Free Newborns and Young Infants (Birth to Age 1) - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20851A (Rev. 08/2008)

STATE OF WISCONSIN

A. NEWBORNS AND YOUNG INFANTS (BIRTH TO AGE 1) Review each of the areas of functioning listed. Based on your assessment and pertinent records, determine whether or not a child has substantial limitations of functioning in a given area. If a child has substantial needs in that area, check the box. 1. Self care - Ability to respond appropriately to visual, auditory, or tactile stimulation. For example, to respond to the bottle or breast, "rooting" for food, ability to suck bottle, hand or thumb, reach for bottle or food, feed self a cracker or bottle. 2. Receptive and expressive language - Ability to communicate with intention through visual, motor, and vocal exchanges. Looks in the direction of sound, looks at person attempting to gain attention, babbles, vocalizes, coos, chuckles, smiles, responds to their name, makes word sounds like "Ma Ma," "Da Da" or signs, understands words or signs, repeats sounds or signs, ceases to cry when spoken to, vocalizes or signs to gain attention. 3. Learning - Ability to begin to organize and regulate how individual feels and reacts to environment. Cries differently due to different discomforts, falls asleep at appropriate times, plays contentedly near adult activity, imitates gestures and sounds, learns simple games; e.g., Peek-a-Boo, Bye-Bye, Pat-a-Cake. 4. Mobility - Ability to explore environment by moving body and ability to manipulate environment by using hands. Examples: able to position self by rolling over, scooting, crawling, sits alone, beginning to stand or walk around furniture, holds and manipulates toy or object, picks up object, moves from hand to hand. 5. Self-direction - Ability to form and maintain relationships with primary caregivers. Reaches for familiar persons or things, pushes things away, turns away from people he / she does not want to see, distinguishes between persons, protests when left alone, able to quiet self or be content for a period of time.