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Click ‘Get Form’ to open it in the editor.
Begin with Section 1, where the Eligibility Worker fills in the child's Budget Unit ID, Application Date, and personal details such as Name, Address, Birthdate, and Casehead Name.
Proceed to Section 2 for MRT use only. Enter relevant dates and codes related to medical records and decisions.
In Section 3A, list all household members by entering their Last Name, First Name, relationship to the child, and contact numbers.
Continue with Section 3B by asking about the child's physical and mental condition. Fill in responses regarding height, weight, speech clarity, and any medical conditions.
For daily activities in Section 3C, describe the child's routine from waking up to bedtime and note any behavioral changes since their condition began.
In Section 3D on Education/Therapy, indicate if the child attends special education classes or receives therapy. Attach necessary documentation as required.
Complete Section 3E regarding age appropriateness by answering questions about developmental milestones and participation in activities.
Finally, review Section F for any additional observations or remarks from the worker before submitting your completed form.
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