Dd Form 2948 - Special Compensation For Assistance With Activities Of Daily Living (Scaadl) Eligibility - 2011 Page 2

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8. SUPERVISION/PROTECTION (Use Scoring Guide on Page 1)
(3) DID CLINICIAN
OBSERVE?
(1) AREA
(2) SCORE
(4) REASONS FOR SCORE
YES
NO
a. REQUIRES SUPERVISION/
ASSISTANCE AS A RESULT OF
SEIZURES (blackouts or lapses in
mental awareness, etc.)
b. DIFFICULTY WITH PLANNING
AND ORGANIZING (able to adhere
to medication regimen, managing
financial and other household
affairs, etc.)
c. SAFETY RISKS (significant risk of
falling, wandering outside the
home, leaving cook top/oven on,
crossing streets, using electrical
appliances, etc.)
d. DIFFICULTY WITH SLEEP
REGULATION
e. REQUIRES ASSISTANCE/
SUPERVISION AS A RESULT OF
DELUSIONS/HALLUCINATIONS
f. DIFFICULTY WITH RECENT
MEMORY (forgets what day it is,
what happened yesterday, etc.)
g. SELF REGULATION (being able to
moderate moods, agitation/
aggression)
0
h. TOTAL SCORE
9. TOTAL SCORES
a. ADL
b. SUPERVISION/PROTECTION c. TOTAL
d. DEPENDENCE LEVEL
0
0
0
10. APPLICABLE ICD-09/10 CODES
b. DATE
11.a PERSON COMPLETING FORM (Name and Signature)
c. PRINTED NAME OF PHYSICIAN (Last, First, Middle Initial)
d. TITLE
e. TELEPHONE (Include area code)
f. EMAIL ADDRESS
12. SERVICE MEMBER ACKNOWLEDGEMENT
I acknowledge my PCM's assessment of my dependency level. I
do
do not plan to appeal this decision.
a. PERSON COMPLETING FORM (Name and Signature)
b. DATE
c. TELEPHONE (Include area code)
d. EMAIL ADDRESS
DD FORM 2948, SEP 2011
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