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# DLA Official Forms

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Form Information
| Form Number:       | DLA1855-1F                                                                                                                                                                                                         |
|--------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Form Title:        | DLA Child and Youth Program Consent to Perform Caregiving Health Practices and Authorization for Disclosure of Health Information                                                                                  |
| Form Version:      | Aug 2019                                                                                                                                                                                                           |
| Status:            | Active                                                                                                                                                                                                             |
| Functional Area:   | Installation Management                                                                                                                                                                                            |
| Opr:               | DM                                                                                                                                                                                                                 |
| Safeguards:        | PAS, OMB Collections                                                                                                                                                                                               |
| Electronic:        | Yes                                                                                                                                                                                                                |
| Form Link:         | Documents/FormsSite/forms/DL1855-1F.pdf                                                                                                                                                                            |
| Type:              | Primary                                                                                                                                                                                                            |
| Prescribed:        | DLAI 1015.02                                                                                                                                                                                                       |
| Description:       | This form will be used as consent for staff in a Child and Youth Program to perform caregiving health practices and as authorization for disclosure of health information.                                         |
| 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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