| Updated On | [date-and-time] | Received Date | [Date] |
|---|---|---|---|
| Effective Date of Change | [Date] | Change Reason | [field-value] |
| Approval Requested | [True] | Approval Status | [Approved] |
| Status | [Active] | Updated By | [User Name] |
| Disability Type | [field-value] |
|---|
| Brain Injury Category | [field-value] |
|---|
| Disability Duration | [field-value] |
|---|
| Start Date | [Date] | End Date | [Date] |
|---|---|---|---|
| Competency Status | [field-value] | Date Competency Determined | [Date] |
| Established Disability Mode | [field-value] | Meets Previous Child Disability Criteria | [True] |
| 1619(b) Recipient | [True] |
Blind Register Details
| Registered Blind | [True] | Cessation Date | [Date] |
|---|
Comments
| [Comments] |