Form DLA1 Child (ALT)
Q1. Are you claiming for a child under the special rules?
Options: No; Yes
Q2. Their surname or family name
Q3. All their other names in full
Q4. Any other names the child has had
Q5. Their National Insurance (NI) number
Guidance: If you do not know their NI number leave this section blank. See page 8 of the notes.
Q6. Their date of birth
Q7. Their sex
Options: Male; Female
Q8. Their home address
Guidance: Where the child normally lives.
Q9. Their nationality
Guidance: For example British, Polish, Indian or any other nationality as shown on their passport or legal documents.
Q10. If the child is Swiss or European Economic Area (EEA) national, were they living in the United Kingdom (UK) before 1 January 2021?
Options: No; Yes
Guidance: UK is England, Scotland, Wales and Northern Ireland.
Q11. Does the child normally live in England or Wales?
Options: Yes; No
Guidance: We will contact you about this.
Q12. Has the child moved from Scotland to live in England or Wales since 1 July 2021?
Options: No; Yes
Guidance: Go to question 15
Q13. What date did the child move to live in England or Wales?
Q14. Is the child getting or have they made a claim for Child Disability Payment?
Options: No; Yes
Q15. Has the child moved from another country in the last 3 years to live in Great Britain (GB)?
Options: No; Yes; Do not know
Guidance: GB is England, Scotland and Wales.
Q16. What date did they arrive in GB?
Q17. Please tell us the child’s Passport Number, if known
Q18. Has the child been abroad in the last 3 years?
Options: No; Yes
Guidance: Abroad means spending time overseas out of Great Britain (GB). GB is England, Scotland or Wales. For example, travelling frequently for holidays or to visit family and friends overseas.
Q19. Is the child’s parent or guardian getting any pensions or benefits from working in or paying insurance to an EEA state or Switzerland?
Options: No; Yes; Do not know
Guidance: By insurance we mean work contributions, like UK National Insurance.
Q20. Is the child’s parent or guardian paying insurance to an EEA state or Switzerland?
Options: No; Yes; Do not know
Q21. Is the child currently in a hospital?
Options: No; Yes
Guidance: Go to question 22
Q22. Has the child had any overnight stays at a hospice, residential college or similar accommodation in the last 12 months?
Options: No; Yes
Guidance: Please tell us the date they went in. For example, a residential care home, boarding school or similar accommodation.
Q23. Has the child had or are they due to have any assessments by a health professional or specialist to help diagnose, manage or monitor their health condition or disabilities?
Options: No; Yes
Guidance: By ‘health professional assessments’ we mean: audiogram, MRI scan, speech therapy, cognitive development or IQ test or something else.
Q24. Do you have any letters or assessment reports about the child’s health conditions or disabilities that you can send us a copy of?
Options: No; Yes
Guidance: These may be from health professionals or specialists who help the child manage their health condition or disabilities. For example, doctors, health visitors or occupational therapists and councillor or support workers.
Q25. Does the child have any health professionals, who are not their GP, who supports them with their health condition or disabilities?
Options: No; Yes
Q26. Child’s GP’s name
Guidance: If you do not know the GP’s name, tell us the name of the surgery or health centre.
Q27. Surgery address in full
Q28. Surgery phone number, if you know it
Q29. Tell us the date the child last had contact with their GP about their health condition or disabilities
Q30. Name of the school or nursery the child attends
Q31. Address in full
Q32. Please tell us the name of someone we can contact at the school if we need more information
Guidance: For example, a teacher or support worker who knows the child well.
Q33. A phone number we can contact them on, if you know it
Q34. Their email address, if you know it
Q35. Is this a mainstream school?
Options: No; Yes
Q36. Is this a specialist school?
Options: No; Yes
Guidance: For example, a specialist school that gives support to children with learning difficulties or disabilities.
Q37. Does the child have any of the following reports, plans or statements?
Options: Educational Health Care Plan (EHCP); Individual Education Plan (IEP); Individual Behaviour Plan (IBP); A letter, note in lieu or a statement of Special Educational Needs from the local authority; Co-ordinated Support Plan (CSP); I am waiting to hear about one of the above; The child does not have any of the above reports, plans or statements
Q38. Is there anyone else who knows the child and can tell us about their difficulties?
Options: No; Yes
Guidance: As well as filling in this form, it may help us to understand the child’s difficulties by providing additional information from someone who knows the child. This should tell us: • how the child’s health conditions or disabilities affect their daily living and moving around, or • information about any support they may provide for the child. This can be filled in by someone who supports you or who helps care for the child. For example, a health professional, a social worker, teacher or carer.
Q39. Do you give consent for the child’s doctor or other relevant professionals to give DWP more information about their health condition?
Options: Yes – information about the child’s health can be shared with DWP and or the healthcare professionals that work for them.; No – information about the child’s health cannot be shared with DWP or the healthcare professionals that work for them.
Guidance: You do not have to give your consent. If you do not, DWP will make a decision based on the information they have already, as well as any you give yourself. You can change your mind. You can do this by contacting 0800 121 4600 and say you want to give or withdraw your consent. If you withdraw your consent, DWP cannot get information from the child’s doctor or others named on the form.
Q40. Please tell us about the child’s health condition or disabilities:
Guidance: • a health condition or disability may be a physical, sight, hearing, speech, learning or developmental or a mental-health difficulty. If they do not have a diagnosis, still tell us about their difficulties. For example, if they have difficulty learning new things and you do not know why, put ‘learning difficulty’ • when we ask ‘how long’ we mean when did the difficulties start. Tell us when the health condition or disabilities started affecting their day-to-day life, not the date of diagnosis • treatment may be medications such as tablets, creams or injections and therapies like speech, occupational or play, physiotherapy or counselling • how often they have each treatment and for how long. The label on the child’s medication has the name, dose and how often to take it. If you have a spare up-to-date prescription list send it to us with this claim form.
Q41. Does the child use, or have they been prescribed or had an occupational health assessment for any aids or adaptations?
Options: No; Yes
Guidance: Aids such as hand rails, perching stools, walking sticks or wheelchairs.
Q42. Does the child’s needs stay the same on the majority of the days or does it change from day to day?
Options: majority of days; changes from day to day
Guidance: Tell us how their needs change from day to day. For example: • every 3 to 4 weeks they have a couple of good days • they need more looking after when their health condition or disabilities get worse, 2 or 3 times a year, or • they have treatment 3 times a week that affects their health condition or disabilities and they need more assistance or supervision the day after.
Q43. Can the child physically walk?
Options: No; Yes
Guidance: Go to question 51
Q44. Does the child have any difficulties with standing and moving around due to a health condition or disability?
Options: No; Yes
Guidance: For example: • difficulty with how far they can walk • how long it takes them • their walking speed: very slow, slow, normal • the way they walk. Such as: limp, altered gait • refusal to walk or displaying behaviours that risks harm to themselves or others.
Q45. How far can they walk without having severe discomfort and how long does it take them?
Guidance: Mobility can only be awarded to a child from age 3. If the child is under 3, please go to question 54. This means the total distance they can walk before they need to stop and rest or cannot move any further because it would cause severe discomfort or distress. This may include: • short stops and rests to catch their breath or reduce their pain, or • cannot move any further as it will cause behavioural distress.
Q46. Please tell us about their walking speed
Options: Normal – they can walk at the same speed as other similar children who do not have a health condition or disability.; Slow – it would take them twice the amount of time to walk the same distance as other similar children who do not have a health condition or disability.; Very slow – they cannot keep up with other similar children who do not have a health condition or disability.
Q47. Please tell us about the way they walk
Options: They walk normally; They walk with a limp; They shuffle; They drag their leg; They walk with one leg or both feet turned inwards; They walk on their toes; They have a poor balance; They have times when they are unable to walk; They refuse to walk or display distressed behaviours that affects their ability to walk; Something else
Q48. Does the child have any other difficulties either during or after standing and moving around that affects their health?
Options: No; Yes
Guidance: For example, dizziness, anxiety, breathlessness, tiredness or pain. For example, walking can cause bleeding into the ankle joints.
Q49. Do they need guidance or supervision most of the time when they walk outdoors?
Options: No; Yes
Guidance: See page 10 of the information booklet.
Q50. Do they fall due to their health condition or disability?
Options: No; Yes
Guidance: Go to question 51
Q51. When did the child’s mobility needs start?
Guidance: Normally, the child can only get the mobility part of DLA if they have needed help for more than 3 months. If you cannot remember the exact date, tell us roughly when this was.
Q52. If the child is eligible for help from Motability, would you like us to send you information about the help they can offer?
Options: Yes; No
Guidance: We will not share any personal details with Motability. If you decide you do not want to receive information about Motability in the future, please contact us on 0800 121 4600 to let us know.
Q53. Tell us anything else we need to know about their difficulties with standing and moving around or how their needs change from day to day.
Guidance: If you need more space, please continue at question 89 ‘More information’.
Q54. Does the child need encouragement, prompting, or assistance to settle in bed during the day?
Options: No; Yes
Guidance: Such as: • waking up • lifting their legs into or out of bed • sitting up from lying down, or • settling in bed ready to go to sleep. See page 11 of the information booklet.
Q55. Do they need encouragement, prompting or assistance to manage their toilet needs?
Options: No; Yes
Guidance: This means: • being able to get on or off a standard toilet and emptying their bowel or bladder, including if they use a collecting device such as a bucket, bottle or catheter • cleaning themselves after using the toilet. See page 12 of the information booklet.
Q56. Do they need encouragement, prompting or assistance to help move around indoors, use stairs or get into or out of a chair during the day?
Options: No; Yes
Guidance: Indoors is in their home, a friend’s home, school, college, or anywhere else inside. See page 13 of the information booklet.
Q57. Do they need encouragement, prompting or assistance to wash, bathe, shower and clean themselves during the day?
Options: No; Yes
Guidance: This means: • getting in and out of a bath or shower • washing their hair each time • drying themselves • using soap • using a toothbrush • checking their appearance. See page 14 of the information booklet.
Q58. Do they need encouragement, prompting or assistance to dress and undress during the day?
Options: No; Yes
Guidance: This means: • choosing the right clothes for the weather or activity appropriate clothes • choosing clean clothes • putting clothes on in the correct order • moving their arms or legs to put clothes on or take them off. This is any dressing or undressing except when using the toilet. See page 15 of the information booklet.
Q59. Do they need encouragement, prompting or assistance to eat and drink during the day?
Options: No; Yes
Guidance: Such as: • remembering when to eat • cutting food into pieces • putting food and drink in their mouth • chewing and swallowing food and drink. See page 16 of the information booklet.
Q60. Do they need encouragement, prompting or assistance with managing their medication or monitoring or managing any treatments carried out at home during the day?
Options: No; Yes
Guidance: Such as: • monitoring pain, blood sugar and oxygen levels • reminding or supervision to take medication • removing medication from the blister packs • home treatments such as physiotherapy and home dialysis. See page 17 of the information booklet.
Q61. Do they have difficulty seeing?
Options: No; Yes
Guidance: This includes when using their glasses or contact lenses. See page 17 of the information booklet.
Q62. Do they have difficulty hearing?
Options: No; Yes
Guidance: This means hearing sounds or someone speaking when using their hearing aid. Are they certified as severely sight impaired or sight impaired? See page 18 of the information booklet.
Q63. Do they have difficulty speaking?
Options: No; Yes
Guidance: This means the ability to say words out loud and talk clearly. See page 19 of the information booklet.
Q64. Do they have difficulty and need help communicating?
Options: No; Yes
Guidance: This means: • understanding what is being said to them and answering questions • telling people how they feel • giving and following instructions. See page 20 of the information booklet.
Q65. Do they have fits, blackouts, seizures, or something similar?
Options: No; Yes
Guidance: This means epileptic, non-epileptic or febrile fits, faints, absences, loss of consciousness and ‘hypos’ (hypoglycaemic attacks). See page 21 of the information booklet.
Q66. Do they need to be supervised during the day to keep them safe?
Options: No; Yes
Guidance: This means they need someone to keep an eye on them because of how they feel or behave, or how they react to people, changing situations and things around them. See page 22 of the information booklet.
Q67. Do they need extra help with their development?
Options: No; Yes
Guidance: This means any extra help they need to improve their understanding of how to behave and react to people, situations and things around them. See page 22 of the information booklet.
Q68. Do they need encouragement, prompting or assistance at school or nursery?
Options: No; Yes
Guidance: See page 23 of the information booklet.
Q69. Do they need encouragement, prompting or assistance to take part in hobbies, interests, social or religious activities?
Options: No; Yes
Guidance: See page 24 of the information booklet.
Q70. Due to a health condition or disability do they wake and need assistance or supervision during the night?
Options: No; Yes
Guidance: See page 24 and 25 of the information booklet.
Q71. What date did the child’s difficulties with their care needs start?
Guidance: If you cannot remember the exact date, tell us roughly when this started. Normally, the child can only get the care part of Disability Living Allowance if they have needed help for more than 3 months.
Q72. Tell us anything else we need to know about their difficulties with their daily living and care needs or how their needs change from day to day.
Guidance: If you need more space please continue at question 89 or use a separate piece of paper. Please put the child’s name, National Insurance (NI) number and date of birth on any extra pieces of paper you send us.
Q73. Your surname or family name
Q74. All other names in full
Q75. Your date of birth
Q76. Your National Insurance (NI) number
Q77. Your address, if different to the child’s
Q78. If you live in Wales do you want us to communicate with you in Welsh?
Options: No; Yes
Q79. Your contact details
Q80. What is your relationship to the child?
Q81. What is your nationality?
Guidance: For example British, Polish, Indian or any other nationality as shown on your passport or legal documents.
Q82. Are you getting or waiting to hear about Income Support?
Options: No; Yes
Q83. Is anyone within your household getting or waiting to hear about Income Support?
Options: No; Yes
Q84. Name of the account holder
Guidance: Please write the name of the account holder exactly as it is shown on the debit card, statement or chequebook.
Q85. Full name of the bank or building society
Q86. Sort code
Guidance: Tell us all 6 numbers, for example 12-34-56.
Q87. Account number
Guidance: Most account numbers are 8 numbers long. If your account number has fewer than 10 numbers, please fill in the numbers from the left.
Q88. Building society roll or reference number
Guidance: If you are using a building society account you may need to tell us a roll or reference number. This may be made up of letters and numbers, and may be up to 18 characters long. If you are not sure if the account has a roll or reference number, ask the building society.
Q89. Tell us anything else you think we should know about the child’s day to day difficulties.
Guidance: If you need more space continue on a separate piece of paper. Please put the child’s name, National Insurance (NI) number and date of birth on any extra pieces of paper you send us.
Q90. Signature
Q91. Print your name here
Q92. Date