OCDD/OAAS Participant Data
Name
*
First Name
Last Name
Waiver Type
*
Children's Choice (CC)
Supports Waiver (SW)
Residential Options Waiver (ROW)
New Opportunities Waiver (NOW)
Community Choice Waiver (CCW)
Adult Day Health Services (ADHC)
Gender
*
Male
Female
Ethnicity
*
Caucasian/White (Non-Hispanic)
African American/Black (Non-Hispanic)
Asian
North American or Alaska Native
Hispanic/Latino
Native Hawaiian and other Pacific Islander
Unknown/Declined
Other
Diagnosis #1
*
Autism Spectrum Disorder
Cerebral Palsy
Intellectual/Cognitive Disability
Hearing Disability
Physical/Mobility Disability
Psychological Disability
Social Emotional Disability
Vision Disability
Speech or Language Impairment
Diagnosis #2
*
Autism Spectrum Disorder
Cerebral Palsy
Intellectual/Cognitive Disability
Hearing Disability
Physical/Mobility Disability
Psychological Disability
Social Emotional Disability
Vision Disability
Speech or Language Impairment
Diagnosis #3
*
Autism Spectrum Disorder
Cerebral Palsy
Intellectual/Cognitive Disability
Hearing Disability
Physical/Mobility Disability
Psychological Disability
Social Emotional Disability
Vision Disability
Speech or Language Impairment
Employment Status: For children under the age of 18 leave blank
Employed
Unemployed
Retired
Primary Language
*
English
Spanish
French
Vietnamese
Arabic
Hindi
Louisiana Creole
Koasati
Tagalong
German
Military/Veteran Status
*
National Guard or Reserve
Veteran
Retired Military
Military Dependent
No Military Affiliation
Linkage Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Certification Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: