Table1 Survey Form-Community Profile

Name of community __________ Serial No. of the community __________

Name of people responsible ____________________________

Date completed _____ day _____ month _____ year

Total population __________ Number of disabled person __________

Total number of households _______________________

Number of households with disabled people ______________

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* Main nation _____ Ethnic _____ Religion _______

* Name of NGOs __________ Name of networks _______

* Local epidemic disease _______ Disability prevalence _____

* Income source :

industry _____ agriculture _____ commerce _____
fishing _____ animal husbandry _____ other _______

* GNP _____________ Average income/person year _____

* Transport: convenient _____ difficulty _____

* Health situation

* Employment situation of disabled people

* Education situation of disabled people

* Number of consumers according to their disabilities

* Age distribution of disabled persons

* Attitudes to disabled persons (describe briefly)

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Table 2 Survey Form - Households Visit

Name of community _______ Serial No. of the households _____

Address of household __________________________________

Household held :

Name _______ Sex _______ Age _______
Occupation __________ Relationship __________

Total number of people in household ____ Under 15 years ___ Over 15 years ___

Number of disabled people in household ______________________

Your name ______ Date completed _____ day _____ month _____ year

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Table 3 Survey Form -Disabled Person

Name of community ______ Serial number of disabled person _____

Address of household ______ Name of investigator ___________

Name of household head _____ Date complete___ day___month___year

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* Name of disabled ___ Sex ___ Age ___ Nation _____ Religion _____

* Education level ________ Occupation _______ Name of work unit _____

* Marital status : Single _____ Married _____ Divorced _____ Other _____

* Income source: One's own ______ Family ______ Social relief ______

* Difficulty in

Seeing _____ hearing or speaking _____ moving ___ fit _____

no feeling in hand/feet ____Strange behavior ___ learning ___

other ________________________________________________

* Degree of difficulty : Severe _______ Moderate _______ Mild _______

* Cause of disability

Congenital defect _____ Hereditary disease _____ Inbreeding _____

Communicable disease _____ Non communicable disease _____

Accident injury ___ Alcoholism ___ Drug abuse ___ Malnutrition ___

Psychiatric disturbance _______ Other _______

* When did the disability start on _____ date _____ month _____ year.

* Measure accepted

Drug _____ Operation _____ Functional training _____

With aid or equipment ___ Referral ___ Other ___ No treatment ___

* Daily living ability

* Communication ability

* Play and learning like children of the same age

* Employment and participation in social life

* Rehabilitation needs:

Medical care __________ Functional training __________

Aids or equipment ___ Early intervention _______

Schooling ______ Vocational training _______

Get job _______ Marriage _______

Barry-free facilities _____ Get knowledge on rehab ___

Participate in family life ___ and social activities _____

Other ____________________________________

* Self attitude (describe briefly) ____________________________

! Please mark "X", or give description according to the facts.

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Table 4 Record Form - Visit to the Home

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Table 5 Monthly Report Form

TO (name of supervisor): _____________________________

FROM (name of Local Supervisor): _____________________

Community: _________________________________

Month: ____________________ Year: ____________

____________________________________________

Number of people who made at least one step of progress
during this month:

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Go back to the CONTENTS

Evaluating Community Based Rehabilitation :
Guidelines for Accountable Practice

By Dr. Tizun Zhao, Joseph K.F. Kwok Ph.D, J.P.