Form F-00367L "Age-Specific Adl/Iadl Answer Choices for Children's Long-Term Support Programs Age: 18 Years and up" - Wisconsin

What Is Form F-00367L?

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 December 1, 2012;
  • 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-00367L by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form F-00367L "Age-Specific Adl/Iadl Answer Choices for Children's Long-Term Support Programs Age: 18 Years and up" - Wisconsin

Download PDF

Fill PDF online

Rate (4.8 / 5) 26 votes
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Long Term Care
F-00367L (12/2012)
AGE-SPECIFIC ADL / IADL ANSWER CHOICES
FOR CHILDREN’S LONG-TERM SUPPORT PROGRAMS
AGE: 18 Years and Up
ACTIVITIES OF DAILY LIVING (ADL)
Bathing
Needs adaptive equipment.
Is combative during bathing (e.g., flails, takes two caregivers to accomplish task).
Needs physical help with bathing tasks.
Needs help getting in and out of bathtub or shower.
Needs step-by-step cueing to complete the task.
Lacks an understanding of risk and must be supervised for safety.
Exhibits non-compliant behavior that is extreme to point that child does not perform bathing tasks for at least 5 or
more consecutive days.
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
Grooming (brushing teeth, washing hands and face)
Is combative during grooming (e.g., flails, clamps mouth shut, takes two caregivers to accomplish task).
Needs physical help with grooming tasks.
Needs step-by-step cueing to complete grooming tasks.
Exhibits non-compliant behavior that is extreme to the point that child does not brush their teeth for at least 5 or
more consecutive days.
None of the above apply.
Is at least one of the grooming (brushing teeth, washing hands and face) functional impairments expected to last for at
least one year from the date of screening?
Yes
No
Dressing
Needs physical assistance with getting clothing on. This does not include fasteners such as buttons, zippers, and
snaps.
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
Needs help with tube feedings or TPN.
Needs to be fed.
Needs one-on-one monitoring to prevent choking, aspiration, or other serious complications.
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
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Long Term Care
F-00367L (12/2012)
AGE-SPECIFIC ADL / IADL ANSWER CHOICES
FOR CHILDREN’S LONG-TERM SUPPORT PROGRAMS
AGE: 18 Years and Up
ACTIVITIES OF DAILY LIVING (ADL)
Bathing
Needs adaptive equipment.
Is combative during bathing (e.g., flails, takes two caregivers to accomplish task).
Needs physical help with bathing tasks.
Needs help getting in and out of bathtub or shower.
Needs step-by-step cueing to complete the task.
Lacks an understanding of risk and must be supervised for safety.
Exhibits non-compliant behavior that is extreme to point that child does not perform bathing tasks for at least 5 or
more consecutive days.
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
Grooming (brushing teeth, washing hands and face)
Is combative during grooming (e.g., flails, clamps mouth shut, takes two caregivers to accomplish task).
Needs physical help with grooming tasks.
Needs step-by-step cueing to complete grooming tasks.
Exhibits non-compliant behavior that is extreme to the point that child does not brush their teeth for at least 5 or
more consecutive days.
None of the above apply.
Is at least one of the grooming (brushing teeth, washing hands and face) functional impairments expected to last for at
least one year from the date of screening?
Yes
No
Dressing
Needs physical assistance with getting clothing on. This does not include fasteners such as buttons, zippers, and
snaps.
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
Needs help with tube feedings or TPN.
Needs to be fed.
Needs one-on-one monitoring to prevent choking, aspiration, or other serious complications.
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
F-00367L Page 2, Age-Specific ADL / IADL, 18 Years and Up
Toileting
Incontinent of bowel and/or bladder.
Needs physical help, step-by-step cues, or a toileting schedule.
None of the above apply.
Is at least one of the toileting functional impairments expected to last for at least one year from the date of screening?
Yes
No
Mobility
Does not walk or needs physical help to walk.
Uses a wheelchair or other mobility device not including a single cane.
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
Transfers (does not include bathtub or shower)
Needs physical help with transfers.
Uses a mechanical lift.
None of the above apply.
Is at least one of the transfers (not including bathtub or shower) functional impairments expected to last for at least one
year from the date of screening?
Yes
No
NOTES
F-00367L Page 3, Age-Specific ADL / IADL, 18 Years and Up
INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)
Communication
A norm referenced assessment in receptive language within the last three (3) years. (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 three (3) years. (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 follow 3-step instructions that are related and are not routine.
Does not follow 2 single step instructions given at the same time that are unrelated and are not routine.
Does not use language to share information other than basic needs or wants.
Is not understood by strangers.
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
Has a valid full scale IQ (A substantial functional impairment is defined by a full scale IQ score of 75 or less.)
IQ Test: ________________________________________________
Score: ___________
A norm referenced assessment in cognition within the last three (3) years. (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
Is three or more grade levels behind in two academic subjects.
Requires supervision due to inability to problem solve routine issues.
Does not use time to follow a schedule.
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-00367L Page 4, Age-Specific ADL / IADL, 18 Years and Up
Meal Preparation
Needs help making simple meals for self.
None of the above apply.
Is at least one of the meal preparation functional impairments expected to last for at least one year from the date of
screening?
Yes
No
Money Management
Needs help with managing money.
None of the above apply.
Is at least one of the money management functional impairments expected to last for at least one year from the date of
screening?
Yes
No
Social Competency
Does not show respect for other people.
Does not get along with a variety of people, use pro-social manners, or show gratitude towards others.
Does not demonstrate the capacity for intimacy with another.
Has not established close relationships that are open, honest, caring and trusting.
Does not avoid situations that may get him / her into trouble.
Makes unhealthy and unsafe decisions concerning drinking alcohol, using drugs, safe driving, safer sex, use of the
internet, and other comparable situations.
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 4