Skill areas: Socialization Community use Communication Self-care Self-direction Functional academics Health and safety Mobility Leisure Work Home/school living Domain areas Communication skills Socialization Conceptual Practical Social Daily living skills Notes Form left purposely because eligibility entered into eXPRS by eligibility specialist Eligibility specialist signature: Date: Eligibility specialist name: Part II: Case manager’s evaluation The case manager should review the individual’s file, conduct a face-to-face meeting and complete this form (during or after the meeting). The case manager must review this form with the individual on an annual basis. See instructions for further details. Vision function with correction, if needed (check one): 1 full vision 2 difficulty at level of print 3 difficulty with obstacles 4 blind Comments: Hearing function with correction, if needed (check one): 1 full hearing 2 difficulty hearing others 3 difficulty with sounds 4 deaf Comments: Self-care (check one): 1 no assists needed 2 occasional assists needed 3 assists needed 4 frequent assists needed 5 total assists needed Comments: Personal mobility status (check one):
Skill areas: Socialization Self-care Health and safety Work Community use Self-direction Mobility Home/school living Communication Functional academics Leisure Domain areas Communication Conceptual Daily living skills skills Practical Socialization Social Notes Form left purposely because eligibility entered into eXPRS by eligibility specialist Eligibility specialist signature: Date: Eligibility specialist name: Part II: Case manager’s evaluation The case manager should review the individual’s file, conduct a face-to-face meeting and complete this form (during or after the meeting). The case manager must review this form with the individual on an annual basis. See instructions for further details. Vision function with correction, if needed (check one): 1 full vision 2 difficulty at level of print 3 difficulty with obstacles 4 blind Comments: Hearing function with correction, if needed (check one): 1 full hearing 2 difficulty hearing others 3 difficulty with sounds 4 deaf Comments: Self-care (check one): 1 no assists needed 2 occasional assists needed 3 assists needed 4 frequent assists needed 5 total assists needed Comments: Personal mobility status (check one):
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