Child Disability Packet for a Child or Young Adult Under the Age of 21

To be completed by the parent/guardian or authorized representative:

  • Disability Questionnaire: DOH-5139 (English) (Español) (PDF)
  • Description of Child Activities: DOH-5153 (English) (Español) (PDF)
  • Authorization for the Release of Information Pursuant to HIPAA - DOH-5173 (PDF)

To be completed by the child´s doctor:

  • Childhood Medical Disability Report - DOH-5151 (PDF)

To be completed by the child´s teacher or administrator:

  • Questionnaire of School Performance - DOH-5152. (PDF)

For questions regarding disability documentation requirements call the State Disability Review Unit toll free number 1-866-330-0591 Monday through Friday 8am-5pm .