Fillable Checklist - Child Checklist – Childhood Disability Interview

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Checklist - Child Checklist – Childhood Disability Interview

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U.S.A. forms for Social Security Administration

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Checklist – Childhood 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.
;
Check o the items below as you gather them for your interview.
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 certied copy of the child’s birth certicate. 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 benets, child support).
Proof of resources for the child and parents living in the household (for example, bank
account statements, life insurance policies, certicates of deposit, stocks or bonds).
The enclosed Medical and School Worksheet will help you collect the
information you need for your interview.
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Checklist - Child Checklist Childhood Disability Interview

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Completed 15 March 2020

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