Free Pre-School Children (Age 3 to Attainment of Age 6) - Wisconsin

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

STATE OF WISCONSIN

C. PRE-SCHOOL CHILDREN (AGE 3 TO ATTAINMENT OF AGE 6) Review each of the areas of functioning listed. Based on your assessment and pertinent records, determine whether or not child has substantial limitations of functioning in a given area. Check the box if child has substantial needs in that area. 1. Self care - Ability to help or ability to cooperate with others in taking care of personal needs, in adapting to environment, in learning new skills at a pace appropriate to age. Child is typically toilet trained, independent in eating, uses napkin, stays at table, washes and dries face, brushes teeth, may be able to get a drink or snack alone, dresses, undresses independently except for fasteners, bathes self except back, neck and ears. 2. Receptive and expressive language - Ability to communicate by telling, requesting, predicting, and relating information, by following and giving directions, by describing actions and functions, and by expressing needs, feelings, and preferences in an increasingly intelligible manner. Child is typically able to answer the telephone, contribute to adult conversation, state their feelings, start to identify colors, shapes, can talk about experiences, begins to read letters or simple words. 3. Learning - Ability to understand, to reason to solve problems, and to use acquired knowledge and concepts. When standardized tests are used as the measure of functional abilities, a valid score that is two standard deviations below the norm for the test (e.g., an overall score of 70 on the WISC-R) will be considered a severe limitation. 4. Mobility - Ability to move and use arms and legs in increasingly more intricate and coordinated activities. The child is able with or without adaptive equipment to move around the environment to meet self care needs and to get from one place to another. The child is able to play on swing or adaptive playground equipment, uses hands with increasing coordination, to manipulate objects for self care such as clothing off or on, hold spoon, cup, toothbrush, or during play is able to hold objects, crayon / pencil to draw. 5. Self-direction - Ability to respond to social environment through appropriate self-control and increasingly complex interpersonal behaviors, such as sharing, cooperating, helping, and relating to a group. Child competes in games, tag, hide and seek, able to understand taking turns, interacts with other children, cooperates with adult requests most of the time, responsible for some small chores, beginning imaginary play, make believe, comforts others, understands rules; i.e., socially acceptable public behavior, apologizes, understanding of cleaning up after self, child beginning to develop awareness of danger and understand safety issues.