Dd Form 2948 PDF Details

Are you familiar with the Dd Form 2948? If not, you should be. This document is crucial for taxpayers who want to claim a foreign tax credit on their federal income tax return. Here's what you need to know about the Dd Form 2948 so that you can take advantage of this valuable tax break. The Dd Form 2948 is used by taxpayers to claim a foreign tax credit on their federal income tax return. This form is used to document the taxes that have been paid to a foreign country, as well as the corresponding Foreign Tax Credit (FTC) claimed on the U.S. return. The FTC is designed to offset the amount of U.S. taxes that would otherwise be owed on income

QuestionAnswer
Form NameDd Form 2948
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdd 2948, ICD-09, ADL, Katz

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SPECIAL COMPENSATION FOR ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (SCAADL) ELIGIBILITY

PRIVACY ACT STATEMENT

AUTHORITY: 37 U.S.C. Section 439; DoDD 5154.02; DoDI 1341.12, and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): To allow a licensed physician to certify or recertify that the applicant needs assistance from another person

to perform the personal functions required in everyday living or requires constant supervision and in the absence of the provision of such care would require hospitalization, nursing home, or other residential institutional care. To allow the Services to provide certified, detailed monthly listings

of individuals with such determinations to the Defense Finance and Accounting Service of the effective start and stop date of payments for special compensation for assistance with activities of daily living.

ROUTINE USE(S): The DoD "Blanket Routine Uses" found at http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html apply to this collection.

DISCLOSURE: Voluntary. However, failure to provide requested information may result in a denial or delay in processing your request for special compensation for assistance with activities of daily living.

In accordance with DoDI 1341.12, the following information is provided to determine the compensation for the referenced Service member.

1.SERVICE MEMBER NAME (Last, First, Middle)

2.DOD ID NUMBER/ SSN (Last 4 digits)

3. DATE OF BIRTH (YYYYMMDD)

4. SOURCES USED TO COMPLETE THIS TOOL (X all that apply)

 

DIRECT OBSERVATION

 

CHART REVIEW

 

REPORT OF PRIMARY FAMILY CAREGIVER

5. FACILITY/LOCATION

 

 

6. SERVICE MEMBER ADDRESS (City, State and ZIP Code)

 

 

 

 

 

 

REFERENCES:

-Katz Basic Activities of Daily Living Scale

-The UK Functional Independence Measure and Functional Assessment Measure

-The Neuropsychiatric Inventory

 

 

SCORING GUIDE

 

4

- Total Assistance (Service member completes less than 25% of the task/activity or is unable to do the task without assistance).

3

- Maximal Assistance (Service member completes 25% - 49% of the task/activity with some hands on help).

2

- Moderate Assistance (Service member completes 50% - 74% of the task/activity with some hands on help).

1

- Minimum Assistance (Service member completes 75% or more of the task/activity with supervision/coaching assistance).

0

- Complete Independence (Service member completes task/activity without help).

 

TOTAL SCORE: High Dependence: 28 - 21

Moderate Dependence: 20 - 13

Low Dependence: 12 - 1

7.ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL)

(3)DID CLINICIAN

(1) AREA

(2) SCORE

OBSERVE?

(4) REASONS FOR SCORE

 

 

YES

NO

 

 

 

 

 

 

a.EATING

b.GROOMING

c.BATHING

d.DRESSING

e.TOILETING

f.NEEDS ASSISTANCE WITH PROSTHETIC OR OTHER DEVICE (beyond that of the average person)

g.DIFFICULTY WITH MOBILITY (walking, going up stairs, getting in and out of bed, etc.)

h. TOTAL SCORE

0

 

 

 

 

DD FORM 2948, SEP 2011

 

Page 1 of 2 Pages

Adobe Professional 8.0

8.

SUPERVISION/PROTECTION (Use Scoring Guide on Page 1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3) DID CLINICIAN

 

 

 

 

 

(1) AREA

(2) SCORE

OBSERVE?

 

 

(4) REASONS FOR SCORE

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. REQUIRES SUPERVISION/

 

 

 

 

 

 

 

 

 

 

ASSISTANCE AS A RESULT OF

 

 

 

 

 

 

 

 

 

 

SEIZURES (blackouts or lapses in

 

 

 

 

 

 

 

 

 

 

mental awareness, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. DIFFICULTY WITH PLANNING

 

 

 

 

 

 

 

 

 

 

AND ORGANIZING (able to adhere

 

 

 

 

 

 

 

 

 

 

to medication regimen, managing

 

 

 

 

 

 

 

 

 

 

financial and other household

 

 

 

 

 

 

 

 

 

 

affairs, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. SAFETY RISKS (significant risk of

 

 

 

 

 

 

 

 

 

 

falling, wandering outside the

 

 

 

 

 

 

 

 

 

 

home, leaving cook top/oven on,

 

 

 

 

 

 

 

 

 

 

crossing streets, using electrical

 

 

 

 

 

 

 

 

 

 

appliances, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. DIFFICULTY WITH SLEEP

 

 

 

 

 

 

 

 

 

 

REGULATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. REQUIRES ASSISTANCE/

 

 

 

 

 

 

 

 

 

 

SUPERVISION AS A RESULT OF

 

 

 

 

 

 

 

 

 

 

DELUSIONS/HALLUCINATIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. DIFFICULTY WITH RECENT

 

 

 

 

 

 

 

 

 

 

MEMORY (forgets what day it is,

 

 

 

 

 

 

 

 

 

 

what happened yesterday, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g. SELF REGULATION (being able to

 

 

 

 

 

 

 

 

 

 

moderate moods, agitation/

 

 

 

 

 

 

 

 

 

 

aggression)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H. TOTAL SCORE

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. TOTAL SCORES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. ADL

b. SUPERVISION/PROTECTION

c. TOTAL

 

d. DEPENDENCE LEVEL

 

0

 

0

 

 

 

 

 

0

 

 

 

 

 

 

 

 

 

 

 

10. APPLICABLE ICD-09/10 CODES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.A PERSON COMPLETING FORM (Name and Signature)

 

 

 

 

 

b. DATE

 

 

 

 

 

 

 

 

c. PRINTED NAME OF PHYSICIAN (Last, First, Middle Initial)

 

 

d. TITLE

 

 

 

 

 

 

 

 

 

 

e. TELEPHONE (Include area code)

f. EMAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. SERVICE MEMBER ACKNOWLEDGEMENT

 

 

 

 

 

 

 

 

 

I acknowledge my PCM's assessment of my dependency level. I

 

do

 

do not plan to appeal this decision.

 

 

 

 

 

 

 

 

 

 

 

a. PERSON COMPLETING FORM (Name and Signature)

 

 

 

 

 

b. DATE

 

 

 

 

 

 

 

 

c. TELEPHONE (Include area code)

d. EMAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DD FORM 2948, SEP 2011

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