Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
4. MOBILITY - A person’s physical ability to move their body from place to place, control and coordinate gross motor
movement.
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
5. SELF DIRECTION - A person’s ability to establish and maintain interpersonal and social relationships, manage
emotional responses, display socially appropriate behavior, focus and attend appropriately, use judgment, make
decisions, solve problems, plan and execute tasks, and direct behavior toward goals.
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
6. CAPACITY FOR INDEPENDENT LIVING – For age 16+, a
person’s ability to maintain a household and access
necessary community resources.
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
7. CAPACITY FOR ECONOMIC SELF-SUFFICIENCY –
For age 16+
and not enrolled in educational
programs, a person’s ability to financially meet their needs such as food, clothing, housing, utilities, and
transportation.
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
Document Name_______________________________________Date______________Pg#_______
INFORMATION RELEASE AND ASSURANCES
A separate Authorization for Release of Information must be completed for each agency
or individual with whom you wish Senior and Disabilities Services to share information about yourself.
I certify that the information contained herein is correct and accurate to the best of my knowledge.
Applicant/Guardian Signature: _______________________________________Date: ______________________
The Developmental Disability Determination decision will be conveyed
in writing to the applicant or the applicant’s legal representative.
IDD-01 DDD Application Rev. 12-18-15
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