Form Dd-525 - Application For Eligibility Determination Page 5
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5DD-525 (9-17) PAGE 5
NAME (Last, First, M.I.)
DATE OF BIRTH
DOCUMENTED DISABILITIES (To be completed by DDD representative, if eligible)
Autism
Cerebral Palsy
Cognitive / Intellectual Disability
Epilepsy
At Risk
LEVEL OF COGNITIVE / INTELLECTUAL DISABILITY (If applicable):
Mild
Moderate
Severe
Profound
Undetermined
FUNCTIONAL LIMITATIONS (For applicants 6 years of age and over):
Self-Care
Receptive and Expressive Language
Learning
Mobility
Capacity for Independent Living
Self-Direction
Economic Self-Sufficiency
Az EIP Eligibility (As determined by AzEIP - Early Intervention Program)
YES
NO
NOT APPLICABLE
DETERMINATION & APPROVAL
DETERMINED BY (Print name)
TITLE
SIGNATURE
DATE
ELIGIBLE
NOT ELIGIBLE
SC/Intake Supervisor
Eligibility Review Committee (attach ERC response)
District/OAR
APPROVED BY (Print name)
TITLE
SIGNATURE
DATE
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination
in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age,
disability, genetics and retaliation. To request this document in alternative format or for further information about this policy,
contact the Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free
language assistance for DES services is available upon request. Disponible en español en línea o en la oficina local.
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