Free School-Age Children (Age 6 to Attainment of Age 12) - Wisconsin

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

STATE OF WISCONSIN

D. SCHOOL-AGE CHILDREN (AGE 6 TO ATTAINMENT OF AGE 12) 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 help self or ability to cooperate with others in taking care of personal needs and safety. Child is typically able to provide self care alone or with use of adaptive devices, is independent or needs minimal supervision in bathing, eating, toileting and dressing. 2. Receptive and expressive language - Ability to communicate pragmatically to meet personal needs and conversationally to exchange information or ideas in classroom, or with peers or family. Child is able to contribute to adult conversation, to state, sign, or use adaptive communication device to express feelings, ideas and experiences. 3. Learning - Ability to progress in learning the skills involved in reading, writing and mathematics and to learn new skills at a pace appropriate to age. 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 engage in the physical activities involved in play, physical education, and self care appropriate to age with or without the use of adaptive aids. Child is able to move around the environment, get from one place to another, is able to manipulate objects for self care such as dressing and undressing, holding spoon, cup and toothbrush, or manipulate toys. Child is able to transfer unassisted. 5. Self-direction - Ability to play alone, or with another child, or in a group; to develop friendships, and to relate to siblings and parents or caregivers. Ability to understand authority relationships and school rules. Ability to develop a sense of responsibility for self and respect for others. Ability to physically sustain these activities for a period of time and at a pace appropriate to age. Child has awareness of danger and understands safety issues.