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Child Disability Starter Kit

Child Disability Starter Kit

Checklist - Child Disability Interview

You should have as much of the following information as possible before your interview. This is in addition to the items requested in the enclosed appointment letter. Be ready to give us your observations about the child’s daily activities.

Keep your appointment, even if you do not have all of this information. We will help you get any missing information.

Medical Information
	Name, address, and phone number of every doctor, therapist, hospital and clinic that has seen or treated the child for at least the last year.
	Any medical records you already have, including the dates the child was seen or treated and the child’s patient ID number(s), if known.
	Medication(s) the child is taking. These can be found on the medicine containers.
	Child’s medical assistance number, if any.

Other Information

	Names, addresses and phone numbers of any schools the child attended in the past 12 months, including the names of teachers, psychologists, counselors, speech and other therapists who have seen or treated the child.
	The child's Individualized Family Service Plan (IFSP) for early intervention services or Individualized Education Program (IEP) for special education services, if the child has one; and any other school records that you may have.
	Names, addresses and phone numbers of any social service programs and the name of caseworkers that have information about the child.
	Name, address and phone number of another adult who helps care for the child and can help us get information, if necessary.
	Names, addresses and phone numbers of any employers the child has had.
	An original or certified copy of the child’s birth certificate. If the child was born in another country, we also need proof of U.S. citizenship or legal residency.
	Names and Social Security Numbers for all the children and adults who live in the household.
	Proof of current income for the child and family members living in the household (for example, pay stubs, self-employment tax returns, unemployment or other program benefits, child support).
	Proof of resources for the child and parents living in the household (for example, bank account statements, life insurance policies, certificates of deposit, stocks or bonds).

The enclosed Medical and School Worksheet will help you collect
the information you need for your interview.