Schedule 1—Questionnaires
(Section 9)
Part 1 Assessment of care load questionnaire
Domain A – Behaviour 1
For each question, the claimant must tick only the response code that best describes how well the child in care usually manages.
Question 1
| The child’s ability to do everyday things (e.g. eating, bathing, talking, walking and mixing with other people etc) is: | |
|---|
| Improving over time (i.e. the child is likely to require less help in the future) | |
| Becoming worse over time (i.e. the child is likely to require more help in the future) | |
| Relatively stable (i.e. the child is likely to require the same level of help in the future) | |
| Fluctuating or episodic (i.e. the child’s condition and ability to do everyday things goes up and down from day to day or week to week) | |
| Unsure | |
Question 2
Settling down to sleep at night
(e.g. repeated efforts needed to get the child to go to sleep at night
| The child never has difficulty settling down to sleep at night | |
|---|
| The child sometimes has difficulty settling down to sleep at night (e.g. one or two nights a week) | |
| The child often has difficulty settling down to sleep at night (e.g. more than two nights a week) | |
| The child always has difficulty settling down to sleep at night (e.g. every night) | |
Question 3
Disrupted sleep at night
(e.g. waking up many times during the night, awake for long periods during the night, or having nightmares)
| The child never has disrupted sleep at night | |
|---|
| The child sometimes has disrupted sleep at night (e.g. one or two nights a week) | |
| The child often has disrupted sleep at night (e.g. more than two nights a week) | |
| The child always has disrupted sleep at night (e.g. every night) | |
Question 4
Irritable behaviour
(e.g. crying all the time, not able to be calmed down, or for an older child, continually agitated, prone to angry outbursts)
| The child never has irritable behaviour | |
|---|
| The child sometimes has irritable behaviour (e.g. one or two days a week) | |
| The child often has irritable behaviour (e.g. more than two days a week) | |
| The child always has irritable behaviour (e.g. every day) | |
Question 5
Speaking and Communicating
(i.e. speaking and communicating everyday needs)
| The child’s speech and communication is appropriate for their age (e.g. the child can speak and communicate their everyday needs in the same way as other children of the same age. For young babies this may include crying when hungry, smiling or babbling.) | |
|---|
| The child has difficulty speaking or communicating their needs in other ways (e.g. speech is unclear and can only be understood by people who know the child very well or the child is aged over 4 years and can only say or sign a few words) | |
| The child uses other ways to communicate (e.g. sign language, picture board, electronic communicator, gestures, pointing) | |
| The child cannot talk or communicate their needs effectively in any way | |
Question 6
Understanding speech
(i.e. the child understanding what you say to him or her)
| The child is able to understand everything that I would expect for a child of this age | |
|---|
| The child sometimes needs me to speak more simply, repeat things or give reminders (e.g. once or twice a day) | |
| The child often needs me to speak more simply, repeat things or give reminders (e.g. the child has a lot of difficulty understanding what I say several times a day) | |
| The child cannot understand most things I say (e.g. the child does not appear to understand simple instructions or questions such as ‘do you want a drink?’) | |
Question 7
Playing and mixing with other children
| The child plays and mixes with other children as expected for a child of their age | |
|---|
| The child sometimes needs help to play and mix appropriately with other children (e.g. once or twice a week) | |
| The child often needs help to play and mix appropriately with other children (e.g. several times a week) | |
| The child cannot play or mix with other children at all (e.g. the child has extreme behaviour problems or the child cannot play with other children because of a severe disability or medical condition) | |
Question 8
Is the child aged under 3 years?
| No | | Go to next question |
|---|
| Yes | | Go to question 20 (domain C) |
Domain B – Behaviour 2
Questions 9 to 19 ask you about the child’s behaviour (e.g. running away, aggressive behaviours, self‑harming behaviours, extreme anxiety or withdrawal). For each question, please select the response that best describes the child’s behaviour and the effect that this behaviour has on you during the day and the night.
Question 9
Does the child have severe behaviour difficulties?
| No | | Go to question 20 (domain C) |
|---|
| Yes | | Go to next question |
| Not sure | | Go to next question |
Question 10
| The child wanders, escapes or runs away from home, school or community settings | |
|---|
| Never (The child never has this behaviour) | |
| Sometimes (e.g. the child sometimes wanders or runs away but not every week) | |
| Often (e.g. the child would wander or run away at least once a week if not closely supervised) | |
| Always (e.g. the child continually wanders or runs away unless hand is held or doors and gates are locked) | |
Question 11
| The child shouts, screams at, or threatens other people or makes so much noise that other people become alarmed. | |
|---|
| Never (The child never has this behaviour) | |
| Sometimes (The child sometimes has this behaviour, but not every week) | |
| Often (The child often has this behaviour e.g. at least once a week) | |
| Always (The child has this behaviour all the time e.g. every day) | |
Question 12
| The child becomes physically aggressive and harms others by hitting, pushing, kicking, biting or throwing objects. | |
|---|
| Never (The child never has this behaviour) | |
| Sometimes (The child sometimes has this behaviour, but not every week) | |
| Often (The child often has this behaviour e.g. at least once a week) | |
| Always (The child has this behaviour all the time e.g. every day) | |
Question 13
| The child gets extremely upset for little or no apparent reason (e.g. the child has episodes of intense crying or screaming and is very difficult to calm down). | |
|---|
| Never (The child never has this behaviour) | |
| Sometimes (The child sometimes has this behaviour, but not every week) | |
| Often (The child often has this behaviour e.g. at least once a week) | |
| Always (The child has this behaviour all the time e.g. every day) | |
Question 14
| The child gets extremely anxious, fearful or becomes emotionally withdrawn. | |
|---|
| Never (The child never has this behaviour) | |
| Sometimes (The child sometimes has this behaviour, but not every week) | |
| Often (The child often has this behaviour e.g. at least once a week) | |
| Always (The child has this behaviour all the time e.g. every day) | |
Question 15
| The child has very strange behaviours such as unusual routines, repetitive or obsessive behaviours, hearing voices or seeing things that are not there. | |
|---|
| Never (The child never has this behaviour) | |
| Sometimes (The child sometimes has this behaviour, but not every week) | |
| Often (The child often has this behaviour e.g. at least once a week) | |
| Always (The child has this behaviour all the time e.g. every day) | |
Question 16
| The child displays high‑risk behaviour that causes a danger to themself or to others, including family members. The child requires supervision and actions such as locking away household items that would not normally have to be locked away, preventing the child from running into traffic, etc. | |
|---|
| Never (The child never has this behaviour) | |
| Sometimes (The child sometimes has this behaviour, but not every week) | |
| Often (The child often has this behaviour e.g. at least once a week) | |
| Always (The child has this behaviour all the time e.g. every day) | |
Question 17
| The child behaves in ways that result in injury to themself. This may include head‑banging, hand‑biting or other self-harming behaviours. | |
|---|
| Never (The child never has this behaviour) | |
| Sometimes (The child sometimes has this behaviour, but not every week) | |
| Often (The child often has this behaviour e.g. at least once a week) | |
| Always (The child has this behaviour all the time e.g. every day) | |
Question 18
| The child has displayed suicidal behaviours (e.g. the child has suicidal thoughts and has planned or attempted suicide). | |
|---|
| Never (The child has never displayed suicidal thoughts or behaviours) | |
| Sometimes (The child has displayed suicidal behaviours once or twice in the past two years) | |
| Often (The child has displayed suicidal behaviours more than twice in the past two years) | |
| Always (The child is continually displaying suicidal thoughts or behaviours e.g. suicidal thoughts every week and several suicide attempts in the past two years) | |
Question 19
| The child does or says things that are sexually inappropriate. | |
|---|
| Never (The child never has this behaviour) | |
| Sometimes (The child sometimes has this behaviour, but not every week) | |
| Often (The child often has this behaviour e.g. at least once a week) | |
| Always (The child has this behaviour all the time e.g. every day) | |
Domain C – Functional Abilities
Question 20
Does the child have more problems and need more help doing everyday tasks (e.g. eating, grooming, bathing, using the toilet, walking) than other children of the same age?
| No | | Go to question 37 (domain D) |
|---|
| Yes | | Go to next question |
| Not sure | | Go to next question |
Question 21
Is the child aged under 12 months?
| No | | Go to next question |
|---|
| Yes | | Go to question 37 (domain D) |
Instructions for domain C
Questions 22 to 36 ask you to rate the child’s ability to perform a number of different tasks. You must answer all of these questions.
For each question, select the response that best describes the child’s ability. Please base your responses on what the child does when using any aids, appliances or home modifications that assist with the care of the child.
If the child has a condition that changes from day to day, please base your answers on the child’s usual ability i.e. what the child is able to do most of the time. Help includes supervision, prompting, reminding or training required as well as physical help.
The child’s age will be taken into account when assessing your responses.
Domain C – Functional abilities – subdomain 1
Question 22
| Does the child feed themself once food is prepared? | |
|---|
| The child feeds themself with no help (e.g. the child needs no help from me) | |
| The child needs a little help (e.g. prompting, reminding or a small amount of physical help) | |
| The child needs a lot of help (e.g. a lot of physical help) | |
| The child is completely dependent on me to feed him/her (e.g. I have to hold the child’s bottle, spoon feed the child or feed the child through a naso‑gastric feeding tube, gastrostomy or Percutaneous Endoscopic Gastrostomy (P.E.G.)) | |
Question 23
| Does the child do everyday grooming tasks (e.g. brush teeth, brush/comb hair, wash and rinse hands and face)? | |
|---|
| The child grooms themself with no help (e.g. the child needs no help from me) | |
| The child needs a little help (e.g. prompting, reminding or a small amount of physical help) | |
| The child needs a lot of help (e.g. a lot of physical help) | |
| The child is completely dependent on me to do their grooming | |
Question 24
| Does the child wash themself from the neck down (except for their back) in the bath, shower or sponge/bed bath? | |
|---|
| The child washes themself with no help (e.g. the child needs no help from me) | |
| The child needs a little help (e.g. prompting, reminding or a small amount of physical help) | |
| The child needs a lot of help (e.g. a lot of physical help) | |
| The child is completely dependent and needs me to wash them | |
Question 25
| Does the child dress themself from the waist up (e.g. putting on singlets, t‑shirts, jumpers, jackets)? | |
|---|
| The child dresses themself from the waist up with no help (e.g. the child needs no help from me) | |
| The child needs a little help (e.g. prompting, reminding or a small amount of physical help) | |
| The child needs a lot of help (e.g. a lot of physical help) | |
| The child is completely dependent and needs me to dress them | |
Domain C – Functional abilities – everyday tasks
Question 26
| Does the child dress themself from the waist down (e.g. putting on underpants, skirts/pants/trousers, socks, shoes)? | |
|---|
| The child dresses themself from the waist down with no help (e.g. the child needs no help from me) | |
| The child needs a little help (e.g. prompting, reminding or a small amount of physical help) | |
| The child needs a lot of help (e.g. a lot of physical help) | |
| The child is completely dependent and needs me to dress them | |
Question 27
| Does the child wipe themself and adjust their clothing before and after using the toilet? | |
|---|
| The child uses the toilet with no help (e.g. the child needs no help from me) | |
| The child needs a little help (e.g. prompting, reminding or a small amount of physical help) | |
| The child needs a lot of help (e.g. a lot of physical help) | |
| The child is completely dependent for toileting, or wears nappies or incontinence pads day and night | |
Domain C – Functional abilities – subdomain 2
Question 28
| Does the child have bladder accidents (i.e. wets their pants or nappy)? | |
|---|
| The child never has bladder accidents (e.g. the child is dry during the day and at night) | |
| The child has bladder accidents during the night but is dry during the day (e.g. the child wets the bed or nappy at night only) | |
| The child has occasional bladder accidents during the day and at night (e.g. the child sometimes wets their pants or nappy during the day and wets the bed at night) | |
| The child has frequent bladder accidents during the day and at night (e.g. the child wets their pants or nappy several times during the day AND wets the bed or nappy most nights, or the child has a catheter or stoma to pass urine) | |
Question 29
| Does the child have bowel accidents (i.e. soils their pants or nappy)? | |
|---|
| The child never has bowel accidents | |
| The child sometimes has bowel accidents (e.g. the child occasionally soils their pants or nappy during the day or night) | |
| The child often has bowel accidents (e.g. the child soils their pants or nappy several times a week) | |
| The child is completely incontinent of faeces (e.g. the child has no bowel control, or the child needs an enema or suppository to have a bowel motion, or the child has a stoma to pass faeces such as from a colostomy or ileostomy) | |
Domain C – Functional abilities – subdomain 3
Question 30
| Does the child sit down and get up from the toilet or potty? | |
|---|
| The child sits down and gets up from the toilet or potty with no help (e.g. the child needs no help from me) | |
| The child needs a little help (e.g. prompting, reminding or a small amount of physical help) | |
| The child needs a lot of help (e.g. a lot of physical help) | |
| The child is completely dependent for toileting (e.g. the child needs to be lifted on and off the toilet or potty or cannot sit on a toilet or potty) | |
Question 31
| Does the child sit down and get up from a chair or wheelchair? | |
|---|
| The child sits down and gets up from a chair with no help (e.g. the child needs no help from me) | |
| The child needs a little help (e.g. prompting, reminding or a small amount of physical help) | |
| The child needs a lot of help (e.g. a lot of physical help) | |
| The child cannot sit in a chair or is completely dependent (e.g. the child needs to be lifted on and off the chair or wheelchair) | |
Question 32
| Does the child get into or out of a bath or shower (whichever is used more often)? | |
|---|
| The child gets into and out of a bath or shower with no help (e.g. the child needs no help from me) | |
| The child needs a little help (e.g. prompting, reminding or a small amount of physical help) | |
| The child needs a lot of help (e.g. a lot of physical help) | |
| The child is completely dependent (e.g. the child cannot get into or out of a bath or shower and needs complete physical help or lifting) | |
Question 33
| How does the child move around? | |
|---|
| The child moves around by walking | |
| The child moves around using a wheelchair or other mobility aids (e.g. stroller, crutches, walking sticks, walking frame or other mobility equipment) | |
| The child moves around by crawling, rolling or bottom‑hitching (e.g. the child does not walk but can move around on the floor) | |
| The child is not able to move around by themself | |
Question 34
| Does the child move around by themself indoors on an even surface? | |
|---|
| The child moves around on an even surface with no help (e.g. the child needs no help from me) | |
| The child needs a little help (e.g. supervision or a small amount of physical help from me) | |
| The child needs a lot of help (e.g. a lot of physical help from me) | |
| The child is completely dependent (e.g. the child cannot move around indoors by themself) | |
Question 35
| Does the child move around by themself outdoors on uneven surfaces? | |
|---|
| The child moves around outdoors on uneven surfaces with no help (e.g. the child needs no help from me) | |
| The child needs a little help (e.g. supervision or a small amount of physical help from me) | |
| The child needs a lot of help (e.g. a lot of physical help from me) | |
| The child is completely dependent (e.g. the child cannot move around outdoors by themself) | |
Question 36
| Does the child go up and down stairs? | |
|---|
| The child goes up and down a flight of stairs with no help from me | |
| The child goes up and down two or three steps with no help from me | |
| The child goes up and down a single step or kerb with no help from me | |
| The child needs physical help from me to go up and down steps or stairs OR the child cannot use steps or stairs at all | |
Domain D – Special care needs
Instructions for special care needs questions
Questions 37 to 53 ask you to indicate the child’s special care needs.
If the child has a condition that changes from day to day, please base your answers on the child’s usual and ongoing needs.
Domain D – Special care needs – subdomain 1
Question 37
Does the child use any of the following to help with breathing?
| Tracheostomy (A tracheostomy is an opening made by a surgeon through the front of the child’s neck into the windpipe. A tracheostomy tube is used to keep the tracheostomy open) | |
|---|
| Ventilator (A ventilator is a machine which breathes for the child and connects to the child’s airway – usually through a tube into the windpipe known as a tracheostomy tube) | |
| Oxygen (The child is regularly given extra oxygen to breathe from an oxygen cylinder at home as directed by a medical practitioner) | |
| CPAP/BiPAP (A CPAP or BiPAP machine helps to keep the child’s airway open by providing a flow of air at pressure, usually through a mask fitted firmly to the face) | |
| NO ‑ Go to next question | |
Question 38
Does the child receive dialysis (due to a kidney condition)?
(Dialysis is the assisted removal of waste products from the body for people with kidney failure.)
Question 39
Do you provide Total Parenteral Nutrition (TPN) for the child?
TPN is a technique in which nutrients are given to a person through a tube directly into their veins, usually because they cannot digest regular food.
Question 40
Do you do postural drainage for the child?
Postural drainage means using positioning to help drain mucus from the child’s lungs and airways. This often includes physical techniques such as patting the child’s chest with cupped hands (percussion) to help clear the secretions.
| No | | Go to next question |
|---|
| Yes | | Please indicate how often you provide postural drainage for the child |
Question 41
Do you clear the child’s airways through suctioning?
Suctioning is the use of a tube connected to equipment to remove mucus or saliva from the child’s mouth, throat or airway.
| No | | Go to next question |
|---|
| Yes | | Please indicate how often you provide suctioning for the child |
Question 42
Do you physically assist or position the jaw of the child to help with chewing and/or swallowing?
| No | | Go to next question |
|---|
| Yes | | Please indicate how often you physically assist with chewing and/or swallowing |
Question 43
Do you Percutaneous Endoscopic Gastrostomy (P.E.G.) feed or use a feeding tube to feed the child?
When a child is P.E.G. fed they have a tube or button that goes directly into their stomach, and are fed through that tube.
| No | | Go to next question |
|---|
| Yes | | Please indicate how often you P.E.G. feed or use a feeding tube for the child over a 24 hour period |
Question 44
Do you provide physical assistance to turn or position the child because they are unable to do so independently?
| No | | Go to next question |
|---|
| Yes | | Please indicate how often you physically assist the child to turn or position themself |
Question 45
Do you manage any wounds and/or dressings for the child?
| No | | Go to next question |
|---|
| Yes | | Please indicate how much time you spend managing wounds or dressings for the child |
| Less than 30 minutes per day | |
|---|
| 30-60 minutes per day | |
| 1-2 hours per day | |
| More than 2 hours per day | |
Question 46
Do you give emergency medication or first aid for poorly controlled seizures?
| No | | Go to next question |
|---|
| Yes | | Please indicate how often you give emergency medication or first aid for poorly controlled seizures |
| Less than monthly | |
|---|
| Once or twice a month | |
| Three or more times a month | |
Question 47
Do you provide stoma care (e.g. colostomy, ileostomy) for the child?
A stoma is an opening in the abdominal wall and is used to enable waste materials from the intestines to empty into a pouch or bag.
| No | | Go to next question |
|---|
| Yes | | Please indicate how often you provide stoma care for the child over a 24 hour period |
Domain D – Special care needs – subdomain 2
Question 48
Does the child have an eating disorder that has been diagnosed by a medical practitioner (e.g. anorexia nervosa or bulimia)?
Question 49
Is the child receiving a course of chemotherapy or radiotherapy treatment?
Question 50
Do you prepare or administer medications related to the child’s medical condition?
(Medications include tablets, other oral medicines, injections, puffers/inhalers, suppositories, enemas, ointments or creams prescribed by a medical practitioner)
| No | | Go to next question |
|---|
| Yes | | Please indicate how many minutes PER DAY on average you spend preparing and/or administering medications |
Question 51
Do you provide any of the following supports of treatments for the child?
| Attending health care appointments related to the child’s disability or medical condition multiple times per month | |
|---|
| Exercises prescribed by a physiotherapist, speech therapist, occupational therapist or other specialist at least twice a week | |
| Applying daily splints, braces, special garments or mobility aids recommended by a health practitioner | |
| Behavioural program recommended by a psychologist, psychiatrist or other therapist | |
| Early childhood intervention activities recommended by a teacher, therapist or other disability specialist | |
| Sign language or hearing equipment where the child is deaf or has a severe hearing impairment | |
| Equipment or tactile aids or other assistance around the home where the child is blind or has a severe visual impairment | |
| Blood testing or urine testing performed by you at least three times a day | |
Question 52
Do any of these other care needs apply to you and the child you care for?
| I am unable to access general child care, after‑school hours care or vacation care programs due to this child’s special care needs | |
|---|
| I am often called to the child’s school or child care to attend to their special care requirements or collect them due to their health or behavioural problems | |
| This child has been excluded from school or child care for more than one day in the last school term because of their health care needs or behavioural issues | |
| This child can only attend school part‑time due to the severity of their disability or medical condition or because school supports are not available | |
| I have to attend and stay at school or child care to provide care for my child due to the severity of their disability or medical condition or because school supports are not available | |
| I can only leave this child in the care of others when they have had specific training and are willing to manage the child’s care needs | |
Question 53
Please describe any other care needs that the child has.
Question 54
Please describe any other effects that the child’s disability or medical condition has on you (e.g. any other effects on your daily routine, ability to take up paid employment, your health, social activities or emotional effects).
Question 55
If there are any other comments about your situation that you feel are relevant, please write them in the space below.
Part 2 Professional questionnaire
Functional domains – abilities
- Please indicate the statement that describes the child’s usual ability.
- If the child cannot do any of the skills listed in a question, tick the last box.
- If the child’s ability is appropriate for the age of the child, tick the first box.
- The child’s abilities include what they can do when using their aids, appliances or special equipment items.
- Where the child’s disability or medical condition is episodic or is only apparent at certain times, the question should be answered for what the child is currently able to do most of the time.
| Question | Response Code |
|---|
| 1 | Receptive language skills (listening, reading and understanding) | |
| Child’s ability is age appropriate | M‑1l |
| 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 storybook 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 2 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 |
| 2 | Expressive language skills (talking or signing) | |
| Child’s ability is age appropriate | M‑2l |
| 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 his or her own first name by handwriting or typing. Child can state his or her 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 |
| 3 | Feeding and mealtime skills | |
| Child’s ability is age appropriate | M‑3l |
| 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 |
| 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 |
| 4 | Hygiene and grooming skills | |
| Child’s ability is age appropriate | M-4k |
| 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 |
| 5 | Dressing skills | |
| Child’s ability is age appropriate | M-5l |
| Child can purchase and care for own clothing without assistance | M-5j |
| 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 themself 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 |
| 6 | Social and community skills | |
| Child’s ability is age appropriate | M-6l |
| 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 |
| 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 |
| 7 | Mobility – fine motor | |
| Child’s ability is age appropriate | M-7l |
| 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 his or her 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 |
| 8 | Mobility – gross motor | |
| Child’s ability is age appropriate | M-8k |
| 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 1 leg for 3 seconds. Child can hop on 1 leg | M-8f |
| Child can balance briefly while standing on 1 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 |
Functional domains – behaviour and needs
For the functional domains numbered 9 and 10, the treating health professional must mark any statement that describes the child’s behaviours or special care needs in each functional domain. The response should be based on an assessment by the treating health professional and, if available, any clinical assessments and written reports on the child from other treating health professionals (if any) who have assessed the child. If the child is receiving prescribed medication, the response should be based on the child’s behaviours when the child is receiving the prescribed medication.
Note The treating health professional may mark more than 1 statement for each domain.
| Question | Response Code |
|---|
| 9 | Behaviour | |
| 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 | |
| Child receives all food and fluids by nasogastric or gastrostomy tube or percutaneous enterogastric tube (PEG) | M‑10a |
| Child has a tracheostomyChild requires a ventilator to support respiration.Child requires regular oxygen therapy at home.Child requires a CPAP or BiPAP machine. | M‑10b1M‑10b2M‑10b3M‑10b4 |
| 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 |
| 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 or enzyme replacement therapy and nutritional supplements are required and provided on a daily basis | M‑10k |
| Child is receiving a course of chemotherapy or radiotherapy treatment for cancer | M‑10l |
| The child has poorly controlled seizures which frequently require emergency medication or first aid? | M‑10m |
| Child is assisted on a daily basis with at least 2 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 |
| Child has a severe eating disorder such as anorexia nervosa or bulimia. | M‑10o |