Claiming Disability Living Allowance
for a child under 16
Where to send the completed form
Please send the completed DLA Child new claim requests form to:
Disability Benefit Centre 4
Post Handling Site B
Wolverhampton
WV99 1BY
All other Child forms and letters should be sent to the address above.
For further help you can phone the DLA Helpline on 0800 121 4600
or use a textphone and call on 0800 121 4523 if you have speech or hearing
difficulties.
Phone: 0800 121 4600
Help using this PDF claim form
You can save data typed into this PDF claim form if you use Adobe Reader XI.
This means that you do not have to fill the form in one session.
This form will only save if:
the form is saved onto your computer, and
• opened in Adobe Reader XI.
The form will not save in:
• older versions of Acrobat Reader
other pdf readers, for example Preview on a Mac or Foxit on a PC.
You can download Adobe Reader XI free of charge from the Adobe website
If you are having technical difficulties:
• downloading the form
navigating around the form, or
• printing the form
Please contact the DWP Online helpdesk.
Phone: 0800 169 0154
Email: dwponline.helpdesk@dwp.gsi.gov.uk
Opening hours
Monday to Friday: 8.00am - 6.00pm
Closed on weekends and all Public and Bank Holidays.
For help and advice on the information you need to put on the form or about
the benefit you want to claim, contact the office that deals with the benefit.
in the form, use this information booklet to help you understand and
answer the questions.
Disability Living Allowance
for a child under 16
Information booklet
This information booklet will help you fill in the form and will:
l explain the questions we ask
l tell you how to answer the questions
l give you examples of other things you can tell us, and
l tell you about Disability Living Allowance (DLA), other benefits and organisations who
can help you
This booklet gives general information and doesn’t cover everything.
DLA1A Child July 2018
Please use black ink to fill in the form. Do not worry if you are not sure how to spell something or you
make a mistake. If you want to correct a mistake, please cross it out with a pen – do not use
correction fluid.
i
When you see
What is Disability Living Allowance?
Disability Living Allowance (DLA) is a benefit to help with extra costs if a child under 16 has a
disability, illness or health condition severe enough they:
l need much more looking after than a child of the same age without a disability, or
l have walking difficulties, or both
You may not think of the child as being disabled, but if they need the type of help explained in
these notes, they may get DLA.
Who can claim DLA for a child?
You can claim DLA for a child as long as you look after them as if you are their parent. ‘Parent’
includes step-parents, guardians, grandparents, foster-parents, and even older brothers
or sisters.
DLA is tax-free. You can claim even if you work or if your family has savings or money coming in.
Can I get DLA for a child?
To get DLA a child must normally:
l live in and be present in Great Britain or, live in the European Economic Area or Switzerland and
the United Kingdom (UK) is responsible for paying them sickness benefits or
l be allowed to enter or stay in the UK and not be stopped from getting benefits or
l need extra looking after or have walking difficulties or
l need much more day-to-day help than children of the same age and
l have had these needs for at least 3 months and these needs are likely to last for at least
another 6 months unless you are claiming for them under the special rules
The special rules are explained in the claim form on page 2.
When can I claim DLA for a child?
You can claim straight away. We will deal with the claim as soon as possible.
How is DLA worked out?
There are two parts of DLA – mobility and care. A child can get money for one part or both. The
official word for these parts is ‘component’.
You may see the word ‘component’ in forms and letters. How much they get is based on how
much help they need, not their disability or health condition.
Mobility
There are two mobility rates.
Lower rate
For a child aged 5 or over who can walk but needs extra help from someone to guide or
supervise them to get around outdoors in places they don’t know well.
Higher rate
For a child aged 3 or over who, because of a physical disability:
l cannot walk at all or
l can walk, but their ability to walk outdoors without severe discomfort is so limited they can be
considered virtually unable to walk or
l can walk but the effort needed could seriously affect their health.
A child may also get the higher rate if they:
l have had both legs amputated above the ankle or through the ankle, or were born without
legs or feet or
l are certified as severely sight impaired or blind and meet other conditions relating to their
sight loss or
l are deaf and blind and they need someone with them when they are outdoors or
l are severely mentally impaired with severe behavioural problems and qualify for the highest
rate of the care part
By ‘extra’ we mean much more than a child of the same age without a disability.
2
Care
There are three care rates.
Lowest rate
If a child needs extra looking after for some of the day, which can be about an hour.
Middle rate
If a child:
l needs extra looking after several times at short intervals right through the day or
l needs extra looking after more than once a night or once for about 20 minutes or more or
l needs extra supervision right through the day or
l needs someone to be awake at night to watch over them several times or once for 20
minutes or more
Highest rate
If a child needs help during the day and night.
A child may also get the highest rate if a claim is made under the special rules. The special
rules are explained in the claim form on page 2.
By ‘extra’ we mean much more than a child of the same age without a disability.
How the Department for Work and Pensions collects and uses information
When we collect information about you and the child we may use it for any of our purposes.
These include dealing with:
l social security benefits and allowances
l child support
l employment and training
l financial planning for retirement
l occupational and personal pension schemes
We may get information about you and the child from others for any of our purposes if the law
allows us to do so. We may also share information with certain other organisations if the law
allows us to.
To find out more about how we use information, visit our website at www.gov.uk or contact
any of our offices.
Where to get help and advice about DLA and other benefits
You can:
l phone the DLA Helpline on 0800 121 4600
l use a textphone and call 0800 121 4523 if you have speech or hearing difficulties
l contact your local Jobcentre Plus. The phone number and address are in the business
number section of The Phone Book
l contact an advice centre like Citizens Advice
l Visit www.gov.uk/browse/benefits
If the child is awarded DLA you may be entitled to:
l Carer’s Allowance or Carer’s Credit.
l Extra money if you or anyone in your household is on Income Support, Jobseeker’s
Allowance, Pension Credit, Child Tax Credit or Working Tax Credit. You should contact
the office who pays the benefit to claim the extra money.
3
Information about Carer’s Allowance and Carer’s Credit
Carer’s Allowance
A person could get Carer's Allowance (CA) if they:
l are aged 16 or over, and
l spend at least 35 hours a week caring for a disabled child
The child must be awarded DLA at the middle or the highest rate of care before the CA claim
is made.
Other CA claim conditions apply.
CA should be claimed within 3 months of the DLA decision being made or the carer could
lose benefit.
Carer’s Allowance and other benefits
Some benefits, allowances or pensions can affect how much CA we pay.
However, extra money could be paid with:
l income-based Jobseeker’s Allowance
l income-related Employment and Support Allowance
l Universal Credit
l Income Support
l Pension Credit
l Housing Benefit
Carer’s Credit
This is a National Insurance credit for carers of working age who:
l can’t get CA, and
l look after one or more disabled children for 20 hours or more a week
If the child or children being cared for don’t receive DLA (at the middle or highest rate of care), the
carer must get a care certificate for each child they look after.
Other Carer’s Credit claim conditions apply.
If you get Child Benefit for a child under age 12, or CA, you will already be getting NI credits.
For more information about Carer’s Allowance or Carer’s Credit:
l phone us from 8.30am to 5pm Monday to Thursday, or 8.30am to 4.30pm on Friday on
0800 731 0297
l if you have speech or hearing difficulties, you can contact us using a textphone on
0800 731 0317
l visit our website at: www.gov.uk
l email: cau.customer-services@dwp.gsi.gov.uk
l write to: Carer’s Allowance Unit, Mail Handling Site A, Wolverhampton, WV98 2AB
Other organisations who can help
Contact a family
If you need confidential, independent advice about any aspect of caring for a disabled child you can:
l phone Contact a Family helpline on 0808 808 3555 Monday to Friday, 9.30am to 5pm
l visit the website at: www.cafamily.org.uk
Family fund
You may also be able to get help from the Family Fund. You can:
l visit the website at: www.familyfund.org.uk
l write to: Family Fund, 4 Alpha Court, Monks Cross Drive, York YO32 9WN
General tips for filling in the claim form
The claim form asks for a lot of information about the child and what help they need. It may help to
get together any supporting health information such as:
l medical reports
l care or treatment plans
l test results
l up to date prescriptions
4
We need you to send in photocopies of this supporting information with the claim form, if you
have it. It will help us make a decision on the amount of help the child needs.
Don’t delay sending in the claim form if you are waiting for supporting information. Tell us at
question 70 what you are waiting for and send us photocopies of the supporting information
when you get it.
We don’t need information like:
l appointment letters
l general information about the disability or health condition from the internet or a leaflet
l general information about medication prescribed for the child
Not all questions will apply to the child, please read the questions carefully along with the
information in this booklet.
You may find it hard to fill in the form in one go. It may help to do it in stages – take regular
breaks before completing the next part.
We understand it may be upsetting to describe in detail what help the child needs. We only ask
for all this information so that we can make sure we make the right decision.
If you can, it may be useful to photocopy the claim form once you’ve filled it in. If we award
DLA and there is a change in the amount of help the child needs or we need to review the DLA
award, it will be useful for you to know what you’ve said previously.
About the questions in the claim form
This is about aids and adaptations they use or have been assessed for.
Aids are things like:
l braces
l supports
l crutches
l buggies
l wheelchairs
l commodes
l reading and learning aids such as computer programmes
Adaptations are things like:
l ramps
l slopes
l rails
l alterations to the home, such as widened doorways
You should include any aid or adaptation they can use with or without help.
Here are a few examples of the help they may need to use an aid or adaptation. It’s not a
full list and doesn’t cover everything.
They may need help to:
l use an aid or adaptation safely
l get on and off a raised toilet seat
l put on and take off a back brace or incontinence pants
l maintain a hearing aid, keep it clean and ensure small parts like batteries are not put in their
mouth
l be reminded or encouraged to use the aids
l propel a wheelchair up a ramp or a slope
This question is about how far they can walk before they stop because of severe discomfort.
To estimate the distance they can walk it may help you to know:
l an average adult step is just under one metre (one yard)
l a double-decker bus is about 11 metres (12 yards) long
l 12 cars parked end-to-end with a small gap between them would be at least 50 metres (55
yards)
l two full-size football pitches are about 200 metres (218 yards) long
This question is about how they walk, please tick any boxes that describe these difficulties.
Here are a few examples of other things you may want to tell us. It’s not a full list and doesn’t
cover everything.
If you want to tell us why you’ve ticked the boxes, any other difficulties or anything else you
think we should know, use the box below.
5
23
27
29
They may:
l refuse to walk even if they can physically walk
l have a stiff leg causing uneven steps
l have an upper body stoop which causes a lack of balance
These are about needing someone to guide or supervise them most of the time when outdoors.
Guide means to physically lead or verbally direct them to safely find their way around.
Supervise means checking routes for dangers or obstacles, keeping an eye on how they are and
if they can carry on walking. It includes coaxing, encouraging, persuading or talking so they
carry on walking to avoid danger.
For example
If they walk safely next to a busy road without putting themselves or others in danger but can’t
cross a road safely, you would answer like this:
Can they:
walk safely next to a busy road?
cross a road safely?
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
Here are a few examples of other things you may want to tell us. It’s not a full list and
doesn’t cover everything.
They may:
l follow simple directions but wouldn’t ask for help if lost
l accept sweets or a ride in a car even if they didn’t know the person
l get upset by traffic noise or crowds, and panic
l suddenly run across the road if they see a friend on the other side
l only be able to cross roads using a pedestrian crossing
l become unsteady and may fall
6
to
32
34
P
P
Yes No
They can go to the local shop on their own. It’s next to a busy road, but they don’t have
to cross it. We took this route together many times before they could go on their own.
This is about help needed to get in, out, or settle in bed during the day. It can be
encouragement, prompting or physical help.
For example
If they need encouragement to get out of bed in the morning and again after an afternoon
nap, and it takes 4 minutes each time, you would answer like this:
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l need help to sit up and get out of bed due to stiffness
l not understand it is time to get up or go to bed
l need to be told to get up as they can’t read a clock or hear an alarm
l need to let their medicine take effect before getting out of bed
l be distressed because they are in pain, or need settling and comforting and the covers put in
place
This is about help needed to go to or use the toilet during the day. It can be encouragement,
prompting or physical help.
For example
If they need to be prompted to go to the toilet, to take their underwear down, to wipe
themselves and to wash and dry their hands, you would answer like this:
They need encouragement, prompting or physical help to:
go to the toilet
manage clothes
get on and off the toilet
wipe themselves
wash and dry their hands
7
They need encouragement, prompting How often How long
or physical help to: each day? each time?
get out of bed twice 4 minutes
37
They don’t want to get up in a morning because they’re depressed and would
just lie in bed all day. At least twice a week it takes up to an hour to persuade
them to get up. Their medicine makes them so drowsy they usually have a nap
in the afternoon. It’s not usually as bad to get them up again in the afternoon
as the morning.
38
P
P
P
P
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l have difficulty moving from a wheelchair to a toilet
l need to have cream applied after using the toilet
l be constipated or have diarrhoea and need encouragement or comforting
l refuse to use toilets other than the one at home
l not be able to manage zips and buttons
l not be able to reach or don’t know to wipe themselves after using the toilet
This is about help needed to move around indoors during the day. It can be encouragement,
prompting or physical help.
For example
If they need physical help to get up and down stairs, you would answer like this:
They need encouragement, prompting or physical help to:
go upstairs
go downstairs
8
They won’t go to the toilet unless told. I have to keep telling them or they will soil
themselves. They keep telling me they don’t need to go so it takes a long time. If
they soil themselves they won’t tell me and will smear their faeces. When they are
at the toilet, I have to be with them to tell them what to do.
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
39
P
P
They can go up and down one or two steps. If there are more than two steps they are
carried. They’ve fallen on the stairs at home as there are too many steps for them to
manage. Going up and down steps makes them very breathless and this makes them
likely to fall.
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l stiffen up if they sit for too long
l become dizzy if they get up from a chair or wheelchair too quickly
l need to be encouraged to get up and move around
l be able to sit down in a chair but can’t get out of it
l need the support of cushions or pillows to sit upright
l only be able to get out of a chair that has arms
This is about help needed to keep clean and check their appearance during the day. It can be
encouragement, prompting or physical help.
For example
If they need encouragement to have a wash and clean their teeth in a morning and before
bed, and have a wash when dirty, you would answer like this:
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l follow a set or lengthy routine
l get very tired bathing or have pain when getting in or out of the bath
l not be able to reach all parts of their body to wash or dry
l feel they often need to wash or bath
l need extra care due to allergies
l refuse to have baths
9
40
They need encouragement, prompting How often How long
or physical help to: each day? each time?
have a wash 2–6 3 minutes
clean their teeth 2 2 minutes
They don’t like having a wash or cleaning their teeth so I have to encourage them to
put toothpaste on the brush, use soap, turn taps off etc. They don’t know when they
are dirty and need to wash, and would stay dirty if left. I’ve tried different ways to
teach them when and why to do this but nothing works.
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
This is about help needed to dress or undress during the day. It can be encouragement,
prompting or physical help.
For example
If they need physical help to manage buttons, when putting a coat on and off to go to and from
school, and it takes about a minute each time, you would answer like this:
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l only wear certain colours
l need to follow a time-consuming, set routine
l be easily distracted and need to be repeatedly prompted to dress or undress
l have involuntary movements, making dressing difficult
l undress inappropriately
l have difficulty with some types of clothes
l only wear their favourite clothes
This is about help needed to eat and drink during the day. It can be encouragement, prompting
or physical help.
For example
If they use a spoon to eat but need help to cut up the food at each meal, and this takes about 2
minutes each time, you would answer like this:
10
They can put their clothes on and take them off but they can’t use their fingers well
enough to do buttons and zips so I need to help with any clothes that have them. This
includes putting their coat on when going to school or out to play. They are ok with
shoes without laces.
They need encouragement, prompting How often How long
or help to: each day? each time?
manage zips, buttons or other 4 1 minute(s)
fastenings
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
41
42
They need encouragement, prompting How often How long
or physical help to: each day? each time?
cut up food on their plate 3 2 minutes
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l continually have to be prompted or encouraged to eat
l have problems sucking, swallowing or chewing
l not be able to see what is on their plate
l not be able to understand when to eat
l eat inappropriate foods
l compulsively eat
l have special dietary needs
l have problems keeping food down and may be sick after eating
This is about help needed to take medicine or have therapy during the day. It can be
encouragement, prompting or physical help.
For example
If they need to be prompted to do their therapy twice a day and encouraged during, say, 30-minute
therapy sessions, you would answer like this:
11
Although they can use a spoon to eat it takes a long time and they make a mess. They
will only eat certain foods such as pasta and cheese and at times will refuse to eat
anything at all, even their favourite food.
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
43
They don’t like doing therapy as they feel different to their friends so they avoid doing it.
They need to do 30 minutes each day but if left they will do a couple of minutes and say
they’ve finished. I try to make it fun to keep them calm and to stop them becoming
distressed.
They need encouragement, prompting How often How long
or physical help to: each day? each time?
do their therapy 2 30 minutes
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
Here are a few examples of other things you may want to tell us. It’s not a full list and
doesn’t cover everything.
They may:
l avoid taking medicine due to side effects
l not be able to monitor their condition
l be able to take their medicine but need supervising
l refuse to take part in therapy
l not know how much and when to have medicine or therapy
This is about difficulty seeing.
For example
If they can see well enough to recognise someone’s face across a room but can’t recognise
someone across a street, you would answer like this:
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l become distressed or frustrated due to difficulty seeing
l have to sit very close to the TV to watch and follow a programme or DVD
l lack confidence and need to be encouraged
l have difficulty seeing outside at night
l have reduced field of vision
This is about difficulty hearing.
For example
If they can hear a loud voice in a quiet room but can’t hear a normal voice in a quiet room, you
would answer like this:
12
44
P
P
Yes NoThey can recognise:
someone’s face across a room
someone across a street
They can only recognise someone’s face across a room if it’s someone they know very
well like me or their dad, brother or sister. They would only recognise someone less
familiar if they knew they were there or if they spoke.
If you want to tell us why you have ticked the boxes, how their needs vary or
anything else you think we should know, use the box below.
They can recognise:
a normal voice in a quiet room
a loud voice in a quiet room
P
P
Yes No
45
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l hear voices but not clearly enough to know what is being said
l hear only muffled noises that make them disorientated
l not be able to hear things the first time they are said and need to have them repeated
l not be able to hear sounds at a particular pitch or tone
l not be able to follow a conversation using a phone
l need help to use and maintain hearing aids
l have a cochlear implant or other surgically implanted hearing aid
This is about difficulty speaking.
For example
If they speak clearly in sentences, you would answer like this:
13
They can hear someone speaking if they raise their voice and there is no other noise
around. If the TV was on or other people were talking, they wouldn’t be able to hear
what was being said to them – they would just hear noise. It’s easier to hear someone
if they can see their face. If watching TV or listening to music, they need the volume
turned up.
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
46
They can put a few words together to make sentences but nothing very long or
complicated. They can talk to other people as long as the conversation is kept
simple.
P
Yes No
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
They can:
speak clearly in sentences
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l get easily excited, start speaking very quickly becoming hard to understand
l be depressed and withdraw from conversation
l choose not to speak
l have a stammer, lisp or other speech difficulty
l become frustrated if they can’t be understood
l only speak with family or friends
This is about difficulty communicating.
For example
If they communicate using Makaton but only with people they know, you would answer
like this:
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l have difficulty reading, using British Sign Language or lip-reading due to sight problems
l take what is said literally and be confused by figures of speech
l have difficulty understanding facial expressions or body language
l only be able to understand if things are repeatedly expressed in different ways
l be able to draw simple pictures to communicate
l need an interpreter when communicating with a person who can’t sign
14
47
P
P
P
Yes No
To communicate they use:
Makaton
They can communicate:
with someone they know
With someone they don’t know
They use Makaton to communicate. This means they can only communicate with
other people who use Makaton. Even then, they will only communicate with someone
they know. If the support worker is off work and someone else covers, they won’t
communicate even if I’m there.
If you want to tell us why you have ticked the boxes, how their needs vary or
anything else you think we should know, use the box below.
This is about fits, blackouts, seizures or something similar.
For example
If they black out a couple of days a month and have no warning, you would answer like this:
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l be incontinent during a fit and need help to clean themselves
l lose consciousness
l regularly have cuts and bruises
l have needed emergency hospital treatment
15
48
They fall to the floor and lose consciousness, their muscles stiffen and then their
arms and legs jerk and they usually wet themselves. They come round slowly and
feel tired, confused and disorientated for a few hours after. A couple of times a year,
they have 4 or 5 days a month when this happens.
If you want to tell us why you have ticked the boxes, how their needs vary or
anything else you think we should know, use the box below.
P
Doctors don’t know the kind of fit they have or why.
They drop to the floor and lie still for 2 minutes.
They’re confused for a couple of hours after.
They:
have no warning
Yes No
Tell us:
the number of days affected each month 2 days
how many fits they have on these days 1
Tell us what type they have
and what happens
This is about needing someone to supervise them during the day.
For example
If they regularly become verbally aggressive and act impulsively, you would answer like this:
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l be easily distracted and have difficulty concentrating on things
l climb onto window sills to reach open windows
l get agitated and do things without thinking
This is about help needed with their development.
For example
If they will play on their own but not with others, you would anwer like this:
16
P
P
Yes No
Do they regularly:
become verbally or physically agressive or destructive?
act impulsively?
49
If they see someone looking at them, they will shout, swear and threaten them.
They’ve never acted on the threats they’ve made but they’re very intimidating and
because of their size (over 5 feet) they can frighten people who don’t know them.
This happens every time we go out.
If you want to tell us why you have ticked the boxes, how their needs vary or
anything else you think we should know, use the box below.
50
P
P
Yes No
They can recognise:
play with others
play on their own
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l have difficulty keeping friends due to the way they behave
l interact well with adults but have difficulty with children of their age
l be easily distracted and have difficulty concentrating on things
l be fidgety and talk excessively
l interrupt and not be able to wait their turn
l only be able to play with much younger children
This is about the help needed at school or nursery. It can be encouragement, prompting or
physical help.
For example
If they need help to communicate and need extra help with learning, you would answer
like this:
They sit and play on their own ignoring other children around them. They don’t
recognise any other children there. If another child wants to play with the toy they
have, they’ll hold on to it as if their life depended on it. They won’t share it or let the
other child have it. They don’t understand when another child wants to play with
them.
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
51
They spend 2 days a week in the school’s special unit where they get
one-to-one help. The school also provide exercises for them to do at home.
They can hear what is being said but don’t always understand it. They need to be
given time to process what is said and sometimes need things to be repeated or
explained in a simpler way before they understand.
P
Yes No
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
What extra help do they need with learning?
They need encouragement, prompting or physical help to:
communicate
17
18
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l come home for medicine or therapy or to have lunch
l take a packed lunch as they can eat it without help
l take a change of clothes to school as they often have accidents
l need extra support, but it is not available
l regularly get into trouble
l need someone to go to school to give them their medicine or therapy
This is about difficulty taking part in hobbies, interests, or social or religious activities.
At home this could be difficulty with:
l drawing and painting
l doing crafts
l reading
l playing computer games
l model making
l playing board games
When they go out, they may have difficulty during, for example:
l after-school activities or clubs
l youth club
l swimming
l bowling
l cinema
l computer club
l chess club
l dance classes
l drama club
l visits to the library
The hobbies, interests, social or religious activities can be what they do or would do if they had
the help they needed to do them.
For example
l something they do:
They go to a youth club once a week. At the club, they’re encouraged to join in the activities
with other children. The help is needed for 2 hours.
l something they would do:
They would go on nature trails and similar activities at weekends. They would need help to get
to and from the activity, push the wheelchair, get to and from the toilet and general moving
around. This would be for about 2 to 3 hours.
These are only examples of activities they may do or would do.
It’s not a full list and doesn’t cover everything.
52
19
This is about help needed at night. It can be encouragement, prompting or physical help. It can
also be watching over them for their or others’ safety.
For example
If someone needs to watch over them because they wake up and wander about, you would
answer like this:
53
When they wake up during the night, they usually get out of bed. Sometimes they
will play in their bedroom. A couple of nights a week they will wander about,
playing with things like the TV and other electrical equipment and don’t understand
the dangers. They’ve previously blocked the bathroom sink with toilet paper and
turned the taps on. They thought this was funny.
They need watching over as they: How often How long
each night? each time?
may wander about 1 10 minutes
If you want to tell us why you have ticked the boxes, how their needs vary or anything
else you think we should know, use the box below.
Here are a few examples of other things you may want to tell us.
It’s not a full list and doesn’t cover everything.
They may:
l turn on taps or electrical equipment when awake
l unlock doors to go outside
l disturb others when they are awake
l become breathless and cough more when lying down
l need propping up to sleep and checking they are still okay
l have night terrors
This is about how we pay you.
Please read these notes before you tell us any account details at question 69.
We normally pay DLA into an account
Many banks and building societies will let you collect the money at the post office.
We will tell you when we will make the first payment and how much it will be for. We will tell
you if the amount we pay into the account is going to change.
Finding out how much we have paid into the account.
You can check the payments on account statements. The statements may show your National
Insurance (NI) number next to any payments we have made. If you think a payment is wrong,
get in touch with the office that pays, straight away.
If we pay too much money
We’ve the right to take back any money we pay that the child shouldn’t get. This may be
because of the way the system works for payments into an account. For example, you may give
us some information, which means the child should get less money. Sometimes we may not be
able to change the amount we’ve already paid. This means we will have paid you money that
the child should not get.
We will contact you before we take back any money.
69
20
What to do now
Tell us about the account you want to use at question 69. By giving us the account details you:
l agree that we will pay DLA into an account, and
l understand what we have told you above in the section If we pay too much money
If you’re going to open an account, please tell us the account details as soon as you get them.
If you don’t have an account, please contact us and we will give you more information.
Fill in the rest of the form. You do not have to wait until you have opened an account, or
contacted us.
About the account you want to use:
l you can use an account in your name, or a joint account
l you can use a credit union account. You must tell us the credit union’s account details. Your
credit union will be able to help you with this
l if you’re an appointee or a legal representative acting on behalf of the customer, the account
should be in your name only
You can find the account details on the debit card, statement or chequebook. If you don’t
know the account details, ask the bank or building society.
Daily diary: a record of the child’s needs
We understand that, when caring for a disabled child, it can be difficult to remember what help
you give and how often you give it.
You may find keeping a diary or daily record helps you fill in the claim form.
If their needs are the same most of the time, you may want to keep a record for just one day.
If their needs vary, it may be helpful to keep a record on different days.
You must decide if you want to keep a diary.
This could include details about:
l the help you give the child
l the help they need
l how long it takes
l their behaviour
l how they felt
l if it was a good or bad day
The next page gives an example of how you can do this and the things you can write down.
You may want to write things down in a different way. Use the way that is easiest and most
helpful to you.
The diary is to help you fill in the claim form. You don’t have to send it to us.
Example
Date
Monday 3 December 2016
The morning
Include any help needed:
l waking up
l getting out of bed
l moving around
l going to the toilet
l washing
l dressing
l having breakfast
l taking medicine
l doing therapy
l school runs
Woken at 7:30
Helped out of bed – 5 minutes
Helped with toileting – 5 minutes
Helped wash, put on clothes, get downstairs. He took off
pyjamas – 20 minutes
Ate cereal without help
Gave medicine – 2 minutes
Helped to car – 5 minutes
Took to school. Helped out of car – 5 minutes. His helper met
us.
During the day
Include any help needed:
l
at nursery or school
l
moving around
l
going to the toilet
l
dressing
l
eating
l taking medicine
l doing therapy
l
after school clubs
Helper does everything at school – toilet, moving around during
lessons, encouraging him to join in.
Tried to walk between lessons but in too much pain.
I had to collect him from school early as he had wet himself and
was upset.
Didn’t go to Youth Club tonight, still upset.
Early evening
Include any help needed:
l
eating
l
washing
l
dressing
l
taking medicine
l
doing therapy
l
moving around
l
going to the toilet
l
hobbies and interests
l
getting into bed
l
settling in bed
I cut up his food. Fed himself using a spoon – did well (it was his
favourite).
Changed for bed (he tried to help) – 10 minutes
Gave medicine – 2 minutes
Play therapy – 1 hour
Helped to toilet 3 times – 5 minutes each time
Watched favourite DVD over and over. Hit younger sister (she
wanted to watch something else). Had to stop him.
8:30 bedtime, help with stairs, to get into bed and settle – 30
minutes.
During the night
Include any help needed when
everyone in the house is in bed
with:
l getting out of bed
l going to the toilet
l
taking medicine
l doing therapy
l turning in bed
l settling in bed
Woke at 2:10 – helped out of bed to toilet – 15 minutes
Had to stay until he settled – 15 minutes
Apart from being upset, today was a good day.
21
22
Include any help needed:
l at nursery or school
l moving around
l going to the toilet
l dressing
l eating
l taking medicine
l doing therapy
l after school clubs
Include any help needed:
l eating
l washing
l dressing
l taking medicine
l doing therapy
l moving around
l going to the toilet
l hobbies and interests
l getting into bed
l settling in bed
Include any help needed when
everyone in the house is in bed
with:
l getting out of bed
l going to the toilet
l taking medicine
l doing therapy
l turning in bed
l settling in bed
During the day
The morning
Date
Include any help needed:
l waking up
l getting out of bed
l moving around
l going to the toilet
l washing
l dressing
l having breakfast
l taking medicine
l doing therapy
l school runs
Early evening
During the night
About the child
Please use BLOCK CAPITALS when completing the child’s names.
All other names in full
Child reference number
(if you know it)
Surname or family name
1
Date of birth
(day/month/year)
DLA1A Child July 2018
If you want help filling in any part of this claim form, read the information booklet or call us on
0800 121 4600.
If you have speech or hearing difficulties, you can contact us by textphone on 0800 121 4523.
We can provide an interpreter if you phone or visit us.
This form is available in large print or braille. Please phone 0800 121 4600.
2
3
Male
Female
Sex
4
Please also give us any other names
the child has been known as
Full address where the child lives
Postcode
5
Disability Living Allowance
for a child under 16
2
Are you claiming for the child under the special rules?
The special rules apply to children who have a progressive disease and are not expected to live
longer than another 6 months.
Make sure you:
l answer all the questions on the form that apply to you or the child you’re claiming for
l answer questions 25 to 36 if the child has any walking difficulties
l you don’t have to answer questions 37 to 55
To help us deal with the claim as quickly as possible it’s important you send us a DS1500 report
about the child’s medical condition. You can get the report from the child’s doctor or specialist. You
won’t have to pay for it and the child doesn’t have to see the doctor. The doctor’s receptionist, a
nurse or a social worker can arrange it for you.
If you haven’t got a DS1500 report by the time you’ve filled in the claim form, send the claim form
anyway. If you wait the child’s payment could be delayed. Send the DS1500 report as soon as you
can or ask your doctor or specialist to send it to us for you.
Getting Disability Living Allowance (DLA) under the special rules means:
l the child gets the care part of DLA at the highest rate
l they get paid straight away unless they are in a residential care home, boarding school or similar
place
l we deal with the claim more quickly
You must still tell us about any changes that may affect how much money the child gets.
Please continue below.
Go to question 7.
Yes No
Special rules
6
Yes
No
Does the child normally live in Great Britain?
Great Britain is England, Scotland and Wales.
8
What is the child’s nationality?
For example, British, Spanish, Turkish
7
Has the child come from another country to live in Great Britain in the last 2 years?
Which country did they come from?
Go to question 9.
What date did they arrive in Great Britain?
Has the child been abroad for more than 4 weeks at a time in the last 3 years?
Abroad means out of Great Britain.
Go to question 10.
Please give us details
below.
9
Date they left Date they came
back
Where they went Why they went
Yes
Yes
No
No
3
Benefits from another European Economic Area state or Switzerland
10
Is the child’s parent or guardian getting any pensions or benefits from another European
Economic Area (EEA) state or Switzerland?
Go to question 11.We will contact you about this. NoYes
We will contact you about this.
Don’t know
Other benefits from another EEA state or Switzerland
11
Is the child’s parent or guardian working in or paying insurance to another EEA state or Switzerland?
By insurance we mean connected to work, like UK National Insurance.
Go to question 12.
We will contact you about this.
No
Yes
We will contact you about this.
Don’t know
Phone number
Include the dialling code.
Why did they go in?
Does or did the NHS f
und their stay?
In
Out
Out
Please tell us when they went in and when they came out.
Full name and address of the hospital
or hospice
Go to question 13.
Yes
No
Please continue below.
Is the child in an NHS hospital or hospice now? Or have they been admitted in the past 12 months?
12
In
Postcode
No
Yes
4
Is the child in a residential college or similar place now, or have they been in the past 12
months?
For example, a residential care home, boarding school or similar place.
If the child is in a residential college or similar place when you claim we will not usually pay DLA care
unless you are paying all the costs of their accommodation, board and personal care without help
from a local or public authority.
Please tell us when they went in and when they came out.
13
In
Out
In Out
Go to question 14.Yes
No
Please continue below.
We ask about people involved in the child’s care and may contact them before we make a decision.
They don’t decide if the child can get DLA.
Full name and address of where they
are or were staying
Phone number
Include the dialling code.
Does or did the local authority or a government department pay any costs for them to live there?
Which local authority or government department pays or paid?
Go to question 14.
Yes
No
Please continue below.
Postcode
In the last 12 months, has the child seen anyone apart from their GP about their illnesses or
disabilities?
For example, a hospital doctor, consultant, nurse, occupational therapist, physiotherapist, educational
psychologist, social worker or support worker.
If they see or have recently seen more than one health professional, it is important you tell us the
other health professionals’ details at question 70 Extra information. This will help us deal with the
claim more quickly.
14
Go to question 15.
Tell us below who they
have seen.
Full address
For example, health centre, hospital, office
or their place of work.
Profession or specialist area
Name
For example, Mr, Mrs, Miss, Ms, Dr.
Postcode
Yes
No
5
Full address
Name of the child’s GP
If you don’t know the GP’s name, tell us
the name of the surgery or health centre.
Phone number
Include the dialling code.
When did they last see the child about
their illness or disability?
Has the child had or are they waiting for tests to help diagnose, treat or monitor their illnesses or
disabilities?
For example, audiogram, MRI scan, cognitive development or IQ test, or something else.
Date and type of test
Example
June 2016 Eyesight test
What did the test show?
They needed to see a hospital doctor
15
16
Go to question 17.
Tell us about it in the table
below.
The child’s hospital record number
You can find this on their appointment
card or letter.
Phone number
Include the dialling code.
Which illness or disability do they see
the child about?
When did they last see the child about
their illness or disability?
Postcode
Yes
No
6
Does the child have or are they waiting to hear about an Educational Health and Care Plan (EHCP),
Individual Education Plan (IEP), Individual Behaviour Plan (IBP) or statement of Special Educational
Needs (statement)? In Scotland the statement is called a Co-ordinated Support Plan (CSP).
If the child needs help under School Action or School Action Plus, a teacher prepares the IEP or IBP which
sets out the help they need. If more help is needed, the local authority may complete an assessment and
issue a letter, a Note in Lieu, or a statement.
They have an ECHP, IEP or IBP.
They have a statement, Note in Lieu, letter or CSP.
I am waiting to hear.
Name of the child’s school or
nursery
Full address
Phone number
Include the dialling code.
Person we can contact
F
or example, a teacher.
Send us a copy, if you can, as it may help us deal with your claim. Please do not send original copies as
they cannot be returned.
18
19
Go to question 20.
Yes
No
Please tick the boxes
that apply.
Do you have any reports, letters or assessments about the child’s illnesses or disabilities?
These may be from the people who treat or help them with their illnesses or disabilities. For example, doctors,
health visitors or occupational therapists.
Tell us what reports you have. For example, educational psychologist’s report or Certificate of Vision
Impairment (CVI). Please don’t include things like appointment letters or general information about the child’s
condition like fact sheets or information from the Internet.
17
Go to question 18.
Yes
NoPlease continue below.
Please send us this supporting information with this form, but make sure it’s:
l the most up-to-date information you have
l photocopies only, we can’t return any documents
l not on CD, DVD, memory stick or any type of electronic media as we can’t access these
What sort of school is it?
For example, a mainstream school or a
special school that helps with the child’s
illness or disability.
Postcode
7
Statement from someone who knows the child
This part does not have to be filled in but if it is filled in, this may help us deal with your claim more
quickly. It could be filled in by someone who treats or is involved in the child’s care. For example, a
health professional, a social worker or a teacher.
Statement to be filled in by the person who knows the child.
Use the space below to tell us:
l the child’s illnesses or disabilities and how they affect the child, and
l how you help the child
Signature Date
Name (please use block capitals)
Full address
Phone number
Include the dialling code.
Job or profession
When did you last see the child?
20
Relationship to child,
if applicable.
Postcode
Please remember to sign and date the form after printing.
8
Consent
To make sure we have all the information to support the child’s claim:
l we may contact the child’s GP or the people or organisations involved with the child. This may
include medical information
l you don’t have to agree to us contacting these people or organisations however, if you don’t agree,
this may mean we can’t decide if the child can get DLA
l please remember to send us photocopies of the supporting information you already have
l we or any health professional working for an organisation approved by the Secretary of State, may
ask any person or organisation to give them or us any information, including medical information,
which we need to deal with:
- this claim for benefit, or
- any appeal or other request to reconsider a decision about this claim
It’s important you tick one of the consent options, then sign and date below.
I agree to you contacting the people or organisations described in the
statement above.
Signature
21
Yes
No
Date
Please make sure you also sign and date the declaration at question 71.
The Motability Scheme
The Motability Scheme allows disabled people to lease a car, scooter or powered wheelchair in
exchange for all or some of their mobility payments. Parents and carers can join the scheme on
behalf of a child aged three and above.
If the child is eligible for help from Motability, would you like us to post you information about the
help they can offer? We won’t share any personal details with Motability.
Yes
No
If you decide you don’t want to receive information about Motability in the future, please contact
us on 0800 121 4600 to let us know.
Please remember to sign and date the
form after printing.
9
The questions we ask and why we ask them
DLA is a benefit to help with extra costs because:
l the child has difficulties walking, or
l the child needs extra looking after, because of their illness or disability
By ‘extra looking after’ we mean much more than another child of the same age.
We ask about the child’s illnesses or disabilities, the treatment they have, the difficulties they have
walking outdoors and the extra looking after they need.
We ask for a lot of information about the child, it may be easier to fill in the information in parts over
a few days. Try not to worry about how long the form is, complete as much information about the
child for each question that applies – take a break when you need to.
We understand it may be upsetting for you to think about what the child can’t do, but we need this
information to make the right decision.
Tell us about the help they need most of the time. You can use the box at the end of each question
to tell us:
l about your tick-box answers
l how their needs vary
l anything else you think we should know about the help they need
When you see
If you need help to fill in the rest of the form
In the information booklet we:
l explain the questions we ask
l tell you how to answer the questions
l give you examples of other things you can tell us
you can use the information booklet to help you
understand and answer the questions.
i
10
If you need more space to tell us about their illnesses or disabilities, please continue at question 70
Extra information.
Illness or
disability
Examples
ADHD
Eczema
Visually
impaired
How long have
they had it?
Problems
started
aged 4
About one
year
From birth
What treatment do
they have for it?
Cognitive behaviour therapy
Ritalin 30 milligrams (mg)
Promethazine 5 mg
1% Hydrocortisone cream
E45 Emollient bath oil
Play therapy
How often do they
have treatment?
One hourly session a week
One a day
One before bed
3 times a day
Daily
Every day
About the child’s illnesses or disabilities
List the child’s illnesses or disabilities in the table below.
l illness or disability may be a physical, sight, hearing, speech, learning or developmental difficulty,
or a mental-health problem. If they don’t have a diagnosis, tell us their difficulty. For example, if
they have problems learning new things and you don’t know why, put ‘Learning problem’
l how long may be from birth or the date the problem started. It is not the date of diagnosis
l treatment may be medicines such as tablets, creams or injections and things like speech,
occupational or play therapy, physiotherapy or counselling
l how often they have each treatment and for how long. The label on the child’s medicine has the
name, dose and how often to take it
If you have a spare up-to-date prescription list send it to us with this claim form.
22
11
Aids and adaptations
Example of aid
Picture Exchange Cards
Example of adaptation
Bed rails
What help do they need to use the aid or
adaptation?
Encouragement to use cards to
communicate
No help needed
Tell us in the table below about any:
l aids used at home, at school or anywhere else
l aids or adaptations they have been assessed for or are waiting for
l help they need to use it. This could be encouragement, prompting or physical help
Put a tick next to the aid or adaptation if it was prescribed by a health care professional. For example, an
occupational therapist.
If you need more space to tell us about their aids or adaptation, please continue at question 70 Extra
information.
P
P
Use page 5 of the information booklet.
Does the child use, or have they been assessed for, any aids or adaptations?
23
Go to question 24.Please continue below.
i
Yes
No
12
When the child needs help
We understand the help a child needs can vary from day to day or week to week.
To make the right decision, we need to know if the help the child needs is the same most of the time
or varies.
Tick the box below that applies to them.
The help they need:
l is the same most of the time
l varies
Tell us in the box below how their needs vary.
For example:
l every 3 to 4 weeks they have a couple of good days
l they need more looking after when their condition gets worse, 2 to 3 times a year, or
l they have treatment 3 times a week and need more looking after the day after
Mobility questions
Mobility – these questions are about the difficulty that the child has walking outdoors because of their
illnesses or disabilities.
Questions 25 to 31 are about the physical difficulties a child has walking. This is for children age 3 and
over.
Questions 32 to 34 are about the guidance and supervision they need when walking outdoors most of
the time. This is for children age 5 and over.
The following questions ask about ‘they’. This means the child you are claiming DLA for.
24
These are about their ability to physically walk outdoors on a reasonably flat surface. We can’t
consider any problems they have walking on steps, slopes or uneven ground. If their problems are not
physical, do not answer questions 25 to 31. Tell us about any behavioural difficulties with walking at
questions 32 to 34.
Mobility
Go to question 26.
Go to question 36 to tell us how long they
have been unable to walk.
Yes
No
Can they physically walk?
Tick No if they cannot walk at all.
25
Go to question 27.
Yes
Do they have physical difficulties walking?
This means problems with how far they can walk, how long it takes, their walking speed, the way they walk,
or the effort of walking and how this may affect their health.
26
Go to question 32.
No
13
Please tick the boxes that best describe how far they can walk without severe discomfort and how long
it takes them.
This means the total distance they can walk before they stop and can’t go on because of severe discomfort.
This may include short stops to catch their breath or ease pain.
We understand this can be difficult to work out.
It may help to do the following things when you are out walking with the child:
l count the steps you take to see how far they have walked. If they walk 100 of your steps, they have
walked about 90 metres (100 yards)
l check the time when you start and stop to see how long it takes
They can walk:
l over 200 metres (218 yards)
l 51 to 200 metres (56 to 218 yards)
l 50 metres (55 yards) or less
l a few steps
It takes them:
l more than 5 minutes
l 3 to 4 minutes
l 1 to 2 minutes
l less than a minute
Use page 5 of the information booklet.
27
i
Normal
This means they can easily keep up with friends.
Slow
This means they can only keep up with friends with a lot of effort.
Very Slow
This means they can’t keep up with friends.
Please tick the box that best describes their walking speed.
28
14
Please tick the box that best describes the way they walk.
They:
l walk normally
l walk with a limp
l shuffle
l drag their leg
l walk with one or both feet turned inwards
l walk on their toes
l have poor balance
29
If they have other difficulties with the way they walk, tell us below what they are.
Does the effort of walking seriously affect their health?
For example, walking can cause bleeding into the knee and ankle joints.
If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think
we should know, use the box below.
For example, they have more pain or tiredness if they walk too far the day before.
30
31
Tell us below how their
health is affected.
Yes Go to question 31.
No
15
Do they need guidance or supervision most of the time when they walk outdoors?
Can they:
l find their way around places they know?
l ask for and follow directions?
l walk safely next to a busy road?
l cross a road safely?
l understand common dangers outdoors?
Do they regularly:
l become anxious, confused or disorientated?
l display unpredictable behaviour?
l need physical restraint?
Yes No
Use page 6 of the information booklet.
Do they fall due to their disability?
They:
l can get up without help
l have had injuries needing hospital treatment
Yes
No
Tell us the number of falls each month
32
33
i
Tick the boxes that apply.
Yes Go to question 33.
No
Please continue below.
Yes Go to question 34.
No
34
If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think
we should know, use the box below.
For example, they are frightened by loud noises and behave without thinking about danger.
Yes No
16
Extra information about mobility
If you want to tell us anything else about their mobility, use the box below.
When did the child’s mobility needs you have told us about start?
Normally, the child can only get the mobility part of DLA if they have needed help for more than 3 months.
Please tell us the date the mobility needs you have told us about started.
If you can’t remember the exact date, tell us roughly when this was.
35
36
If you are claiming under the special rules, go straight to question 56.
17
Care questions
Care – these questions are about the extra looking after that the child needs because of their illnesses or
disabilities. These questions are for children of all ages.
Questions 37 to 52 are about the help they need during the day.
For example, if a child gets up at 7am and goes to bed at 8pm and the parents get up at 7am and go to
bed at 11pm, day time would be 7am to 11pm. Any help needed after 11pm would count as help during
the night.
The following questions ask about ‘they’. This means the child you are claiming DLA for.
If you want to tell us why they need help, how their needs vary or anything else you think we should
know, use the box below.
For example, they may need to follow a set routine to go to or get out of bed.
minutes
minutes
minutes
minutes
Tell us how often they need help each day and how long it takes each time.
They need encouragement, prompting How often How long
or physical help to: each day? each time?
l wake up
l get out of bed
l get into bed
l settle in bed
Care
Do they need encouragement, prompting, or physical help to get into or out of or settle in bed during
the day?
This means waking up, lifting their legs into or out of bed, sitting up from lying down or settling in bed ready
to go to sleep.
Use page 7 of the information booklet.
37
i
Please continue below.
Yes Go to question 38.
No
18
Do they need encouragement, prompting, or physical help to go to or use the toilet during
the day?
This means going to the toilet, managing their clothes, getting on and off the toilet, using the
toilet, cleaning themselves and coping with continence care.
They need encouragement, prompting or physical help to:
l go to the toilet
l manage clothes
l get on and off the toilet
l wipe themselves
l wash and dry their hands
l manage a catheter, ostomy or stoma
l manage nappies or pads
If you want to tell us why you have ticked the boxes, how their needs vary or anything else you
think we should know, use the box below.
For example, they have pain and become distressed.
Use page 7 of the information booklet.
38
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Tick the boxes that apply.
Yes Go to question 39.
No
19
Do they need encouragement, prompting, or physical help to move around indoors, use stairs
or get into or out of a chair during the day?
A chair is any type of chair including a wheelchair.
This means moving from one place to another, using stairs, getting into, sitting in, and getting
out of a chair. Indoors is in their home, a friend’s home, school, college, or anywhere else inside.
They need encouragement, prompting or physical help to:
l go up and down one step
l go upstairs
l go downstairs
l move around safely
l get into or out of a chair
l sit in a chair
If you want to tell us why you have ticked the boxes, how their needs vary or anything else
you think we should know, use the box below.
For example, they bump into furniture and doors.
39
Tick the boxes that apply.
Yes Go to question 40.
No
Use page 8 of the information booklet.
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Do they need encouragement, prompting, or physical help to wash, bath, shower and check
their appearance during the day.
This means getting in and out of a bath or shower, washing their hair, drying themselves, using
soap, using a toothbrush and checking their appearance.
Tell us how often they need help each day and how long it takes each time.
If you want to tell us why they need help, how their needs vary or anything else you think we
should know, use the box below.
For example, when they are in the bath they need telling repeatedly what to do and how to do it.
40
Please continue below.
Yes Go to question 41.
No
minutes
minutes
minutes
minutes
They need encouragement, prompting How often How long
or physical help to: each day? each time?
l have a wash
l clean their teeth
l wash their hair
l get in or out of the bath
l get in or out of the shower
l clean themselves in the bath or shower
l dry themselves after a bath or shower
l check their appearance
minutes
minutes
minutes
minutes
Use page 9 of the information booklet.
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Do they need encouragement, prompting, or physical help to dress and undress during the day?
This means choosing the right clothes for the weather or activity, choosing clean clothes, putting
clothes on in the correct order, moving their arms or legs to put clothes on or take them off. This is any
dressing or undressing except when using the toilet.
Tell us how often they need help each day and how long it takes each time.
If you want to tell us why they need help, how their needs vary or anything else you think we should
know, use the box below.
For example, they follow a set routine that takes a long time.
41
Please continue below.
Yes Go to question 42.
No
minutes
minutes
minutes
minutes
They need encouragement, prompting How often How long
or physical help to: each day? each time?
l dress
l undress
l manage zips, buttons or other fastenings
l choose appropriate clothes
Do they need encouragement, prompting, or physical help to eat and drink during the day?
This means getting food into their mouth, chewing, swallowing, using cutlery, cutting up food, holding a
cup, getting it to their mouth and drinking.
42
Please continue below.
Yes Go to question 43.
No
i
Use page 10 of the information booklet.
i
Use page 10 of the information booklet.
22
Tell us how often they need help each day and how long it takes each time.
If you want to tell us why they need help, how their needs vary or anything else you think we
should know, use the box below.
For example, they can’t see what food is on the plate.
minutes
minutes
minutes
minutes
They need encouragement, prompting How often How long
or physical help to: each day? each time?
l eat
l use a spoon
l cut up food on their plate
l drink using a cup
l be tube or pump fed
minutes
Do they need encouragement, prompting, or physical help to take medicine or have therapy during
the day?
Taking medicine includes tablets, injections, eye drops, knowing what to take, how much to take and
when to take it.
Having therapy includes blood sugar testing, peak flow checks, physio, oxygen, speech, play and
behaviour therapy, knowing what to do, how much to do and when to do it.
Tell us how often they need help each day and how long it takes each time.
43
Please continue below.
Yes Go to question 44.
No
minutes
minutes
minutes
minutes
They need encouragement, prompting How often How long
or physical help to: each day? each time?
l take the correct medicine
l know when to take their medicine
l do their therapy
l know when to do their therapy
Use page 11 of the information booklet.
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If you want to tell us why they need help, how their needs vary or anything else you think we should
know, use the box below.
For example, they become angry with their condition and refuse to take their medicine.
Do they have difficulty seeing?
This means when using their aids like glasses or contact lenses.
Are they certified sight impaired or severely sight impaired?
If they are certified they will have been examined at a hospital or eye clinic.
A Certificate of Vision Impairment (CVI) will have been sent to the local social services department. You
will have been given a copy.
If they are certified, please send us a copy of the CVI. Please do not send original copies as they cannot
be returned.
44
Please continue below.
Yes Go to question 45.
No
Certified severely sight impaired
Certified sight impaired
Go to question 45.
Tick the boxes that apply.
They can see:
l computer keyboard keys or large print in a book
l a TV and follow the actions to a story
l the shape of furniture in a room
They can recognise:
l someone’s face across a room
l someone across a street
Yes No
Use page 12 of the information booklet.
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Yes No
24
If you want to tell us more about the boxes you have ticked, how their needs vary or anything else
you think we should know, use the box below.
For example, they have difficulty seeing in poorly lit places like a cinema.
Do they have difficulty hearing?
This means hearing sound or someone speaking when using their hearing aid.
They can hear:
l a whisper in a quiet room
l a normal voice in a quiet room
l a loud voice in a quiet room
l a TV, radio or CD but only at a very loud volume
l a school bell or car horn
Have they had an audiology test in the last 6 months?
If you send us a photocopy of the report it may help us deal with the child’s claim.
Please do not send original copies as they cannot be returned.
45
Tick the boxes that apply.
Yes Go to question 46.
No
Yes No
Yes No
If you want to tell us more about the boxes you have ticked, how their needs vary or anything else
you think we should know, use the box below.
For example, they can’t hear things if there is a lot of background noise.
Use page 12 of the information booklet.
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25
Do they have difficulty speaking?
This means the ability to say words out loud and talk clearly.
If you want to tell us more about the boxes you have ticked, how their needs vary or anything
else you think we should know, use the box below.
For example, they get embarrassed about the way they talk and will only speak to people they know.
They can:
l speak clearly in sentences
l put words together to make simple sentences
l speak single words
They can communicate using speech:
l with someone they know
l with someone they don’t know
46
Tick the boxes that apply.
Yes Go to question 47.
No
Yes No
Do they have difficulty and need help communicating?
This means passing on inf
ormation, asking and answering questions, telling people how they feel,
giving and following instructions.
47
Tick the boxes that apply.
Yes Go to question 48.
No
To communicate they use:
l writing
l BSL (British Sign Language)
l lip-reading
l using hand movements, facial expressions and body language
l Makaton
Yes No
Use page 14 of the information booklet.
i
Use page 13 of the information booklet.
i
Yes No
26
If you want to tell us more about the boxes you have ticked, how their needs vary or anything else
you think we should know, use the box below.
For example, they may be at risk because they don’t understand a warning.
If they use another form of communication, tell us below what it is. This could be Sign Supported English
(SSE), Signed English (SE), Finger Spelling, Picture Exchange Communication System (PECS), Tadoma or
something else.
They can communicate:
l with someone they know
l with someone they don’t know
Yes No
Do they have fits, blackouts, seizures, or something similar?
This means epileptic, non-epileptic or febrile fits, faints, absences, loss of consciousness and ‘hypos’
(hypoglycaemic attacks).
Tell us what type they have and
what happens
48
Tick the boxes that apply.
Yes Go to question 49.
No
They:
l can recognise a warning and tell an adult
l can recognise a warning and take appropriate action
l have no warning
l have had a serious injury in the last 6 months because of a fit,
blackout or seizure
l display dangerous behaviour after a fit, blackout or seizure
Yes No
Use page 15 of the information booklet.
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27
Have they had an episode of status epilepticus in the past 12 months?
This is where there is persistent epileptic activity for more than 30 minutes, or they have several seizures
without becoming conscious between each seizure.
Tell us:
l the number of days affected each month
l how many fits they have on these days
l the number of nights affected each month
l how many fits they have on these nights
If you want to tell us more about the boxes you have ticked, how their needs vary or anything else
you think we should know, use the box below.
For example, they become distressed and need reassurance.
Continue at question 70 if necessary.
days
nights
Yes
No
Do they need to be supervised during the day to keep safe?
This means they need someone to keep an eye on them because of how they feel or behave, or how
they react to people, changing situations and things around them.
49
Tick the boxes that apply.
Yes
Go to question 50.
No
C
an they:
l recognise and react to common dangers?
l cope with planned changes to daily routine?
l cope with unplanned changes to daily routine?
Yes No
Use page 16 of the information booklet.
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Do they regularly:
l feel anxious or panic?
l become upset or frustrated?
l harm themselves or others?
l feel someone may harm them?
l become verbally or physically aggressive or destructive?
l act impulsively?
l have tantrums?
If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think
we should know, use the box below.
For example, they behave without thinking about dangers or how it will affect others.
Yes No
Do they need extra help with their development?
This means any extra help they need to improve their understanding of how to behave and react to
people, situations and things around them.
They need help to:
l understand the world around them
l recognise their surroundings
l follow instructions
l play with others
l play on their own
l join in activities with others
l behave appropriately
l understand other people’s behaviour
50
Tick the boxes that apply.
Yes Go to question 51.
No
Yes No
Use page 16 of the information booklet.
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29
If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think
we should know, use the box below.
For example, they may have difficulty making friends.
Do they need encouragement, prompting or physical help at school or nursery?
They need encouragement, prompting or physical help to:
l go to and use the toilet
l safely move between lessons
l change into different clothes for physical education and other school activities
l eat meals
l take medicine or do their therapy
l communicate
51
Tick the boxes that apply.
Yes Go to question 52.
No
Yes No
What extra help do they need with learning?
What is their behaviour like at school or nursery?
How do they usually get to and from school or nursery?
Use page 17 of the information booklet.
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30
If you want to tell us more about the boxes you have ticked, how their needs vary or anything else
you think we should know, use the box below.
For example, they have one-to-one help from a teaching assistant.
52
Do they need encouragement, prompting or physical help to take part in hobbies, interests, social or
religious activities?
Tell us:
l what they do or would do if they had help
l what help they need or would need to do this
l how often they do it or would do it if they had the help, and
l how long they need or would need help each time
Use page 18 of the information booklet.
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At home
Activity
Example
Art
Help needed
Encouragement to get paints, brushes
and paper. Motivate to keep interested.
Help to wash hands afterwards.
How often? How long
each time?
2 times a
week
One hour
Please continue below.
Yes Go to question 53.
No
31
When they go out
Activity
Example
Swimming
Help needed
To get changed, to get in and out of the
pool, to dry themselves.
How often? How long
each time?
Once a week 45 minutes
Do they wake and need help at night, or need someone to be awake to watch over them at night?
Question 53 is about the help needed during the night.
Night is when everyone in the house is in bed. For example, if a child goes to bed at 8pm and the parents go
to bed at 11pm, night would start at 11pm. Any help needed before 11pm would count as help during the
day.
53
Use page 19 of the information booklet.
i
Please continue below.
Yes Go to question 54.
No
Tell us how often each night they need help and how long it takes each time.
They need encouragement, prompting or How often How long
physical help to: each night? each time?
l get into, get out of or turn in bed
l get to and use the toilet, manage nappies
or pads
l have treatment
l settle or re-settle
minutes
minutes
minutes
minutes
They need watching over because they: How often How long
each night? each time?
l are unaware of danger and may
harm themselves or others
l may wander about
l have behavioural problems
minutes
minutes
minutes
32
If you want to tell us why they need help or watching over, how their needs vary or anything else you
think we should know, use the box below.
For example, they don’t sleep regular hours each night.
Extra information about care
If you want to tell us anything else about their care needs, use the box below.
54
When did the child’s care needs you have told us about start?
Normally, the child can only get the care part of DLA if they have needed help for more than 3 months.
Please tell us the date the care needs you have told us about started.
If you can’t remember the exact date, tell us roughly when this was.
55
33
About you
Use this page to tell us about yourself, not the child.
Your date of birth
Your surname or family name
Letters Numbers Letter
Your National Insurance number
Address if different to the child’s
If you live in Wales and would like us to contact you in Welsh, tick this box.
Your daytime phone number where we can contact you or leave a message.
Phone number
Include the dialling code.
If you have speech or hearing difficulties and want us to contact you by textphone, please
tick this box.
Textphone number
What is your nationality?
What is your relationship to the
child?
Postcode
All other names in full
Title
For example, Mr, Mrs, Miss, Ms
56
57
58
59
60
61
62
63
What is the Child Benefit number for
the child?
64
Mobile phone number,
if different.
34
About Income Support
Are you getting or waiting to hear about Income Support?
65
Please tell us their name:
Is anyone within your household getting or waiting to hear about Income Support?
66
Their National Insurance number:
Their relationship to you:
About tax credits
Is anyone within your household getting or waiting to hear about Child Tax Credit?
67
Is anyone within your household getting or waiting to hear about Working Tax Credit?
68
Yes
No
No Yes
Letters Numbers Letter
Please tell us their name:
Their National Insurance number:
Their relationship to you:
No Yes
Letters Numbers Letter
Please tell us their name:
Their National Insurance number:
Their r
elationship to you:
No Yes
Letters Numbers Letter
35
Name of the account holder
Please write the name of the account holder exactly as it's shown on the debit card, statement or
chequebook.
It is very important you fill in all the boxes correctly, including the building society roll or reference
number, if there is one. If you tell us the wrong account details, the payment may be delayed or the
child may lose money.
Full name of bank or building society
Sort code
Please tell us all 6 numbers, for example: 12-34-56.
Account number
Most account numbers are 8 numbers long. If your account number has fewer than 10 numbers,
please fill in the numbers from the left.
Building society roll or reference number
If you are using a building society account you may need to tell us a roll or reference number. This may be
made up of letters and numbers, and may be up to 18 characters long. If you are not sure if the account
has a roll or reference number, ask the building society.
You may be getting other benefits and payments we do not pay into an account. If you want us
to pay them into the account above, please tick this box.
How we pay you
Please tell us your account details below.
69
You must read pages 19 and 20 of the information
booklet before you fill in the account details.
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36
Extra information
Tell us anything else you think we should know about the child’s claim.
If you need more space continue on a separate piece of paper. Please put the child’s name and date of
birth on any extra pieces of paper you send us.
70
37
Declaration
We can’t pay any benefit until you have signed the declaration and returned the form to us. Please
return the signed form as soon as you’ve completed it.
I declare the information I have given on this form is correct and complete as far as I know and
believe.
I understand that if I knowingly give false information, my benefit may be stopped and I may be
liable to prosecution or other action.
I understand that I must promptly tell the office that pays the child’s Disability Living Allowance of
anything that may affect my entitlement to, or the amount of, that benefit.
I understand that the Department for Work and Pensions may use the information which it has now
or may get in the future to decide whether I am entitled to:
l the benefit I am claiming for the child
l any other benefit I have claimed
l any other benefit I may claim or be awarded in the future
This is my claim for Disability Living Allowance.
Signature Date
Print your name here
Send the claim form and the documents listed above back to us straight away. You can send
more information to us at any time.
71
Please remember to sign and date the form after printing.
38
What to do now
Check you’ve filled in all the questions that apply to you or the child you are claiming for:
l check you’ve included full details of your GP at question 15
l included full details for anyone else you’ve seen at question 14
l you’ve ticked the relevant box and signed the consent at question 21
l you’ve given us any extra information at question 70
l you’ve signed the declaration at question 71
l check the person whose details are in About You at question 56 is the person who signs the consent and
declaration
Make sure you’ve given as much information as you can.
Read pages 3 to 6 of the information booklet about how we collect and use information and for help and
advice about other benefits.
List below all the supporting information you’re sending with this claim form. For example, a prescription
list, medical report or a statement of Special Educational Needs.
Only send photocopies of up-to-date supporting information you already have as we can’t return any
originals.
Please don’t include things like appointment cards or general information about the child’s condition like
fact sheets or information from the Internet.
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