICAL INFORMATION REQUIRED:

1. MEDICAL DIAGNOSIS: 




2. MEDICAL PROGNOSIS:




3. MEDICAL BASIS FOR INABILITY TO REMAIN IN CURRENT LOCATION:




4. MEDICAL BASIS FOR THE ABILITY TO WORK AT NEW LOCATION:




5. THE TYPE OF MEDICAL CARE, CLIMATE, AND/OR ENVIRONMENT NEEDED TO RELIEVE OR 
IMPROVE THE MEDICAL CONDITION:




   6.   LOCATIONS IDENTIFIED BY DOCTOR THAT CAN MEET THE MEDICAL NEEDS:




7. CAN MEDICAL CONDITION BE TREATED ON THE LOCAL ECONOMY AT THE CURRENT DUTY LOCATION OR AT OTHER LOCATIONS IDENTIFIED BY DOCTOR:




PRINTED NAME/TITLE OF MEDICAL PHYSICIAN:  ____________________________________________

SIGNATURE OF MEDICAL PHYSICIAN:  ______________________________________ DATE: _________


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ATTACHMENT 2