Form Ar1000rc5 - Arkansas Certificate For Individuals With Developmental Disabilities - 2014 Page 2
Download a blank fillable Form Ar1000rc5 - Arkansas Certificate For Individuals With Developmental Disabilities - 2014 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ar1000rc5 - Arkansas Certificate For Individuals With Developmental Disabilities - 2014 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2INSTRUCTIONS FOR AR1000RC5
A developmental disability is a disability which:
(A) (i) Is attributable to intellectual disability, cerebral palsy, epilepsy, autism, Down syndrome, or spina bifida; or
(ii) Is attributable to any other condition found to be closely related to intellectual disability because it results in an
impairment of general intellectual functioning or adaptive behavior similar to that of persons with intellectual dis-
abilities or requires treatment and services similar to those required for such persons; or
(iii) Is attributable to dyslexia resulting from a disability described in (A)(i) of this section; and
(B) Originates before the person attains the age of twenty-two (22) years; and
(C) Has continued or can be expected to continue indefinitely; and
(D) Constitutes a substantial impairment to the person’s ability to function without appropriate support services including,
but not limited to, planned recreational activities, medical services such as physical therapy and speech therapy, and
possibilities for sheltered employment or job training.
DIAGNOSED DISABILITY:
1. Intellectual disability: Individuals are eligible for services if their I.Q. scores fall two or more standard deviations
below the mean of a standardized test or their condition is closely related to intellectual disability by virtue of their
adaptive behavior function and the nature of the treatment and services they require. You must enter the I.Q.
score or check the intellectual disability level in the space provided on the front of the form.
NOTE: The individual must have been eligible for admission into an intermediate care facility for individuals with
developmental disabilities (ICF/MR). To meet ICF/MR level of care, an individual must have had substantial func-
tional limitation in three or more of the following areas of major life activity:
A) Self Care: Ability to care for one’s own toileting, grooming, dressing, and eating needs.
B) Understanding and Use of Language: Ability to communicate needs and responses to others using a formal
speech system.
C) Learning: Ability to process information, retain it, and apply it to different situations as appropriate to the individual’s
age level.
D) Mobility: Ability to move self from place to place either by walking or propelling adaptive equipment.
E) Self-Direction: Ability to make appropriate decisions regarding time, travel, finances, and health.
F) Capacity for Independent Living: Ability to cook, shop, clean, and otherwise maintain self in an independent
living situation.
2. Cerebral Palsy: As established by the results of a medical examination by a licensed physician.
3. Epilepsy: As established by the results of a neurological examination by a licensed neurologist and/or licensed
physician.
4. Autism: As established by the results of a team evaluation by a licensed physician and a licensed psychologist or
psychological examiner.
5.
Down Syndrome: As established by the results of a medical examination by a licensed physician.
Spina Bifida: As established by the results of a medical examination by a licensed physician.
6.
Check the appropriate box of the developmental disability, and list the I.Q. score (if required) in the space
provided on the AR1000RC5.
NOTE: Any of these six conditions, independent of each other, is sufficient for determination of
eligibility. This means a person who has been diagnosed with an intellectual disability does not have to have autism,
epilepsy, cerebral palsy, Down syndrome or spina bifida. Conversely, a person who has autism, cerebral palsy, Down
syndrome, spina bifida, or epilepsy does not have to have intellectual disabilities to be eligible.
AR1000RC5 Instr. (R 10/4/12)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Individual Service Plan (isp) For Individuals With Developmental Disabilities Living In The Community Template
Business
Form Ar1000dc - Arkansas Individual Income Tax Certificate For Individuals With Disabilities - 2014
Financial
Form Ar1000dc - Arkansas Individual Income Tax Certificate For Individuals With Disabilities - 2012
Financial
Related Categories
Parent category: Financial