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Final TBI Waiver Eligibility Determination
Eligible for TBIW-NF
Eligibile for TBIW-NB
Ineligibile for TBI Waiver
Referred for
Services
Traumatic Brain Injury Program (TBI)
TBI Waiver Assessment and Eligibility Determination
Required forms: DHS-3471A
Instructions/Worksheet TBIW Assessment & Eligibility Determination
Minnesota Department of
Human Services
DHS-3471B
TBIW Eligibility & Documentation Checklists
INITIAL ASSESSMENT
REASSESSMENT
DATE
CASE MANAGER/SERVICE COORDINATOR
COUNTY
I. Applicant
NAME: FIRST MIDDLE INITIAL LAST
PMI NUMBER
DATE OF BIRTH
AGE AT ONSET
PRIMARY DIAGNOSIS
ICD-9 CODE
SECONDARY DIAGNOSIS
ICD-9 CODE
II. Cognitive and Behavioral Assessments
A. Modi
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ed Rancho Los Amigos
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Level of Cognitive Functioning
I
Person is completely unresponsive to stimuli.
II
Person reacts inconsistently and non-purposefully to stimuli.
III
Person responds speci
fi
cally but inconsistently to stimuli and may follow simple commands.
IV
Person is in a heightened state of activity with severely decreased ability to process information.
Behavior is non-purposeful relative to the immediate environment.
This information is available in other forms to people with disabilities by contacting us at (651) 582-1940 (voice)
or toll free at (877) 627-3848. TTY/TDD users can call the Minnesota Relay at 711 or (800) 627-3529. For the
Speech-to-Speech Relay, call (877) 627-3848.
Page 1 of 2 Name
PMI#
B. Cognitive Assessment Grid
Cognitive Impairment
Absent/does not
exhibit
Present/requires
occasional support
Present/requires frequent
support
Present and severe/requires
availability of 24-hour support
or monitoring
Attention / Concentration
Initiation
Learning