Form Fc 1633a - Ssi Screening Guide Section A - Disability Screening
Download a blank fillable Form Fc 1633a - Ssi Screening Guide Section A - Disability Screening 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 Fc 1633a - Ssi Screening Guide Section A - Disability Screening 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
1STATE OF CALIFORNIA - HEALTH AND HUMANS SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SSI SCREENING GUIDE
SECTION A - DISABILITY SCREENING
CHILD’S NAME:
CHILD’S DOB:
CHILD’S SS#:
CHILD’S CASE #:
DATE COMPLETED:
NEXT SCREENING DUE (MUST BE DONE AT LEAST ANNUALLY):
Info. Not
DISABILITY SCREENING QUESTIONS
YES
NO
Available
1.
Have the parents/caregivers indicated that the child is receiving SSI?**
**
If "Yes," STOP, inform eligibility worker (or appropriate county staff person) to evaluate and send, if
appropriate, change of payee information to SSA.
2.
Does the child have a serious physical or mental impairment which limits his/her daily activities?
[Check yes if the child has difficulty, as compared to other children of the same age who do not have
impairments, doing any of the following: (1) attending to and completing tasks; (2) interacting and
relating to others; (3) moving about and manipulating objects; (4) caring for himself/herself.]
3.
Has the child been hospitalized or required medical treatment for a medical disability or psychiatric
condition that has lasted or can be expected to last 12 months or result in death?
4.
During the past year, has child required medication on a daily basis?
5.
Has the child had school absenteeism due to health or behavioral problems?
6.
Has the child been tested for OR does the child attend special education classes?
(Does the child have an Independent Education Plan (IEP), a pending IEP, or does the child
qualify for services under Section 504 (504 Plan or accommodations) or is the child being
assessed for these services?
Has the child been designated Seriously Emotionally Disabled (SED)?
Does the child have an Individualized Family Support Plan (IFSP) with Regional Center?
7.
Does the child require adaptations in order to function including assistive devices or appliances such
as eyeglasses, hearing aids, orthopedic devices, or devices for self-care activities such as bathing,
feeding, toileting, and dressing?
8.
Are the child's standardized test scores lower than average?
9.
Does the child receive special services such as counseling or speech therapy?
Info. Not
YES
NO
FAST-TRACK SCREENING QUESTIONS
Available
10. Is the child 16.5 years old or older?
11. Is the child likely to exit Foster Care, through adoption, guardianship, emancipation, or reunification,
in less than one year?
12. Does the child have a presumptive disability:
amputation, deafness, blindness, wheelchair or
bed-bound, cerebral palsy, Down syndrome or obvious mental retardation, prematurity with birth weight
of 1,200 grams or less, or HIV/AIDS?
13. Is the child a minor parent?
14. Is the child eligible for or does the child receive a Specialized Care Increment (SCI) or Regional Center
Rate?
INSTRUCTIONS: Any affirmative response in questions 1 through 9, warrants referral of the child for an SSI assessment. Any
affirmative response in questions 10 through 14 requires that the child be placed in the "Fast Track" assessment process.
Referred to SSI Assessment?
YES
NO
Fast Track?
YES
NO
SIGNATURE OF EMPLOYEE COMPLETING SECTION A
DATE
PRINTED NAME/ID #/CLASSIFICATION OF EMPLOYEE COMPLETING SECTION A
FC 1633A (2/07)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dhmh 4241 (ssi/ltc) - Notice To Review Medical Assistance Eligibility For Ssi Long Term Care
Legal
Form Dhcs 7089 - California Screening Worksheet Disabled Widow-er Checklist Ages 50 To 64 - Health And Human Services Agency
Legal
Form Hsmv 83007 - Application For A Disabled, Disabled Veteran Or Motorcycle International Wheelchair Symbol License Plate
Legal
Form Mvu-33 - Affidavit In Support Of A Claim For Exemption From Sales Or Use Tax For A Motor Vehicle Transferred To A Disabled Person - Massachusetts Department Of Revenue
Financial
Related Categories
Parent category: Legal