Form F-00367B "Age-Specific Adl/Iadl Answer Choices for Children's Long-Term Support Programs Age: 6 - 12 Months" - Wisconsin

What Is Form F-00367B?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2017;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form F-00367B by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Medicaid Services
F-00367B (02/2017)
AGE-SPECIFIC ADL / IADL ANSWER CHOICES
FOR CHILDREN’S LONG-TERM SUPPORT PROGRAMS
AGE: 6 – 12 Months
ACTIVITIES OF DAILY LIVING (ADL)
Bathing
Needs adaptive equipment.
None of the above apply.
Is at least one of the bathing functional impairments expected to last for at least one year from the date of screening?
Yes
No
Dressing
Has physical characteristics that make dressing very difficult—such as contractures, extreme hypotonia or extreme
hypertonia.
None of the above apply.
Is at least one of the dressing functional impairments expected to last for at least one year from the date of screening?
Yes
No
Eating
Requires more than one hour per feeding.
Receives tube feedings or TPN.
Requires more than three hours per day for feeding or eating.
None of the above apply.
Is at least one of the eating functional impairments expected to last for at least one year from the date of screening?
Yes
No
Mobility
Unable to maintain a sitting position when placed.
Unable to move self by rolling, crawling, or creeping.
None of the above apply.
Is at least one of the mobility functional impairments expected to last for at least one year from the date of screening?
Yes
No
NOTES:
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Medicaid Services
F-00367B (02/2017)
AGE-SPECIFIC ADL / IADL ANSWER CHOICES
FOR CHILDREN’S LONG-TERM SUPPORT PROGRAMS
AGE: 6 – 12 Months
ACTIVITIES OF DAILY LIVING (ADL)
Bathing
Needs adaptive equipment.
None of the above apply.
Is at least one of the bathing functional impairments expected to last for at least one year from the date of screening?
Yes
No
Dressing
Has physical characteristics that make dressing very difficult—such as contractures, extreme hypotonia or extreme
hypertonia.
None of the above apply.
Is at least one of the dressing functional impairments expected to last for at least one year from the date of screening?
Yes
No
Eating
Requires more than one hour per feeding.
Receives tube feedings or TPN.
Requires more than three hours per day for feeding or eating.
None of the above apply.
Is at least one of the eating functional impairments expected to last for at least one year from the date of screening?
Yes
No
Mobility
Unable to maintain a sitting position when placed.
Unable to move self by rolling, crawling, or creeping.
None of the above apply.
Is at least one of the mobility functional impairments expected to last for at least one year from the date of screening?
Yes
No
NOTES:
F-00367B Page 2, Age-Specific ADL / IADL, 6 – 12 Months
INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)
Communication
A norm referenced assessment in receptive language within the last three (3) months. (A substantial functional
impairment is defined by results that indicate a delay of 25% or greater or 1.5 Standard Deviations (SD) below the
mean.)
Date of Assessment: _______________ (mm/yyyy)
Assessment Tool: ___________________________________________________________________________
(See list of “Norm-Referenced Assessment Tools for Communication and Learning”)
Assessment Result:
Within normal limits
Less than 25% delay
Greater than or equal to 25% delay
Less than 1.5 Standard Deviations (SD) below the norm
Greater than or equal to 1.5 Standard Deviations (SD) below the norm
A norm referenced assessment in expressive language within the last three (3) months. (A substantial functional
impairment is defined by results that indicate a delay of 25% or greater or 1.5 Standard Deviations (SD) below the
mean.)
Date of Assessment: _______________ (mm/yyyy)
Assessment Tool: ___________________________________________________________________________
(See list of “Norm-Referenced Assessment Tools for Communication and Learning”)
Assessment Result:
Within normal limits
Less than 25% delay
Greater than or equal to 25% delay
Less than 1.5 Standard Deviations (SD) below the norm
Greater than or equal to 1.5 Standard Deviations (SD) below the norm
Does not react to changes in tone of voice.
Does not make any vocal sounds (includes crying).
Does not express his/herself through vocal, visual or gesture exchange.
None of the above apply.
Is at least one of the communication functional impairments expected to last for at least one year from the date of
screening?
Yes
No
Learning
A norm referenced assessment in cognition within the last three (3) months. (A substantial functional impairment is
defined by results that indicate a delay of 25% or greater or 1.5 Standard Deviations (SD) below the mean.)
Date of Assessment: _______________ (mm/yyyy)
Assessment Tool: ___________________________________________________________________________
(See list of “Norm-Referenced Assessment Tools for Communication and Learning”)
Assessment Result:
Within normal limits
Less than 25% delay
Greater than or equal to 25% delay
Less than 1.5 Standard Deviations (SD) below the norm
Greater than or equal to 1.5 Standard Deviations (SD) below the norm
Is not soothed when needs are met.
Does not show an interest in people or objects.
None of the above apply.
Is at least one of the learning functional impairments expected to last for at least one year from the date of screening?
Yes
No
F-00367B Page 3, Age-Specific ADL / IADL, 6 – 12 Months
Social Competency
Does not offer a social smile to immediate family.
A social smile occurs in response to a noise, something within baby’s sight or another person’s smile.
Does not calm down within a half an hour when soothed by a parent.
Unable to respond to comforting actions from familiar adults.
Does not enjoy being picked up and held by family members.
Stiffens and arches his / her back when picked up.
None of the above apply.
Is at least one of the social competency functional impairments expected to last for at least one year from the date of
screening?
Yes
No
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