SFN 451, Eligibility Report on Disability/Incapacity 400-19-165-85

(Revised 6/1/10 ML #3218)

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SFN 451, Eligibility Report on Disability/Incapacity is generally used by the county social service office in reporting current personal and employability factors and conditions about an applicant or family applying for assistance based on disability or incapacity. The form is also used when a review of eligibility is requested by the State Review Team or is desired by the county social service office. In order that the State Review Team is supplied with information that is complete and current, each question on the form must be answered fully.

 

SFN 451 is to be completed in duplicate, with the original submitted to the Department of Human Services. A copy is retained in the county social service office's case record.

NOTE: Other types of eligibility documents such as narrative reports may be substituted for SFN 451 provided all information asked for in the SFN 451 is incorporated into the report.

 

Following are instructions for the proper completion of SFN 451:

 

SECTION I. Information in this section identifies the case information, such as case name, address, case number, the date of application, and the medical approval date.

 

SECTION II. Information in this section concerns only the person whose physical or mental disability or incapacity is the basis of eligibility for assistance.

• Name, Birth Date, and Sex - Self-explanatory.
• Race – Check the appropriate race of the person whose physical or mental disability or incapacity is the basis of eligibility.  If an individual is of mixed ancestry, check all that apply.
• Marital Status, Education and Training - Self-explanatory.
• State Institutions - As requested, indicate if the applicant or recipient is or has been a resident at a state institution and give dates of entry and release, if applicable.
• Benefits - Check if the applicant or recipient receives benefits (monetary and/or medical) from any of the sources listed.
• Employment - All questions relate to the employment record and capacities of the applicant or recipient, the applicant or recipient's future employability and/or Employability Plans. A description of the specific types of work the applicant or recipient has done, as described by the person, and the types of physical and/or mental stresses they have placed upon the person are desirable in visualizing and evaluating the employment factors.

SECTION III. This section pertains to the applicant or recipient and their family, if any, in terms of their living arrangements. Facts about housing can help evaluate the effect of the environment on the medical and social condition of the applicant/recipient. A description of certain individual and/or family problems such as social and financial difficulties and poor family relationships help to better understand and evaluate the person's total stresses and how they may relate to the individual's physical and/or mental functioning.

 

SECTION IV. The information requested here focuses on the physical and/or mental problems as stated by the applicant or recipient and, equally as important, as observed by the worker. A person's own attitude and disability is of great importance and has much to do with determining motivation for improving their position in or returning to the labor market.

 

If the applicant or recipient is in need of personal care, indicate what the specific activity limitations are that require that care.

 

If the applicant's or recipient's primary disability or incapacity appears to be of a psychological, psychiatric or social nature, current psychological, psychiatric, vocational rehabilitation, or social evaluations should be submitted.

 

Include any additional relevant information not provided elsewhere which may assist the State Review Team in reaching an equitable decision on eligibility. This must include the worker's recommendations concerning approval or denial and the appropriateness of a referral to Vocational Rehabilitation.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms. (180kb pdf)

 

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.