Schedule Sch 1 - Child Disability Assessment Determination 2001 - Questionnaires

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Schedule 1 Questionnaires

(section 2.1)

Part 1 Claimant questionnaire

Functional domains — abilities

For the functional domains numbered 1 to 8, the claimant must mark only the statement that describes the best ability that the child has in each functional domain. The child’s abilities include what the child can do when using the child’s aids, appliances or other special equipment items.

1. Communication (listening, reading and understanding)	Response code
Child understands most adult conversations and concepts	C-1j
Child can read and basically understand a newspaper	C-1i
Child can read and understand a short story written for children of the child’s age group	C-1h
Child understands basic adult speech and can read and understand simple written words	C-1g
Child follows complex instructions with two or more steps, for example ‘pick up the book and put it in on the chair’	C-1f
Child can show or say what common objects are used for	C-1e
Child recognises pictures of common objects and animals	C-1d
Child responds to his or her own name	C-1c
Child listens and turns his or her head towards sounds	C-1b
Child looks briefly at your face when you talk to the child	C-1a
Child cannot do any of the things listed above	C-1k
Child’s ability is the same as most other children of the same age	C-1l

2. Communication (talking, writing or signing)	Response code
Child can discuss and debate complex issues such as politics or religion with an adult	C-2j
Child can describe the child’s experiences in detail using complex sentences	C-2i

2. Communication (talking, writing or signing)

Child can tell a complex story involving several people and child can write a short story	C-2h
Child can write the child’s first name by handwriting or typing	C-2g
Child talks or signs well and can use 6 or more words in a sentence	C-2f
Child can say or sign sentences with 3 to 4 words	C-2e
Child can clearly say or sign more than 20 words and can use 2 words in combination, for example ‘Daddy’s car’	C-2d
Child can say or sign 3 or more simple words, for example ‘mum’, ‘dad’, ‘drink’, ‘bed’	C-2c
Child smiles and babbles or makes purposeful sounds, for example to attract attention	C-2b
Child can make a sound other than crying	C-2a
Child cannot do any of the things listed above	C-2k
Child’s ability is the same as most other children of the same age	C-2l

3. Feeding and mealtime skills	Response code
Child can use all cooking equipment and kitchen appliances, for example microwave oven, electric frypan, or mixer, without assistance	C-3j
Child can follow a recipe and prepare a simple meal	C-3i
Child can cook a simple snack, for example toast	C-3h
Child can prepare a simple uncooked snack, for example a sandwich	C-3g
Child can use a fork and spoon at mealtimes	C-3f
Child can eat most solid foods if the food is cut up, for example a raw apple	C-3e
Child uses spoon well	C-3d
Child can drink from a normal cup without help and can feed himself or herself with finger foods	C-3c
Child can drink from a modified cup when the cup is held by you	C-3b
Child can suck from a breast or baby’s feeding bottle	C-3a

4. Hygiene and grooming skills	Response code
Child can style own hair and clean and cut own finger and toe nails without assistance	C-4i
Child can attend to basic hygiene, for example toileting, showering and brushing hair, without assistance	C-4h
Child manages basic hygiene, for example, toileting, showering and brushing hair, with little assistance	C-4g
Child can wash hands and face and brush own teeth	C-4f
Child is reliably toilet-trained during the day and can manage own toileting with minimal assistance	C-4e
Child can indicate toilet needs during the day but needs some assistance with clothing and wiping	C-4d
Child remains dry during the day when toileted regularly after meals and drinks	C-4c
Child requires full assistance with toileting	C-4b
Child cries when nappy is soiled or wet	C-4a
Child cannot do any of the things listed above	C-4j
Child’s ability is the same as most other children of the same age	C-4k

5. Dressing skills	Response code
Child can purchase and care for own clothing without assistance	C-5j
Child can wash and iron own clothing if required to with little assistance	C-5i
Child can choose own clothing appropriate to the weather and can dress and undress without assistance	C-5h
Child can do up buckles and untie shoelaces	C-5g
Child can do up buttons and zippers	C-5f

5. Dressing skills	Response code
Child dresses and undresses self but needs assistance with buttons, laces or tight clothing	C-5e
Child can undress with little assistance	C-5d
Child tries to help with dressing	C-5c
Child lifts arms to be picked up	C-5b
Child snuggles in to an adult when cuddled	C-5a
Child cannot do any of the things listed above	C-5k
Child’s ability is the same as most other children of the same age	C-5l

3. Feeding and mealtime skills	Response code
Child cannot do any of the things listed above	C-3k
Child’s ability is the same as most other children of the same age	C-3l

6. Social and community skills	Response code
Child can use all major community facilities, for example shops, banks or doctors, with little assistance	C-6j
Child is able to undertake basic activities in the community, for example shopping, with little supervision	C-6i
Child understands basic personal safety, for example how to cross the road and not to go with strangers	C-6h
Child is aware of being left in the care of others, for example a school teacher or child care worker, without getting unduly upset	C-6g
Child plays with other children and forms close friendships with other children	C-6f
Child knows whether he or she is a boy or a girl	C-6e
Child initiates contact with other people and involves other people in games or activities	C-6d
Child responds to affection from familiar people	C-6c
Child laughs and giggles when happy and cries when upset or angry	C-6b
Child smiles	C-6a
Child cannot do any of the things listed above	C-6k
Child’s ability is the same as most other children of the same age	C-6l

7. Hand movement	Response code
Child can use a variety of tools or hobby items with accuracy, for example for woodwork, sewing, painting or model building	C-7j
Child can write clearly	C-7i
Child can write all letters of the alphabet clearly	C-7h
Child can hold a pencil and draw basic shapes such as squares and triangles	C-7g
Child can draw at least a head and body of a person stick figure style	C-7f
Child can copy a circle and a cross	C-7e
Child can use larger objects and toys, for example the child can push or pull toys, use posting box toys or build a small tower of blocks	C-7d
Child can make purposeful movements with objects, for example bang on a drum or clap hands	C-7c
Child can hold and let go of objects such as a rattle or feeding bottle	C-7b
Child can hold an adult finger but may need help to release it	C-7a
Child cannot do any of the things listed above	C-7k
Child’s ability is the same as most other children of the same age	C-7l

8. Body movement	Response code
Child can hit a ball with a bat and can kick a ball with reasonable accuracy	C-8i
Child skips well and can catch a small ball, for example a tennis ball	C-8h
Child can jump and can hop on each leg	C-8g
Child can hop on one leg	C-8f
Child can pedal a tricycle	C-8e
Child can walk and can run a few steps	C-8d
Child can pull himself or herself from floor to a standing position and may be able to stand independently	C-8c
Child can crawl or move himself or herself along the floor	C-8b

8. Body movement	Response code
Child can raise head off floor when lying on his or her stomach	C-8a
Child cannot do any of the things listed above	C-8j
Child’s ability is the same as most other children of the same age	C-8k

9. Behaviour	Response code
The child is only taken into community settings when unavoidable because of the child’s extreme anti-social behaviour	C-9a
Child purposefully injures himself or herself through head banging, hand-biting or other forms of self abuse	C-9b
Child displays explosive and unpredictable violent behaviour towards other people or property at least once a month	C-9c
Child is aged 5 years or older and has poor awareness of danger, for example runs into traffic or jumps into water without being able to swim	C-9d
Child continually runs away. Child requires constant supervision and house and other care settings must be locked	C-9e
Child is extremely active and is unable to concentrate on a task for more than 30 seconds	C-9f
Child’s behaviour is such that the child cannot be left with anyone other than the parents or outside the parent’s home	C-9g
Child displays obsessional, repetitive behaviours, for example obsession with particular objects or twirling, or spinning, objects for extended periods of time	C-9h
Child is obsessed with following specific routines and becomes extremely upset and disturbed if regular routine is disrupted	C-9i

10. Special care needs	Response code
Child receives all food and fluids by nasogastric, gastrostomy tube or percutaneous enterogastric tube (PEG)	C-10a
Child has a tracheostomy	C-10b
Child is aged over 4 years and is incontinent, meaning the child wets or soils his or her pants or nappies, both day and night	C-10c
Child is aged over 3 years and cannot stand without support	C-10d
Child requires a wheelchair and needs assistance to propel the wheelchair	C-10e

10. Special care needs	Response code
Child requires a wheelchair, quad sticks, prosthesis, crutches or walking frame but can move around with little assistance using this equipment	C-10f
Child uses an electric wheelchair	C-10g
Child requires urinary catheterisation several times each day	C-10h
Child requires specialised equipment, prosthesis, or technology to communicate, for example a computerised communicator, telephone typewriter (TTY), voice synthesiser, cochlear implant, hearing aids or adaptations to a standard computer	C-10i
Child is over the age of 5 years and requires care provided by parents more than twice each night between the hours of 10pm and 6am	C-10j
Child is over the age of 5 years and has persistent difficulties with memory, concentration, planning and organisation	C-10k
Child has chronic and progressive suppurative lung disease for which ongoing daily airway clearance is provided and/or enzyme replacement therapy and nutritional supplements are required and provided on a daily basis	C-10l
Child has an inherited metabolic disorder that is being treated by medically prescribed diet as the basis of treatment so that it will not lead to neurological disability	C-10m
Child is assisted with the administration of medication on a daily basis to control seizures and medication does not substantially reduce the frequency of seizures and the child may require immediate or emergency attention to prevent harm resulting from a seizure	C-10n
Child is assisted on a daily basis with at least two blood tests to measure blood glucose levels, injections and special dietary management and the child is not capable of determining medication levels, food intake or self-administration of medication	C-10o

1. Receptive language skills (listening, reading and understanding)	Response code
Child understands adult speech or signed language of normal speed and complexity. Child demonstrates full understanding of why they are interacting with a health professional	M-1j
Child can read and interpret a paragraph from the front page of a daily newspaper	M-1i
Child can read a paragraph or page from a children’s story book appropriate for the child’s age group. Child can recall a list of three common objects 30 seconds after the list is read to them	M-1h
Child understands and responds appropriately to simple questions such as ‘do you go to school?’ and ‘what is your favourite colour?’	M-1g
Child follows two step instructions such as ‘pick up the book and put it on the chair’. Child uses toys appropriately for their intended purpose in meaningful play	M-1f
Child knows the difference between ‘big’ and ‘little’. Child can demonstrate what common objects are used for	M-1e
Child recognises pictures of common objects, for example points appropriately when asked ‘where’s the dog?’ or ‘which one is the truck?’	M-1d
Child responds appropriately to very simple questions, for example points to, or looks at, mother when asked ‘where’s mummy?’. Child uses objects purposefully, for example to make a sound	M-1c
Child responds to sound. Child tracks noise-making objects	M-1b
Child looks momentarily at speaker’s face	M-1a
Child cannot do any of the things listed above	M-1k
Child’s ability is age appropriate	M-1l

2. Expressive language skills (talking or signing)	Response code
Child has almost a full adult vocabulary. Child can discuss and debate complex issues such as politics or religion with an adult	M-2j
Child can describe his or her experiences in detail using complex sentences	M-2i
Child can tell a complex story involving several characters. Child can write a short story	M-2h
Child can write their own first name by handwriting or typing. Child can state their name and home address	M-2g
Child talks or signs well and can use 6 or more words in a sentence. Child can describe an event, for example a visit to a special place	M-2f
Child can say sentences with 3 to 4 words. People other than family members can understand the child’s speech	M-2e
Child can clearly say or sign more than 20 words and can use 2 words in combination, for example ‘Daddy’s car’	M-2d
Child can say or sign 3 or more simple words, for example ‘mum’, ‘dad’, ‘drink’, ‘bed’	M-2c
Child smiles and babbles or makes purposeful sounds, for example to attract attention. Child demonstrates good eye contact	M-2b
Child makes a vocal sound other than crying	M-2a
Child cannot do any of the things listed above	M-2k
Child’s ability is age appropriate	M-2l

3. Feeding and mealtime skills	Response code
Child can use all cooking equipment and kitchen appliances, for example a microwave oven, electric frypan, or mixer, without assistance	M-3j
Child can follow a recipe and prepare a simple meal	M-3i
Child can cook a simple snack, for example toast	M-3h
Child can prepare a simple uncooked snack, for example a sandwich	M-3g
Child can use a fork and spoon at mealtimes	M-3f
Child can eat most solid foods if the food is cut up, for example a raw apple	M-3e

3. Feeding and mealtime skills	Response code
Child uses spoon well	M-3d
Child can drink from a normal cup without help and can feed himself or herself with finger foods	M-3c
Child can drink from a modified cup when the cup is held by an adult	M-3b
Child can suck from a breast or baby’s feeding bottle	M-3a
Child cannot do any of the things listed above	M-3k
Child’s ability is age appropriate	M-3l

4. Hygiene and grooming skills	Response code
Child can style own hair and clean and cut own finger and toe nails without assistance	M-4i
Child can attend to basic hygiene, for example toileting, showering and brushing hair, without assistance	M-4h
Child manages basic hygiene, for example toileting, showering and brushing hair, with little assistance	M-4g
Child can wash hands and face and brush own teeth	M-4f
Child is reliably toilet-trained during the day and can manage own toileting with minimal assistance	M-4e
Child can indicate toilet needs during the day but needs some assistance with clothing and wiping	M-4d
Child is toilet-timed during the day or is indicating toilet needs, for example asking for the toilet or potty even if it’s too late or telling parent that pants or nappy are wet	M-4c
Child requires full assistance with toileting	M-4b
Child cries when nappy is soiled or wet	M-4a
Child cannot do any of the things listed above	M-4j
Child’s ability is age appropriate	M-4k

5. Dressing skills	Response code
Child can wash and iron own clothing if required to with little assistance	M-5i
Child can choose own clothing appropriate to the weather and can dress and undress without any assistance	M-5h
Child can do up buckles and untie shoelaces	M-5g
Child can do up buttons and zippers	M-5f
Child dresses and undresses himself or herself but needs assistance with buttons, laces or tight clothing	M-5e
Child can undress with little assistance	M-5d
Child tries to help with dressing	M-5c
Child lifts arms to be picked up	M-5b
Child snuggles in to an adult when cuddled	M-5a
Child cannot do any of the things listed above	M-5k
Child’s ability is age appropriate	M-5l

6. Social and community skills	Response code
Child can use all major community facilities, for example shops, banks, doctors, with little assistance. Child has basic understanding of community laws and regulations	M-6j
Child is able to undertake basic activities in the community, for example shopping, with little supervision	M-6i
Child understands basic personal safety, for example how to cross the road and not to go with strangers. Child relates well to both children and adults	M-6h
Child is aware of being left in the care of others, for example a school teacher or child care worker, without getting unduly upset. Child understands basic concepts of right and wrong	M-6g
Child plays with other children and forms close friendships with other children. Child joins in simple games such as ‘chasey’ and ‘hide and seek’ but may not understand or follow rules of a game	M-6f
Child takes turns in conversations, for example speaks and then listens. Child knows whether they are a boy or a girl	M-6e
Child initiates contact with other people and involves other people in games or activities. Child is starting to cooperate in play with other children	M-6d

6. Social and community skills	Response code
Child responds to affection from familiar people. Child recognises the difference between strangers and familiar people	M-6c
Child laughs and giggles when happy and cries when upset or angry. Child is interested in people and enjoys attention	M-6b
Child smiles. Child settles when picked up and cuddled	M-6a
Child cannot do any of the things listed above	M-6k
Child’s ability is age appropriate	M-6l

7. Mobility — fine motor	Response code
Child can use a variety of tools or hobby items with accuracy, for example for woodwork, sewing, painting or model building	M-7j
Child can write clearly	M-7i
Child can write all letters of the alphabet clearly	M-7h
Child can hold a pencil and draw basic shapes such as squares and triangles. Child can clearly write their own first name	M-7g
Child can manipulate smaller objects accurately, for example jigsaw puzzle pieces. Child can draw at least a head and body on a person stick figure style	M-7f
Child can build a tower of 9 blocks. Child can copy a circle and a cross	M-7e
Child can manipulate larger objects and toys, for example can push or pull toys, use posting box toys or build small tower of blocks. Child can copy a straight vertical line	M-7d
Child can make purposeful movements with objects, for example bang on a drum or clap hands	M-7c
Child grasps and releases objects such as rattle or feeding bottle	M-7b
Child can grasp an adult finger but may need assistance to release it	M-7a
Child cannot do any of the things listed above	M-7k
Child’s ability is age appropriate	M-7l

8. Mobility — gross motor	Response code
Child can hit a ball with a bat and can kick a ball with reasonable accuracy	M-8i
Child can catch a small ball, for example a tennis ball. Child skips well or rides a two-wheel bike	M-8h
Child can jump and can hop on each leg. Child can bounce a ball and catch it	M-8g
Child can run fast. Child can balance on one leg for 3 seconds. Child can hop on one leg	M-8f
Child can balance briefly while standing on one leg. Child can pedal a tricycle	M-8e
Child can walk and can run a few steps. Child can walk up and down steps	M-8d
Child has even muscle tone and strength in all limbs. Child can pull himself or herself from floor to a standing position and may be able to stand independently	M-8c
Child can independently move between prone and supine positions. Child can crawl or otherwise propel himself or herself along	M-8b
Child can lift head when in prone position. Child makes random movements with arms and legs	M-8a
Child cannot do any of the things listed above	M-8j
Child’s ability is age appropriate	M-8k

9. Behaviour	Response code
Child is consistently uncooperative and disruptive during treatment or assessment episodes	M-9a
Child demonstrates self injurious behaviour such as head banging or hand biting and has injuries or signs of past injuries consistent with such behaviours	M-9b
Child displays aggressive behaviour or violence towards other people or property in the treatment or assessment setting	M-9c
Child persistently attempts to leave or abscond from the treatment or assessment setting	M-9d
Child is extremely active and is unable to concentrate on a task for more than 30 seconds	M-9e
Child displays obsessional repetitive behaviours, for example obsession with particular objects or twirling or spinning objects for extended periods of time	M-9f

10. Special care needs	Response code
Child receives all food and fluids by nasogastric or gastrostomy tube or percutaneous enterogastric tube (PEG)	M-10a
Child has a tracheostomy	M-10b
Child is aged over 4 years and is incontinent both day and night	M-10c
Child is aged over 3 years and cannot stand without support	M-10d
Child requires a wheelchair and requires assistance to propel the wheelchair	M-10e
Child requires a wheelchair, quad sticks, prosthesis, crutches or walking frame but can move around with little assistance using the equipment	M-10f
Child uses an electric wheelchair	M-10g
Child requires urinary catheterisation several times each day	M-10h

10. Special care needs	Response code
Child requires specialised equipment, prosthesis or technology to communicate, for example a computerised communicator, telephone typewriter (TTY), voice synthesiser, cochlear implant, hearing aids or adaptations to a standard computer	M-10i
Child is over the age of 5 years and has persistent difficulties with memory, concentration, planning and organisation	M-10j
Child has chronic and progressive suppurative lung disease for which ongoing daily airway clearance is provided and/or enzyme replacement therapy and nutritional supplements are required and provided on a daily basis	M-10k
Child has an inherited metabolic disorder that is being treated by medically prescribed diet as the basis of treatment so that it will not lead to neurological disability	M-10l
Child is assisted with the administration of medication on a daily basis to control seizures and medication does not substantially reduce the frequency of seizures and the child may require immediate or emergency attention to prevent harm resulting from a seizure	M-10m
Child is assisted on a daily basis with at least two blood tests to measure blood glucose levels, injections and special dietary management and the child is not capable of determining medication levels, food intake or self-administration of medication	M-10n