Form Wtw 17 - Waiver Of Calworks Learning Disabilities Screening And/or Evaluation
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1
2CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
WAIVER OF CalWORKs LEARNING DISABILITIES
SCREENING AND/OR EVALUATION
Tell your worker if you need help reading or understanding this form. Go over this form very
carefully with your county worker. Be sure to ask questions about anything you do not understand.
If you do not want to be screened or evaluated for learning disabilities at this time, you will be
asked to sign this form and you will get a copy of this form.
Benefits of a Learning Disabilities Screening and Evaluation
It is very important to screen and evaluate you for possible learning disabilities. Please keep in mind
that most people with learning disabilities are intelligent and many are gifted. If the county finds you
have a learning disability, the county will be able to better help you decide what activity is best for you.
Individuals with a learning disability can be taught to use their strengths and find ways to make it easier
to learn and be more successful at school and on the job.
Getting a screening and evaluation for learning disabilities can help you find, keep, and advance in a
job that is right for you. It can also help you do well in an education or training program. The screening
and evaluation can also get you the kind of help and services you will need to meet the welfare-to-
work requirements. You may also be excused from welfare-to-work requirements if your condition is
so severe that it keeps you from regularly working or participating in welfare-to-work activities: 20 hours
per week for a single-parent with a child under six-years-old, 30 hours per week for a single-parent with
no child under six-years-old, or 35 hours for two-parent families.
If you have a previous evaluation that states you have a learning disability, please provide the
evaluation to your county worker. The county may accept all or part of the evaluation and provide you
with reasonable accommodations or not accept the evaluation and refer you for another evaluation.
Your county worker will include information in your case file that the county has accepted your learning
disabilities evaluation. You do not have to sign this waiver if the county accepts your previous evaluation.
If you do not want to be screened or evaluated for learning disabilities at this time and do not
give us other proof of a learning disability:
1. You will not get accommodations for a learning disability.
2. You will have to meet the welfare-to-work requirements like any other person on CalWORKs who
does not have a learning disability. If you do not meet the welfare-to-work requirements, your cash
aid may be lowered or stopped.
3. You may change your mind at any time and ask for a learning disabilities screening and/or a
learning disabilities evaluation.
If you are later found to have a learning disability, the county will get you the help and services you
need following the date your worker discusses the evaluation findings with you and when you sign a
new welfare-to-work plan, if necessary.
Go to the next page to complete this form.
WTW 17 (12/15) REQUIRED FORM - NO SUBSTITUTES PERMITTED
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