Date request submitted: Reason for assessment request (select one main category only): New to Waiver Exceptional Rate Training Center Post Discharge— 3–6 month review (Optional and only if needed) Significant and sustained increase/decrease in medical or behavioral support needs (Sections 3A/3B of SIS®) over a period of 6 months Provide detailed justification: Sustained and Significant Change in any 2 Life/Activity Domains (Life Activity Domains: Section 1, Parts A-F & Section 2 of the SIS®) Provide detailed justification: Other Comments: Type of assessment being requested (select one): Child (ages 5–15) Adult (ages 16 and over) What is the likely location of the interview? Location Name: Agency: Address: Phone #: City: State: Zip: County Name: Location Type: 5. Will the individual require an interpreter for the SIS® Interviewer? Interpreter Language: 6. Will the individual require other accommodations to participate in the SIS® interview? Other accommodations descriptions: Was this request reviewed by your CSB SIS® Administrator (select one)? Yes No Individual’s Information: Name: Address: Date of Birth: CSB Tracking: # SSN: Medicaid: # ISP Dates: Date of Last SIS® (if applicable): SIS® ID Number (if applicable): to Support Coordinator/Case Manager Information (ONLY ENTER INFO HERE): Name: Agency: Phone: # Phone: # Email Address: Has SC/CM known Individual for 3 months?
Date request submitted: Reason for assessment request (select one main category only): New to Waiver Exceptional Rate Training Center Post Discharge— 3–6 month review (Optional and only if needed) Significant and sustained increase/decrease in medical or behavioral support needs (Sections 3A/3B of SIS®) over a period of 6 months Provide detailed justification: Sustained and Significant Change in any 2 Life/Activity Domains (Life Activity Domains: Section 1, Parts A-F & Section 2 of the SIS®) Provide detailed justification: Other Comments: Type of assessment being requested (select one): Child (ages 5–15) Adult (ages 16 and over) What is the likely location of the interview? Location Name: Agency: Address: Phone #: City: State: Zip: County Name: Location Type: 5. Will the individual require an interpreter for the SIS® Interviewer? Interpreter Language: 6. Will the individual require other accommodations to participate in the SIS® interview? Other accommodations descriptions: Was this request reviewed by your CSB SIS® Administrator (select one)? Yes No Individual’s Information: Name: Address: Date of Birth: CSB Tracking: # SSN: Medicaid: # ISP Dates: to Date of Last SIS® (if applicable): SIS® ID Number (if applicable): Support Coordinator/Case Manager Information (ONLY ENTER INFO HERE): Name: Agency: Phone: # Phone: # Email Address: Has SC/CM known Individual for 3 months?
sis%20initialreassessment%20request%202%20102615.docx