Developmental Disability Determination Application - Alaska Department Of Health And Social Services Page 2
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4DOCUMENTATION OF FUNCTIONAL LIMITATIONS
Please include with your application current documentation of substantial functional limitation in at least three of the areas
listed below. To assist the determination process, please review your documentation to make sure it is relevant to the
determination of developmental disability.
“Substantial functional limitation” means consistently functioning at or near a level that is two standard deviations
delayed, or 25% delayed, or functioning at or below the 2nd percentile, compared to the typical functioning of same age
peers. Substantial functional limitation must be demonstrated globally in areas of major life activity, as defined in AS
47.80.900 (6) (D). Behavioral reluctance or refusal to perform tasks in an area is not considered a limitation of a person’s
ability in an area, but rather, a component in the area of self-direction.
All submitted documentation MUST be signed and dated by the professional who administered the assessment
or evaluation.
Applicants over the age of 22 must submit evidence that substantial limitations existed prior to age 22.
An application submitted without sufficient supporting documentation of disability will result in a denial of
Developmental Disability Determination based on insufficient information.
Examples of supporting documentation include, but are not limited to:
a. Developmental assessment by Early Intervention/Infant Learning Program,
b. School district special education evaluations and evaluation summaries, known in Alaska as
the Evaluation Summary & Eligibility Report (ESER),
c. School district Individual Education Plan (IEP),
d. Individual Family Service Plan (IFSP),
e. Neuropsychological assessment,
f. Psychological assessment,
g. Evaluations from specialists (e.g., occupational, physical, or speech therapy), and
h. Division of Vocational Rehabilitation (DVR) assessments and evaluations.
Documentation of the disability prior to age 22 includes, but is not limited to, school records, health records from village
clinics, Social Security records, and histories of an applicant’s disability as documented in current evaluations or records.
Please indicate below which attached document(s) and which page number(s) provide an assessment of substantial
functional limitation in that specific area.
1. SELF CARE - A person’s ability to perform such tasks as eating/drinking, toileting, dressing, and grooming.
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
2. EXPRESSIVE & RECEPTIVE LANGUAGE - A person’s ability to understand the communication of others and
to communicate with others through any combination of spoken words, signs, or images that may be printed or
electronic.
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
3. LEARNING - A person’s cognitive ability to acquire
knowledge or skills through experience, study, or by being
taught.
Document Name_______________________________________Date______________Pg#_______
IDD-01 DDD Application Rev. 12-18-15
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