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# DLA Official Forms

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| Form Number:  DLA1855-1C                                                                                                                                                                                                               |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Form Title:  DLA Child and Youth Program Epilepsy/Seizure Medical Action Plan                                                                                                                                                          |
| Form Version:  Aug 2019                                                                                                                                                                                                                |
| Status:  Active                                                                                                                                                                                                                        |
| Functional Area:  Installation Management                                                                                                                                                                                              |
| Opr:  DM                                                                                                                                                                                                                               |
| Safeguards:  PAS, PII, OMB Collections                                                                                                                                                                                                 |
| Electronic:  Yes                                                                                                                                                                                                                       |
| Form Link:  Documents/FormsSite/forms/DL1855-1C.pdf                                                                                                                                                                                    |
| Type:  Primary                                                                                                                                                                                                                         |
| Prescribed:  DLAI 1015.02                                                                                                                                                                                                              |
| Description:  This form will be used as the Medical Action Plan for child(ren) in a Child and Youth Program requiring seizure-related medications and measures.                                                                        |
| Records Retention:  7304.1 Child Development Center. Temporary. Cutoff at end of Event. Maintain records as long as a child is enrolled. Upon termination from the program, forward records to Child Development Services Coordinator. |
| Form Audience:                                                                                                                                                                                                                         |

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