Form Soc 837 - Supplement To The Rate Questionnaire Page 2
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3CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
IMPAIRMENTS IN PHYSICAL COORDINATION AND MOBILITY - CONTINUED
4. The child/youth: a) requires use of orthotic or prosthetic devices, or other adaptive equipment, and has limited ability to
walk and move independently; b) is mobile only with the aid of special equipment; c) depends upon the use of walkers
or wheelchairs; d) requires assistance in transferring to the car, toilet, bath, or bed; or e) has limited use of upper
extremities (such as arms, hands, and digits). ( Check YES if the child/youth has any one of the above) .
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YES
NO
DO NOT KNOW
COMMENTS:
MEDICAL CONDITIONS
5. The child/youth has an illness or condition that requires the provision of daily care (e.g.: uncontrolled seizures, apnea
episodes several times per day, ventilator, trachea, suctioning required by the caregiver, in-home nursing care,
continuous oxygen, feeding tube, dialysis treatment, intravenous medication or therapy, and/or total parenteral nutrition) .
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YES (If YES, skip 6, 7, and 8)
NO
DO NOT KNOW
COMMENTS:
6. The child/youth has severe or total impairment in two of the following areas: vision, hearing, or speech.
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YES (If YES, skip 7 and 8)
NO
DO NOT KNOW
COMMENTS:
7. The child/youth has a chronic illness or medical condition(s) that requires frequent caregiver involvement in care and
monitoring such as: weekly care on a reoccurring basis, special diet, multiple medications/management, increased
medical appointments, monitoring on a daily basis, apnea monitor used as a precautionary measure, frequent turning,
weekly in-home nursing care, intermittent use of oxygen or use of other respiratory assistance device.
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YES
NO
DO NOT KNOW
COMMENTS:
8. The child/youth has severe or total impairment in one of the following areas: vision, hearing, or speech.
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YES
NO
DO NOT KNOW
COMMENTS:
PAGE 2 OF 3
SOC 837 (11/08)
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