Disability Living Allowance

for a child under 16

We have many different ways we can communicate with you.

If you need braille, British Sign Language, a hearing loop, translations,
large print, audio or something else please contact us.
Our contact details are:
• Phone: 0800 121 4600
• Textphone: 0800 121 4523
• Relay UK: 18001 8 121 4600.
If you live in Wales and want this form in Welsh call 0800 328 1744.

About filling in this form

What you need to do:
• use this form to claim Disability Living Allowance for a child under 16
• you can also get a claim form sent to you by calling 0800 121 4600
• before you fill in this claim form, please take a few minutes to read the information
booklet that comes with this form. It contains important information and helps
explain some of the questions we ask you and why we are asking them
• if you complete this form using a PDF reader on a desktop or laptop computer,
you can save data typed into this form so you do not have to complete it in one
session. When you have finished you will need to print the claim form to send it
to us. You can also print the form first and complete it all by hand
• if you fill in this form using a pen, use black ink
• if you have difficulty filling in this form, ask for help. You can ask a relative,
friend or someone at an advice centre to help you but you must sign the form
yourself, if you can
• please answer all the questions as fully as possible, and send us all the
documents we have asked for. If you do not give us all the information we ask
for, it may delay your claim. For more information on what evidence you need
to send to us, please see page 7 of the information booklet.

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Special rules
We have special rules for children who are
nearing the end of life and are not expected 01 Are you claiming for a child under the
to live longer than another 12 months. special rules?
To find out more about special rules, please No Go to question 2
read page 5 of the information booklet.
Yes You do not need to answer
the care questions which are
questions 54 to 72.

To help us deal with the claim as quickly as possible, it is important you

send us an SR1 form about the child’s medical condition. You can get the
form from the child’s doctor or specialist. You will not have to pay for it.
The doctor’s receptionist, a nurse or a social worker can arrange it for you.
If you have not got an SR1 form by the time you have filled in the claim
form, send the claim form anyway. If you wait the child’s payments could
be delayed. Send the SR1 form as soon as you can or ask your doctor or
specialist to send it to us for you.

About the child

Please use BLOCK CAPITALS when completing the child’s names.

02 Their surname or family name 07 Their sex

Male
Female
03 All their other names in full
08 Their home address
Where the child normally lives

04 Any other names the child has had

05 Their National Insurance (NI) number Postcode

This is the same as their Child Reference
number. See page 8 of the notes.
09 Their nationality
For example, British, Spanish, Turkish

06 Their date of birth

DD/MM/YYYY

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 10 If the child is a Swiss or European 13 What date did the child move to live in
Economic Area (EEA) national, were England or Wales?
they living in the United Kingdom (UK) DD/MM/YYYY
before 1 January 2021?
UK is England, Scotland, Wales and
Northern Ireland
14 Is the child getting or have they made
No
a claim for Child Disability Payment?
Yes
No
Do not know
Yes
11 Does the child normally live in England
15 Has the child moved from another
or Wales?
country in the last 3 years to live in
No We will contact you about this. Great Britain (GB)?
Yes GB is England, Scotland and Wales
No Go to question 17
12 Has the child moved from Scotland
to live in England or Wales since Yes
1 July 2021?
16 What date did they arrive in GB?
No Go to question 15 DD/MM/YYYY
Yes

17 Please tell us the child’s

Passport Number, if known

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About going abroad

18 Has the child been abroad in the last 3 years?

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.
No Go to question 19
Yes

Please tell us about all the times the child has been abroad in the last 3
years. If you do not, it will delay your claim.

Date they Date they Where they went? Why they went?
left GB arrived back
in GB
DD/MM/YYYY DD/MM/YYYY

If there is not enough space, please tell us at question 89 ‘More information’. If you
need to use a separate sheet of paper, please write the child’s full name and National
Insurance (NI) number on each sheet of paper and sign and date each sheet that you use.

About benefits from a European Economic Area state

or Switzerland

19 Is the child’s parent or guardian 20 Is the child’s parent or guardian

getting any pensions or benefits from working in or paying insurance to an
a European Economic Area (EEA) state EEA state or Switzerland?
or Switzerland? By insurance we mean work
No contributions, like UK National Insurance

Yes No

Do not know Yes

If you have answered Yes or Do not Do not know
know, we will contact you about this. If you have answered Yes or Do not
know, we will contact you about this.

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About time in a hospital, hospice, residential school or
other similar accommodation

21 Is the child currently in a hospital? 22 Has the child had any overnight
stays at a hospice, residential
No Go to question 22 college or similar accommodation in
Yes the last 12 months?
Please tell us the date they went in For example, a residential care home,
boarding school or similar accommodation
DD/MM/YYYY
No Go to question 23
Yes
Please tell us the full name and address
Please tell us the date they went in and
of the hospital.
the date they came out.
DD/MM/YYYY

In

Out
Postcode
Please tell us the full name and address
Phone number of the hospital. of the accommodation.

Why did they go in?

Postcode

Phone number of accommodation, if

you know it

Is the NHS paying the costs for Tell us about any other stays within the
their stay? last 12 months at question 89.
Did any of the following pay any of the
No costs towards them living there?
Yes Local authority
Health authority
Government department
Name of authority or department

NHS
None of these

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About the child’s health professionals or specialist support
To help us understand how the child’s health condition or disabilities
affect their day-to-day life, we may contact the child’s health professionals
for more information about their difficulties.
For example, a hospital doctor, consultant, nurse, occupational therapist,
physiotherapist, educational psychologist, social worker or support worker.
This will help us make a decision on your claim more quickly.

23 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?
By ‘health professional assessments’ we mean: audiogram, MRI scan,
speech therapy, cognitive development or IQ test or something else
No Go to question 24
Yes
Tell us if the child is waiting for an assessment appointment.

Date and type of test What did the test show? Are they
waiting for
results
Example
June 2016 eyesight test. They needed to see a hospital doctor No
Yes

No
Yes
No
Yes
No
Yes
No
Yes

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 24 Do you have any letters or assessment reports about the child’s
health conditions or disabilities?
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.
No Go to question 25
Yes
Tell us what reports you have. For example, educational psychologist’s
report or Certificate of Vision Impairment (CVI). Please do not include
things like appointment letters or general information about the
child’s condition like fact sheets or information from the internet.

It is important you send us this information as it will help us make

a decision on your claim more quickly. Please do not send original
copies as we cannot return them.

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 25 Does the child have any health About the child’s GP
professionals, who are not their GP,
who supports them with their health 26 Child’s GP’s name
condition or disabilities?
If you do not know the GP’s name, tell us
No Go to question 26 the name of the surgery or health centre

Yes
Health professional’s name in full
27 Surgery address in full

Their relationship to the child?

For example, neurologist or
physiotherapist

Postcode

Their address, in full

28 Surgery phone number, if you know it

29 Tell us the date the child last had

contact with their GP about their
Postcode health condition or disabilities
A phone number we can contact them DD/MM/YYYY
on, if you know it

The child’s hospital record number. You

can find this on their appointment card
About the child’s nursery,
or letter school and educational or
specialist needs

Which condition or disability did they see 30 Name of the school or nursery the
the child about? child attends

What date did the child last have contact 31 Address in full
with them about their health condition
or disabilities?
DD/MM/YYYY

If the child has any other health Postcode

professionals, who are not their GP, please
tell us at question 89 ‘More information’

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 32 Please tell us the name of someone we 37 Does the child have any of the
can contact at the school if we need following reports, plans or statements?
more information Please tick all the boxes that apply
For example, a teacher or support worker
who knows the child well Educational Health Care Plan (EHCP)
Individual Education Plan (IEP)
Individual Behaviour Plan (IBP)
33 A phone number we can contact them A letter, note in lieu or a statement
on, if you know it of Special Educational Needs from
the local authority
Co-ordinated Support Plan (CSP)
34 Their email address, if you know it I am waiting to hear about one of
the above
The child does not have any of the
35 Is this a mainstream school? above reports, plans or statements
If you have any of the above reports or
No
statements, please send us a copy. It
Yes Go to question 37 may help us to make a decision on your
claim more quickly. Please do not send
36 Is this a specialist school? originals as we cannot return them.
For example, a specialist school that
gives support to children with learning
difficulties or disabilities
No
Yes
What type of school is it?

If the child needs help under School

Action or School Action Plus, the teacher
will provide a report to the local authority
about the child’s difficulties. If more
support is agreed, the local authority will
complete an assessment and provide a
report or statemented plan.

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More information from someone who knows the child

38 Is there anyone else who knows the child and can tell us about
their difficulties?
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.
No Go to question 39
Yes Please ask them to fill in their statement and then they
must fill in the declaration on page 11.
This statement is about:

Their date of birth

DD/MM/YYYY

If there is not enough space, please use the ‘More information’ box at question 89. If you
need to use a separate sheet of paper, please write the child’s full name and National
Insurance (NI) number on each sheet of paper and sign and date each sheet that you use.

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 The person who knows the child and filled in the statement box on
page 10 must sign to declare the information they have given us
about the child is true.

Signature

Name
Please use block capitals.

Date
DD/MM/YYYY

Job or profession

Phone number
Include the dialling code.

Full address

Postcode

Relationship to child
If applicable.

When did you last see the child?

DD/MM/YYYY

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 39 Sharing information about the child’s DWP can lawfully ask the child’s
health condition doctor, hospital consultant or
The Department for Work and other relevant professionals for
Pensions (DWP) or approved healthcare information about their health
professionals that work for DWP, might condition and how it affects them.
need more information about the This is because we are asking for the
child’s health condition and how it information to help us carry out our
affects them. official social security functions.
They might ask for relevant information
from the child’s doctor, or any You do not have to give your consent.
other relevant professional you tell If you do not, DWP will make a decision
them about. based on the information they have
Do you give consent for the child’s already, as well as any you give
doctor or other relevant professionals DWP yourself.
to give DWP more information about If you change your mind
their health condition?
You can change your mind. You can
Yes – information about the do this by contacting 0800 121 4600
child’s health can be and say you want to give or
shared with DWP or the withdraw your consent.
healthcare professionals
If you withdraw your consent, DWP
that work for them.
cannot get information from the child’s
doctor or others named on the form.
No – information about the
child’s health cannot be I have read and understood how DWP
shared with DWP or the uses information.
healthcare professionals Signature
that work for them.

How DWP uses this information

DWP uses this information to:
• process your claim
• make a decision on your claim, or any
mandatory reconsideration or appeal Date
you make. DD/MM/YYYY
The law allows DWP to get, keep and use
this information.
The child’s doctor (or other relevant
professionals you tell DWP about)
need your consent to give information
to DWP. If you give your consent, this
lets them know that they are legally
allowed to share this information
with DWP.

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About the child’s health condition or disabilities

40 Please tell us about the child’s health condition or disabilities:

• 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.

Health condition How long have What treatment do they How often do they
or disability they had it? have for it? have treatment?

Example 1 Problems Cognitive behaviour therapy. One hourly session

ADHD. started aged 4. Ritalin 30 Milligrams (mg). a week.
One tablet a day.
Example 2 About 1 year. Promethazine 5mg. One before bed.
Eczema. 1% Hydrocortisone cream. 3 times a day.
E45 Emollient bath oil. Daily.
Example 3 From birth. Play therapy. Every day.
Visually impaired.

If you need more space to tell us about their health condition or

disabilities, please tell us at question 89 ‘More information’.

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 41 Does the child use, or have they been prescribed or had an
occupational health assessment for any aids or adaptations?
Aids such as hand rails, perching stools, walking sticks or wheelchairs.
No Go to question 42
Yes
Tell us about:
• aids used at home, at school or anywhere else
• aids or adaptations they have been assessed for or are waiting for
• what help they need to use it. This could be supervision, prompting
or assistance.

See page 8 of information booklet.

Aids and adaptations What help do they need to Was this aid or adaptation
use the aid or adaptation prescribed by a healthcare
professional?
For example, an
occupational therapist or
assessment.
Example of aid: Picture Prompting to use cards to No
Exchange Cards communicate
Yes
Example of adaptation: No help needed No
Hand rails
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
If you need more space to tell us about their aids or adaptation, please
continue at question 89 ‘More information’.

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 42 When the child needs help
We understand the help a child needs can vary from day to day
or week to week.
To make the right decision, we need to know if the help the child needs is
the same on most days or if the help they need changes from day to day.
Does the child’s needs stay the same on the majority of the days or does
it change from day to day?
majority of days
changes from day to day
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.

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About the child’s mobility needs 45 How far can they walk without having
Mobility can only be awarded to a child from severe discomfort and how long does it
age 3. If the child is under 3, please go to take them?
question 54. This means the total distance they
can walk before they need to stop and
We need to know about any difficulties the rest or cannot move any further because
child has with standing and moving around. it would cause severe discomfort or
This could be due to a cognitive, learning or distress. This may include:
physical health condition or disability. • short stops and rests to catch their
We do not pay Disability Living Allowance for breath or reduce their pain, or
a child having a particular health condition or • cannot move any further as it will cause
disability, but for the impact it has on them. behavioural distress.

When making decisions on entitlement to See page 9 of information booklet.

Disability Living Allowance, we look at the How far can they walk?
child’s ability to stand and then move on a
reasonably flat surface. over 200 metres (218 yards)
51 to 200 metres (56 to 218 yards)
43 Can the child physically walk?
50 metres (55 yards or less)
No Go to question 51
a few steps
Yes
How long does it take them?
44 Does the child have any difficulties
with standing and moving around due more than 5 minutes
to a health condition or disability? 3 to 4 minutes
For example:
• difficulty with how far they can walk 1 to 2 minutes
• how long it takes them
• their walking speed: very slow, slow, less than a minute
normal
• the way they walk. Such as: limp, 46 Please tell us about their walking speed
altered gait Tick the box that best describes the way
• refusal to walk or displaying behaviours they walk
that risks harm to themselves or others. Normal – they can walk at the
No Go to question 49 same speed as other similar
children who do not have a health
Yes 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.

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 47 Please tell us about the way they walk 48 Does the child have any other
Tick the box that best describes the way difficulties either during or after
they walk. standing and moving around that
affects their health?
They walk normally For example, dizziness, anxiety,
They walk with a limp breathlessness, tiredness or pain. For
example, walking can cause bleeding into
They shuffle the ankle joints.
They drag their leg No Go to question 49
They walk with one leg or both feet Yes
turned inwards
Please tell us about this
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
Please tell us about this

49 Do they need guidance or

supervision most of the time
when they walk outdoors?
See page 10 of information booklet
No Go to question 50
Yes

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 Can they find their way around places When they fall, can they get up without
they know? help or assistance?
No No
Yes Yes
Can they ask for and follow directions? Have they had injuries from the falls
needing hospital treatment?
No
No
Yes
Can they walk safely next to a busy road? Yes

No 51 When did the child’s mobility needs

start?
Yes
Normally, the child can only get the
Can they cross a road safely? mobility part of DLA if they have needed
No help for more than 3 months.
Please tell us the date their mobility
Yes
needs started.
Can they understand common dangers If you cannot remember the exact date,
outdoors? tell us roughly when this was.
No DD/MM/YYYY
Yes
Do they regularly become anxious,
display distressed behaviours, show
confusion and become disorientated? The Motability Scheme
No The Motability Scheme allows disabled people
to lease a car, scooter or powered wheelchair
Yes in exchange for all or some of their mobility
Do they regularly display unpredictable payments. Parents and carers can join the
behaviour? scheme on behalf of a child aged 3 and above.
No 52 If the child is eligible for help from
Yes Motability, would you like us to send
you information about the help they
Do they regularly need physical restraint?
can offer?
No We will not share any personal details
with Motability
Yes
No
50 Do they fall due to their health
condition or disability? Yes
If you decide you do not want to
No Go to question 51 receive information about Motability
Yes in the future, please contact us on
0800 121 4600 to let us know.
Tell us the number of falls each month

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More information about their mobility needs

53 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.

If you need more space, please continue at question 89 ‘More information’.

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About the child’s care needs
If you are claiming under special rules, for a child who is nearing the end of
life, please go to question 73.
We need to know about any difficulties the child has with their daily living care
needs due to a cognitive, learning or physical health condition or disability.
When making decisions on entitlement to Disability Living Allowance, we look
at the child’s ability to manage their day to day care needs and activities. We
do not pay Disability Living Allowance for a child having a particular health
condition or disability, but for the impact it has on their everyday life.

About help needed during the day

Daytime is any time before the child’s parents or carer goes to bed.
For example:
• the child wakes up at 7am and goes to bed at 8pm
• the child’s parents get up at 7am and go to bed at 11pm
• daytime would be 7am till 11pm. Any help needed after 11pm would count
as help during the night.

54 Does the child need encouragement, How many minutes does this take
prompting, or assistance to settle in each time?
bed during the day?
Such as:
• waking up How often each day do they need
• lifting their legs into or out of bed encouragement, prompting or
• sitting up from lying down, or assistance to help to get into bed?
• settling in bed ready to go to sleep.

See page 11 of information booklet.

How many minutes does this take
No Go to question 55
each time?
Yes
Tell us how often they need help
each day and how long it takes each How often each day do they need
time. If they do not need help for a encouragement, prompting or assistance
certain activity, please write ‘0’. to help settle in bed?
How often each day do they need
encouragement, prompting or assistance
to help them get out of bed? How many minutes does this take
each time?

If you need to tell us more information

about their daily living or care needs, tell
us at question 72.

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 55 Do they need encouragement, 56 Do they need encouragement,
prompting or assistance to manage prompting, or assistance to help
their toilet needs? move around indoors, use stairs
This means: or get into or out of a chair during
• being able to get on or off a standard the day?
toilet and A chair is any type of chair including
• emptying their bowel or bladder, a wheelchair.
including if they use a collecting device This means:
such as a bucket, bottle or catheter • moving from one place to another
• cleaning themselves after using • using stairs
the toilet. • getting into, sitting in, and getting out
of a chair.
See page 12 of information booklet.
Indoors is in their home, a friend’s
No Go to question 56 home, school, college, or anywhere
Yes Tick the boxes that apply. else inside.
They need encouragement, See page 13 of information booklet.
prompting or assistance to: No Go to question 57
go to the toilet Yes Tick the boxes that apply.
manage clothes They need encouragement,
prompting or assistance to:
get on and off the toilet
go up and down one step
wipe and clean themselves
go upstairs
wash and dry their hands
go downstairs
manage a catheter, ostomy
or stoma move around safely
manage nappies or pads get into or out of a chair

If you need to tell us more information sit in a chair

about their care needs or how their If you need to tell us more about their
needs change from day to day, tell us care needs or how their needs change
at question 72. from day to day, tell us at question 72.
For example, they have pain or For example, they bump into furniture
become distressed. and doors.

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 57 Do they need encouragement, How often each day do they need
prompting, or assistance with encouragement, prompting or
washing, bathing, showering and assistance to get in or out of the bath?
cleaning themselves during the day?
This means:
• getting in and out of a bath or shower How many minutes does this take
• washing their hair each time?
• drying themselves
• using soap
• using a toothbrush
• checking their appearance. How often each day do they
need encouragement, prompting
See page 14 of information booklet. or assistance to get in or out of
the shower?
No Go to question 58
Yes
Tell us how often they need help How many minutes does this take
each day and how long it takes each each time?
time. If they do not need help for a
certain activity, please write ‘0’.
How often each day do they need How often each day do they need
prompting or assistance to wash encouragement, prompting or
or bathe? assistance to clean themselves in
the bath or shower?

How many minutes does this take

each time? How many minutes does this take
each time?

How often each day do they need

prompting or assistance to clean How often each day do they need
their teeth? encouragement, prompting or
assistance to dry themselves
after a bath or shower?
How many minutes does this take
each time?
How many minutes does this take
each time?
How often each day do they need
encouragement, prompting or assistance
to wash their hair? How often each day do they need
encouragement, prompting or
assistance to check their appearance?
How many minutes does this take
each time?

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 How many minutes does this take How often each day do they need
each time? encouragement, prompting or
assistance to manage zips, buttons,
or other fastenings?
If you need to tell us more information
about their daily living or care needs,
tell us at question 72. How many minutes does this take
each time?
58 Do they need encouragement,
prompting, or assistance to dress
and undress during the day?
How often each day do they need
This means: encouragement, prompting or
• choosing the right clothes for the assistance to choose appropriate
weather or activity clothes?
• choosing clean clothes
• putting clothes on in the correct order
• moving their arms or legs to put
clothes on or take them off. How many minutes does this take
each time?
This is any dressing or undressing
except when using the toilet.
See page 15 of information booklet.
If you need to tell us more information
No Go to question 59 about their daily living or care needs,
tell us at question 72.
Yes
Tell us how often they need help 59 Do they need encouragement,
each day and how long it takes each prompting, or assistance to
time. If they do not need help for a eat and drink during the day?
certain activity, please write ‘0’. Such as:
How often each day do they need • remembering when to eat
encouragement, prompting or • cutting food into pieces
assistance to dress? • putting food and drink in their mouth
• chewing and swallowing food and drink.

See page 16 of information booklet.

How many minutes does this take
each time? No Go to question 60
Yes
Tell us how often they need help each
How often each day do they need day and how long it takes each time.
encouragement, prompting or If they do not need help for a certain
assistance to undress? activity, please write ‘0’.
How often each day do they need
encouragement, prompting or
How many minutes does this take assistance to eat?
each time?

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 How many minutes does this take 60 Do they need encouragement,
each time? prompting, or assistance with
managing their medication or
monitoring or managing any
treatments carried out at home
How often each day do they need
during the day?
encouragement, prompting or
assistance to use a spoon? Such as:
• monitoring pain, blood sugar and
oxygen levels
• reminding or supervision to
How many minutes does this take take medication
each time? • removing medication from the
blister packs
• home treatments such as
physiotherapy and home dialysis.
How often each day do they need
encouragement, prompting or See page 17 of information booklet.
assistance to cut up food on their plate?
No Go to question 61
Yes
How many minutes does this take Tell us how often they need help each
each time? day and how long it takes each time.
If they do not need help for a certain
activity, please write ‘0’.
How often each day do they need How often each day do they need
encouragement, prompting or encouragement, prompting or assistance
assistance to drink using a cup? to take the correct medication?

How many minutes does this take How many minutes does this take
each time? each time?

How often each day do they need How often each day do they need
encouragement, prompting or encouragement, prompting or assistance
assistance to be tube or pump fed? to know when to take their medication?

How many minutes does this take How many minutes does this take
each time? each time?

If you need to tell us more information How often each day do they need
about their daily living or care needs, tell encouragement, prompting or
us at question 72. assistance to manage their therapy?

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 How many minutes does this take Can they see a TV and follow the
each time? actions to a story?
No

How often each day do they need Yes

encouragement, prompting or Can they see the shape of furniture in
assistance to remind them of when a room?
to do their therapy?
No
Yes
How many minutes does this take
Can they recognise someone’s face
each time?
across a room?
No
If you need to tell us more information Yes
about their daily living or care needs,
Can they recognise someone across
tell us at question 72.
a street?
61 Do they have difficulty seeing? No
This includes when using their glasses
Yes
or contact lenses.
If you need to tell us more information
See page 17 of information booklet.
about their daily living or care needs,
No Go to question 62 tell us at question 72.

Yes 62 Do they have difficulty hearing?

Are they certified as severely sight This means hearing sounds or someone
impaired or sight impaired? speaking when using their hearing aid.

If they are certified they will have been See page 18 of information booklet.
examined at a hospital or eye clinic.
No Go to question 63
A Certificate of Vision Impairment (CVI)
will have been sent to the local social Yes
services department. You will have Have they had an audiology test
been given a copy. in the last 6 months?
If they are certified, please send us No
a copy of the CVI. Please do not send
originals as we cannot return them. Yes
Certified severely sight impaired If you send us a copy of the report it
Go to question 62 may help us make a decision on your
claim more quickly. Please do not send
Certified sight impaired originals as we cannot return them.
Can they see computer keyboard keys
Can they hear a whisper in a quiet room?
or large print in a book?
No
No
Yes
Yes

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 Can they hear a normal voice in a Can they communicate using speech
quiet room? with someone they know?
No No
Yes Yes
Can they hear a loud voice in a Can they communicate using speech
quiet room? with someone they do not know?
No No
Yes Yes

Can they hear a TV, radio or CD but only If you need to tell us more information
at a very loud volume? about their daily living or care needs,
tell us at question 72.
No
Yes 64 Do they have difficulty and need
help communicating?
Can they hear a school bell or car horn?
This means:
No • understanding what is being said to
them and answering questions
Yes • telling people how they feel
If you need to tell us more information • giving and following instructions.
about their daily living or care needs,
See page 20 of information booklet.
tell us at question 72.
No Go to question 65
63 Do they have difficulty speaking?
Yes
This means the ability to say words out
loud and talk clearly. Do they use any of the following
to communicate?
See page 19 of information booklet.
Tick all that apply
No Go to question 64
Writing
Yes British Sign Language (BSL)
Can they speak clearly in sentences?
Lip reading
No
Using hand movements,
Yes facial expressions and
body language
Can they put words together to
make simple sentences? Makaton
No Signed Supported English (SSE)
Yes Signed English (SE)
Can they speak single words? Finger spelling
No Picture Exchange
Yes Communication System (PECS)
Tadoma

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 If they use another form of Do they have any warning before a fit,
communication that has not been listed, blackout or seizure?
please tell us.
No
Yes
Sometimes
Can they recognise a warning and tell
an adult?
Can they communicate with someone
they know? No
No Yes
Yes Sometimes
Can they communicate with someone Can they recognise a warning and take
they do not know? the appropriate action?
No No
Yes Yes
If you need to tell us more information
Sometimes
about their daily living or care needs,
tell us at question 72. Have they had a serious injury in the
last 6 months because of a fit, blackout
65 Do they have fits, blackouts, seizures, or seizure?
or something similar?
No
This means epileptic, non-epileptic
or febrile fits, faints, absences, Yes
loss of consciousness and ‘hypos’ Are they at risk of harm to themselves or
(hypoglycaemic attacks). others after a fit, blackout or seizure?
See page 21 of information booklet. No
No Go to question 66 Yes
Yes How many days on average does
this happen each month?
Tell us what type they have and
what happens:
How many fits do they have on
average on these days?

How many nights on average does

this happen each month?

How many fits do they have

on average on these nights?

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 Have they had an episode of status Do they regularly become upset
epilepticus in the past 12 months? or frustrated?
This is where there is persistent No
epileptic activity for more than
30 minutes, or they have several Yes
seizures without becoming conscious Do they regularly harm themselves
between each seizure. or others?
No No
Yes Yes
If you need to tell us more information Do they regularly feel someone may
about their daily living or care needs, harm them?
tell us at question 72.
No
66 Do they need to be supervised during
Yes
the day to keep them safe?
This means they need someone to keep Do they regularly become verbally
an eye on them because of how they abusive or display distressed
feel or behave, or how they react to behaviours that can cause harm to
people, changing situations and things themselves or others?
around them. No
See page 22 of information booklet. Yes
No Go to question 67 Do they regularly act impulsively?

Yes No

Can they recognise and react to Yes

common dangers? Do they regularly become overwhelmed
or distressed?
No
For example, they may lose their
Yes awareness of where they are or what
Can they cope with planned changes they are doing?
to daily routine? No
No Yes
Yes If you need to tell us more information
Can they cope with unplanned about their difficulties or how their
changes to daily routine? needs change from day to day, tell us
at question 72.
No
Yes

Do they regularly feel anxious or panic?

No
Yes

11/24 28 of 40 DLA1 Child (ALT)

 67 Do they need extra help with Do they need help to understand,
their development? react and respond to other
This means any extra help they need people’s behaviour?
to improve their understanding of
how to behave and react to people, No
situations and things around them. Yes
See page 22 of information booklet. If you need to tell us more information
No Go to question 68 about their difficulties or how their
needs change from day to day, tell us
Yes at question 72.
Do they need help to understand the
world around them? 68 Do they need encouragement,
prompting or assistance at school
No or nursery?
Yes See page 23 of information booklet.
Do they need help to recognise
No Go to question 69
their surroundings?
Yes
No
Do they need encouragement,
Yes prompting or assistance to go to
Do they need help to follow instructions? and use the toilet?

No No

Yes Yes
Do they need help to play with others? Do they need encouragement,
prompting or assistance to safely
No move between lessons?
Yes No
Do they need help to play on their own?
Yes
No Do they need encouragement,
Yes prompting or assistance to change into
different clothes for physical education
Do they need help to join in activities and other school activities?
with others?
No
No
Yes
Yes
Do they need encouragement,
Do they need help to behave prompting or assistance to eat meals?
appropriately?
No
No
Yes
Yes

11/24 29 of 40 DLA1 Child (ALT)

 Do they need encouragement, What is their behaviour like at
prompting or assistance to take school or nursery?
medicine or manage their therapy?
No
Yes
Do they need encouragement,
prompting or assistance to
communicate?
No
Yes

What extra help do they need with

their learning?

How do they usually get to and from

school or nursery?

If you need to tell us more information

about their daily living or care needs,
tell us at question 72.

11/24 30 of 40 DLA1 Child (ALT)

 69 Do they need encouragement, prompting or assistance to take
part in hobbies, interests, social or religious activities?
See page 24 of information booklet.
No Go to About help needed during the night
Yes
Tell us:
• what they do or would do if they had help
• what help they need or would need to do this
• how often they do it or would do it if they had the help, and
• how long they need or would need help each time.

At home

Activity Help needed How often? How long

each time?

Example Encourage to get art supplies. 2 times a week One hour

Art Motivate to keep interested. Help to
wash hands afterwards

When they go out

Activity Help needed How often? How long

each time?

Example To get changed, to get in and out of Once a week 45 minutes

Swimming the pool, to dry themselves

11/24 31 of 40 DLA1 Child (ALT)

About help needed during How many minutes does this take
the night each time?
Night is when everyone in the house is in bed.
For example, the child goes to bed at 8pm.
How many times a night do they need
The child’s parents or carer goes to bed the help?
at 11pm.
Night would start at 11pm.
On average how many nights each week
Any help needed before 11pm would count as do they need encouragement, prompting
help during the day. or assistance to have treatment?
See page 24 of information booklet.

70 Due to a health condition or disability How many minutes does this take
do they wake and need assistance or each time?
supervision during the night?
No Go to question 71
Yes How many times a night do they need
the help?
Tell us how often they need help, how
long it takes each time and how many
nights per week they need help . If they
do not need help for a certain activity, On average how many nights each week
please write ‘0’. do they need encouragement, prompting
or assistance to settle or re-settle?
On average how many nights each
week do they need encouragement,
prompting or assistance to get into,
get out of or turn in bed? How many minutes does this take
each time?

How many minutes does this take

each time? How many times a night do they need
the help?

How many times a night do they need

the help? On average how many nights each
week do they need supervision
because they are unaware of danger
or may harm themselves or others?
On average how many nights each
week do they need encouragement,
prompting or assistance to get to and
use the toilet, manage nappies or pads? How many minutes does this take
each time?

11/24 32 of 40 DLA1 Child (ALT)

 How many times a night do they need Additional information about
the help? care needs

71 What date did the child’s difficulties

On average how many nights each with their care needs start?
week do they need supervision DD/MM/YYYY
because they may wander about?

If you cannot remember the exact date,

How many minutes does this take tell us roughly when this started.
each time? Normally, the child can only get the
care part of Disability Living Allowance
if they have needed help for more than
How many times a night do they need 3 months.
the help?

On average how many nights each

week do they need supervision because
they have behavioural problems?

How many minutes does this take

each time?

How many times a night do they need

the help?

If you need to tell us more information

about their daily living or care needs,
tell us at question 72.

11/24 33 of 40 DLA1 Child (ALT)

More information about their daily living and care needs

72 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.

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.

11/24 34 of 40 DLA1 Child (ALT)

About you If you have speech or hearing
Use this page to tell us about yourself, not difficulties do you want us to
the child. contact you by textphone?
No
73 Your surname or family name
Yes
What is your textphone number?
74 All other names in full

80 What is your relationship to the child?

Title
For example, Mr, Mrs, Miss, Ms
81 What is your nationality?

75 Your date of birth

DD/MM/YYYY
About Income Support

82 Are you getting or waiting to hear

76 Your National Insurance number
about Income Support?
No
Yes
77 Your address, if different to the child’s
83 Is anyone within your household
getting or waiting to hear about
Income Support?
No
Postcode Yes

78 If you live in Wales do you want us to Please tell us their name

communicate with you in Welsh?
No
Their National Insurance number
Yes

79 Your contact details

Their relationship to you
Email address

Telephone number

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How we pay you

Please tell us your account details

You must read pages 25 and 26 of the information booklet
before you fill in the account details.
It is very important you fill in all the boxes correctly, including
the building society roll or reference number, if there is one.
If you tell us the wrong account details, the payment may be
delayed or the child may lose money.
84 Name of the account holder
Please write the name of the account holder exactly as it
is shown on the debit card, statement or chequebook.

85 Full name of the bank or building society

86 Sort code
Tell us all 6 numbers, for example 12-34-56.
— —

87 Account number
Most account numbers are 8 numbers long. If your account number
has fewer than 10 numbers, please fill in the numbers from the left.

88 Building society roll or reference number

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.

11/24 36 of 40 DLA1 Child (ALT)

More information

89 Tell us anything else you think we should know about the child’s
day to day difficulties.

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.

11/24 37 of 40 DLA1 Child (ALT)

Declaration
Please read and sign the declaration.
By submitting this claim you agree that:
• the information you have given is complete and correct and
• while you are getting Disability Living Allowance for a child you will
report changes to your and the child’s circumstances straight away
by calling 0800 121 4600.
If you give wrong or incomplete information, or you do not report changes
straight away, you may:
• be prosecuted
• need to pay a financial penalty
• have the child’s Disability Living Allowance reduced or stopped
• be paid too much Disability Living Allowance and have to pay
the money back
• if we pay you less than we should, we may pay you the money that we
owe you.
I understand that the Department for Work and Pensions may use the
information which it has now or may get in the future to decide whether I am
entitled to:
• the benefit I am claiming for the child
• any other benefit I have claimed
• any other benefit I may claim or be awarded in the future.

This is my claim for Disability Living Allowance.

Signature

Print your name here

Date
DD/MM/YYYY

11/24 38 of 40 DLA1 Child (ALT)

Checklist

To make sure we have all the information we need to process this form please check:
You have included full details for anyone else you have seen about the
child at question 25
You have included full details of your GP at question 26
The person who completed question 38 has signed the declaration
on page 11
You have ticked the relevant box about sharing information at question 39,
and signed the statement about how DWP uses information
The person whose details are in About You on page 35 is the person who
signs the consent and declaration on page 38
You have given us any extra information at question 89
If your claim is going to be late getting to us, you have told us the reason
at question 89

What to do now
Send the claim form and your supporting documents back to us straight away
in the envelope we have sent you. Make sure you add the child’s name and
National Insurance number on any supporting documents you send to us.
If you do not have the envelope, please send the completed form to:
Freepost DWP DLA Child
If you are waiting for some information, do not delay returning your form.
Only send copies of up-to-date supporting information you already have as we
cannot return any originals.
Do not send a CD, DVD, memory stick or any type of electronic media, as we
cannot access these.
Please do not include things like appointment cards or general information about
the child’s condition like fact sheets or information from the internet.

11/24 39 of 40 DLA1 Child (ALT)

More information
Treating people fairly DWP social media channels
We are committed to the Equality Act The official social media accounts in use by the
2010 and treating people fairly. To find out Department for Work and Pensions (DWP) are:
more about this law, search ‘Equality Act’
on www.gov.uk www.youtube.com/dwp

Call charges www.facebook.com/dwp

Calls to 0800 numbers are free from personal www.x.com/dwpgovuk

mobiles and landlines.
www.instagram.com/dwpgovuk
How DWP collects and uses information
When we collect information about you www.linkedin.com/company/dwp
we may use it for any of our purposes.
These include: DWP British Sign Language (BSL) videos
• social security benefits and allowances
www.youtube.com/dwpsign
• child maintenance
• employment and training
• investigating and prosecuting tax
credits offences
• private pensions policy and
• retirement planning.
We may get information about you from
other parties for any of our purposes as the
law allows to check the information you
provide and improve our services. We may give
information about you to other organisations
as the law allows, for example to protect
against crime.
To find out more about our purposes, how we
use personal information for those purposes
and your information rights, including how to
request a copy of your information, go to
www.gov.uk/dwp/personal-information-charter

11/24 40 of 40 DLA1 Child (ALT)