Enclosure (1) to COMDTINST 1754.12
SPECIAL NEEDS CASE DOCUMENTATION FORMAT
IDENTIFYING DATA:
Date:
Name of Sponsor:
Rate or Rank:
Unit:
SSN:
Home Address:
Telephone#: Member's Unit:
Home:
Name of Special Needs Dependent #1:
DOB:
Name of Special Needs Dependent #2:
DOB:
Name of Special Needs Dependent #3:
DOB:
Name of Special Needs Dependent #4:
DOB:
Type of Disability(ies) (state whether dependent(s) with special needsvis spouse or child):
Dependent #1:
Dependent #2:
Dependent #3:
Dependent #4:
CONTACTS:
Include every contact made chronologically. Date and sign all entries including supervision with
Work-Life Supervisor; conversations with conunands, members and families; contacts with
military and civilian service providers and any technical guidance from G-WPW-2
Program Managers.
COAST GUARD PERSONNEL INVOLVED:
NAME
RANK
POSITION or TITLE
PHONE #
OTHER PROFESSIONALS INVOLVED:
NAME
AGENCY
POSITION/TITLE
PHONE #
4
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