Form F-00367D "Age-Specific Adl/Iadl Answer Choices for Children's Long-Term Support Programs Age: 18 to 24 Months" - Wisconsin

What Is Form F-00367D?

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-00367D by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form F-00367D "Age-Specific Adl/Iadl Answer Choices for Children's Long-Term Support Programs Age: 18 to 24 Months" - Wisconsin

Download PDF

Fill PDF online

Rate (4.7 / 5) 17 votes
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Medicaid Services
F-00367D (02/2017)
AGE-SPECIFIC ADL / IADL ANSWER CHOICES
FOR CHILDREN’S LONG-TERM SUPPORT PROGRAMS
AGE: 18 – 24 Months
ACTIVITIES OF DAILY LIVING (ADL)
Bathing
Needs adaptive equipment.
Becomes agitated requiring alternative bathing methods.
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
Does not assist with dressing by helping to place arms in sleeves or legs into pants.
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
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
Requires a stander or someone to support the child’s weight in a standing position.
Uses a wheelchair or other mobility device not including a single cane.
Unable to take steps holding on to furniture.
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-00367D (02/2017)
AGE-SPECIFIC ADL / IADL ANSWER CHOICES
FOR CHILDREN’S LONG-TERM SUPPORT PROGRAMS
AGE: 18 – 24 Months
ACTIVITIES OF DAILY LIVING (ADL)
Bathing
Needs adaptive equipment.
Becomes agitated requiring alternative bathing methods.
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
Does not assist with dressing by helping to place arms in sleeves or legs into pants.
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
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
Requires a stander or someone to support the child’s weight in a standing position.
Uses a wheelchair or other mobility device not including a single cane.
Unable to take steps holding on to furniture.
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-00367D Page 2, Age-Specific ADL / IADL, 18 – 24 Months
INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)
Communication
A norm referenced assessment in receptive language within the last six (6) months. (A substantial functional
impairment is defined by results that indicate a delay of 30% or greater or 2 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 30% delay
Greater than or equal to 30% delay
Less than 2 Standard Deviations (SD) below the norm
Greater than or equal to 2 Standard Deviations (SD) below the norm
A norm referenced assessment in expressive language within the last six (6) months. (A substantial functional
impairment is defined by results that indicate a delay of 30% or greater or 2 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 30% delay
Greater than or equal to 30% delay
Less than 2 Standard Deviations (SD) below the norm
Greater than or equal to 2 Standard Deviations (SD) below the norm
Does not respond to simple requests (e.g., no, stop, come here, give me, look).
Does not point to or look at familiar objects or people when asked.
Does not use more than 10 meaningful words or word approximations.
Does not imitate environmental sounds through any means.
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 six (6) months. (A substantial functional impairment is
defined by results that indicate a delay of 30% or greater or 2 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 30% delay
Greater than or equal to 30% delay
Less than 2 Standard Deviations (SD) below the norm
Greater than or equal to 2 Standard Deviations (SD) below the norm
Cannot imitate gestures or activities (e.g., wave bye-bye, clap hands, make faces).
Does not know any body parts on self or others.
Does not place objects in containers during play.
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-00367D Page 3, Age-Specific ADL / IADL, 18 – 24 Months
Social Competency
Does not play simple interactive games (e.g., So Big, Peek-a-Boo, Pat-a-Cake).
Does not respond to other’s attempts to engage in playful exchange.
Does not enjoy interacting with immediate family members.
Does not like family time looking at books, listening to songs, or rough and tumble play.
Does not like to be around other children.
Prefers to spend time alone even when other children are around.
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
Page of 3