Disability Report - Child (EDCS)

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3820 About the Child
Identification

Date of birth: 1*2000
Age: 6 years 3 months

Standaml Information
Even though the child's height and weight may be in his or her medical records, what you tell us can show
whether the records are up-to-date.

What is the child's height without shoes? feet:
What is the child's weight without shoes? pounds:

inches:
ounces:

Unknown
Unknown

Does the child have a medical assistance card (for example, Medicaid or MediCal) issued by your
state?
This number can help us to get all the child's medical records promptly.
Yes
No
Not yet answered
Medical assistance number:

7

Can the chlld speak and understand English?
Yes
No
Not yet answered
if "NOWjwhat !a~:g!lage can the chi!c' speak?

I t h e child understands any other languages, list them here:

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3820 About You
Applicant identitication

PROVIDENCE, RI 02903
Relationship to chid: AGENCY
Daytime telephone number:
Form Completer
Copy Applicant Information
'First name:

Middle name:

'Last name:

Agency name:
Relationship to child:
A d d m s lnformatlon
Address is:

U.S. Foreign

Street addrecis line 1:
Street address line 2:
Street address line 3:
Street address line 4:

Ci:

State:

Telephone number is:
Type:

Voice

Fax

ZIP Code:

U.S. Foreign

None

TTY

Daytime telephone number: (999-999-9999)
Your number

Message number

Email address:
Information About the Child
Does the child live with you?
Yes
No
Not yet answered
Does the child have a legal guardian or custodian other than you?

suffix:

Page 2 of 2

Yes

No

Not yet answered

Is there another adult who helps care for the child and can help us get information about the child if
necessay7
Yes
No
Not yet a&ered
Language Information
NOTE: If you cannot speak and understand English, we will provide an interpreter, free of charge.
Can you speak and understand Engllsh?
Yes
No
Not yet answered
If"NO", what is your preferred language?

Can you read and undentand English?
Yes
No
Not yetanswered

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3820 Other Contacts
Give the names of other adults or agencies who help cam for the child and can help us get
infonnation about the child i f necessary.
Include:
The child's legal guardian, if you are not the child's legal guardian
The adult with whom the child currentiy lives, if you do not live with the child
An adult who speaks and understands English who can give messages lo the applicant, if you cannot
speak and understand English
Another adult who knows the chikl and helps care for the child, such as a relative, neighbor, or friend

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To add a contact, choose Add Other Contact. To edit, select the contact's name below.
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3820 School History
Alleged onset date: 03/20/2006
Current School
Is the child cumntly enrolled i n kindergarten, elementary, mfddle, or high school?
Answer 'Yes" if the child is normally enrolled during the school year. (A child is considered enrolled even
during school breaks.)
Yes
No
Not yet answered
Is the child too young to be enrolled?

Yes

No

Not yet answered

Explain why the cl~isdis rrst ec~tolled?

C

What is the highest grade in school that the child has completed?

What grade is the child currently enrolled in?
Has the child ever been tested or examlned by Headstart (Tale V)7
Yes
No
Unknown
Not yet answered
Schools and Proera-

L i i all schools and programs that the chlld has attended (currently or in the past 12 months).
Include:
School (K through 12)
After school programs
Home school
Tutoring
Summer school
Preschool
Head start
Daycare
Early intervention program
Other
To add a school or program, choose Add School. To edit, select the school's name below.
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Page 2 of 2

Page 2 o f 3

Has the chlld been tested or examined by any of the following?
Headstart (TMe V)
Or

Child

Yes

No

Unknown

Not yet answered

Yes

No

Unknown

Not yet answered

Yes

No

Unknown

Not yet answered

Yes

No

Unknown

Not yet

Special Yes
Health Care Needs

No

Unknown

Not yet answered

Yes

No

Unknown

Not yet answered

CmmzE
Or

Agency

Women, Infants, EL Children Center
(mc)
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Mental
RetardationCenter

If the child has been tested or examined by any of the types of sources listed above, please add a
source below:
To add a source, choose Add Additional Source. To edit, select the name below.
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Other Yedkrl Sources
Is there anyone eke who has information or medical records about the child's illnesses,
injuries, or conditions? This could Include Workers' Compensation, insurance compnles,
counselors, detention centers, attorneys andlor tutors. Is l e child scheduled to see anyone
else?
Yes
No
Not yet answered
Lit any other people or places that may have the child's medical informdon or records.
To add a medical source, choose Add Other Source. To edit, select the name below.

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3820 Medical Sources
Alleged onset dab: 03/2012006

Has the child been seen by a doctor, hospital, clinic, or anyone else for Illnesses, lnjurleb, or
conditions?
Yes
No
Not yet answered
Has the child been seen by a doctor, hospttal, clinic or anyone else for emotional or mental
c o n d i i n s (Including behavioral problems or learning dlsabilttles)?
Yes
No
Not yet answered
List all medical care providers and each hospital or clinic where the child has been seen.
This l i t should provide information covering at least the past 12 months (or longer for progressive
condiions.)
Include:
All types of medical professionals (pediatricians, doctors, child psychologisk, child psychiatrists.
therapists, optometrists, nurse pmditioners, etc.)
Hospitals and other places where the child had beatmenk, tesk, surgery, or emergency room visik
Residential care facilities or rehabilitation centers
To add a medical care provider, choose Add DodorlHospitaVEtc. To edit, select the name below.

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Add DoctorlHospitaVEtc.
Other Name6 Used

Ust any other name@)the child may have used.
Examples:
Birth name and adopted names
Step-family or foster-family names
Nicknames
Other name variations

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To add a name, choose Add Other Name. To edit, select the name below.
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3820 Illness and Onset
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Alleged onset date from the mainframe b: 0312012006
A b d the CMld's Conditkn
You can help the child's case by providing as much detail as possible about his or her condition. This is
important because children with the same condion may have different symptoms and complications.
' L i and describe all of the child's illnesses. injuries. or conditions.
Indude:
All physical or emotional c o n d i n s
All leamina disabilities or behaviwal ~mblems
Any menG retardation
Any major complications resulting from the child's condition
All conditions, whether or not the child has been receiving heatment
Examples of cond~t~ons
Multiple scleros~s

Do any of the above ever cause the child pain or other symptoms?
Yes
No
Not yet answered

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3820 Medications
Does the child currently take any prescription or nonprescription medications for his or her
condition?
Yes
No
Not yet answered
List all piesc:iptio. , I

a
-",,.; -,,..,~l-prescriptiti"

;neaications that :he chi!& takes for his: or'hei' condition.

To add a medrcat~on,choose Add Medrcatbn To e d ~ select
t
the medlcahon l~stedbelow

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3820 Tests
Has the child had any medical tests, or are there any tests scheduled for the child's condltbn?
Yes
No
Not yet answered
List all medical tests that the child has had (in at least the last 12 months) or will have
To add a test, choose Add Test. To edit, select the name of the test below.

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3820 Vocational Rehabilitation
Alleged onset date: 0312012006
Has the child received Vocational Rehabilitation or other employment support services, to help him or
her go to work?
Examples:
Job Interviewing workshops
Job coaching
Job Placement
Tuition Assistance
Aptitude testing
Yes

No

Not yet answered

Lit all vocational rehabi'tation programs attended by the child.
To add a vocational rehabilktiin program, choose Add Voc. Rehab. Program. To edit, select the program
below.

Add Voc. Rehab. Program
If the child has not received any of these services, and is over the age of 45, would the child iike to
receive Vocational Rehabilitation sewices that could help the child go to work?
Yes
No
Not yet answered

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3820 Work Activity
Has the child ever worked, including sheltered work?
Yes
No
Not yet answered
List the jobs that the child had:
To add a job, choose Add Job. To edit, select the employer's name for the desired job.

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3820 Remarks
Use thib section for any additional information about the child.

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Flags

To add a flag, choose Add Flag. To edit select the flag listed below.

Add Flag

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Messages
To add a message, choose Add Message. To edit, select the message listed below.

Add Message