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Get SSA-3819 2010-2022

Form SSA-3819 2-2010 Use prior editions OVER K. Hospitals clinics doctors or therapists that have seen the child within at least the last 12 months. MEDICAL AND SCHOOL WORKSHEET - CHILD Completing this worksheet will help you get ready for the interview. It will also speed up the interview. We may ask for additional information* If you need more space use blank sheets of paper. A. Child s height and weight. B. Name address phone number and relationship of another adult who helps care for the child and can help us get information about the child if necessary. C. The child s illnesses injuries or conditions. D. When the child s condition s began* E* How they affect the child s activities. F* The child s current grade if in school* G* Schools or preschools the child is currently attending and any other schools he or she attended in the last 12 months. NAME ADDRESS ZIP CODE and PHONE NUMBER DATES ATTENDED KIND S OF SPECIAL ED. SERVICES if any H. Current teacher s name s and school* I. School testing the child has had such as tests for behavior or learning problems. NAME OR KIND OF TEST NAME OF SCHOOL J* Name of any school therapist the child is seeing or has seen for example speech physical or occupational and the school name. PATIENT I. D. NUMBER FIRST SEEN LAST SEEN L* Other agencies or programs that tested or examined the child or that provided services such as Headstart Early Intervention Services or Special Education Public or Community Health Welfare or Social Service Agency Mental Health/Mental Retardation Center. KIND OF TEST OR SERVICE M. Medicine s the child takes and the doctor s name if it is a prescribed medication* NAME OF MEDICINE PRESCRIBED BY N* All medical tests the child had or will have for his or her illnesses injuries or conditions. For example hearing test vision test IQ testing blood tests breathing tests x-rays. NAME OF TEST WHERE DONE WHO SENT CHILD FOR TEST. MEDICAL AND SCHOOL WORKSHEET - CHILD Completing this worksheet will help you get ready for the interview. It will also speed up the interview. We may ask for additional information* If you need more space use blank sheets of paper. It will also speed up the interview. We may ask for additional information* If you need more space use blank sheets of paper. A. Child s height and weight. B. Name address phone number and relationship of another adult who helps care for the child and can help us get information about the child if necessary. A. Child s height and weight. B. Name address phone number and relationship of another adult who helps care for the child and can help us get information about the child if necessary. C. The child s illnesses injuries or conditions. D. When the child s condition s began* E* How they affect the child s activities. C. The child s illnesses injuries or conditions. D. When the child s condition s began* E* How they affect the child s activities. F* The child s current grade if in school* G* Schools or preschools the child is currently attending and any other schools he or she attended in the last 12 months. .

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Keywords relevant to SSA-3819

  • retardation
  • illnesses
  • therapists
  • completing
  • EDITIONS
  • clinics
  • Occupational
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