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
Unit | Health Post | Local Health Center | District Hospital | Provincial Hospital | National Hospital, Rehab-Center |
Number | |||||
Number of Professional | |||||
Service Offered |
* Employment situation of disabled people
Category | Welfare of Shelter Unit | Disabled people Employed | Income source | ||
his/her own | family | Social relief | |||
* Education situation of disabled people
Unit | Special education school | Special education classes | Integrate education | Vocational training |
Number | ||||
Number of disabled |
* Number of consumers according to their disabilities
Difficulty in | Seeing | Hearing or speaking | Moving | No feeling in hands (feet) | Strange behavior | Fit | Learning |
Number |
* Age distribution of disabled persons
Age | 0-4 | 5-14 | 15-54 | 55-69 | >70 |
Number |
* Attitudes to disabled persons (describe briefly)
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
Question | Name of household member with this disability | Age | Sex | How long |
1. Does any person have difficulty seeing? | ||||
2. Does any person have difficulty hearing or speaking? | ||||
3. Does any person have difficulty in moving? | ||||
4. Does any person have no feeling in the hands or feet? | ||||
5. Does any person show strange behavior? | ||||
6. Does any person have fit? | ||||
7. Does any person have difficulty in learning? | ||||
8. Does any person have any other difficulty? Name and describe the disability, if you know what it is, next to the person's name. |
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
Feeding | Cleaning | use the latrine | Dress and undress | Sitting up | Standing up | Moving in any way | Writing | |
Alone | ||||||||
With help | ||||||||
Not at all |
* Communication ability
Express needs | Understand movement or sign | Communication with movement or sign | Lip read | Speak | |
Easily | |||||
Difficulty | |||||
Not at all |
* Play and learning like children of the same age
Play | Learning | |
Yes | ||
Below | ||
Not at all |
* Employment and participation in social life
Has job or income | Join in family activities | Join in community activities | |
Yes | |||
Sometimes | |||
No |
- * 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.
Table 4 Record Form - Visit to the Home
Name of disabled person ___________ Disability type __________ Training content __________________ Name of visitor _________ |
||
Date | Time | Comments |
TO (name of supervisor): _____________________________
FROM (name of Local Supervisor): _____________________
Community: _________________________________
Month: ____________________ Year: ____________
____________________________________________
Number of people in the Community Rehabilitation Programme |
|
People from previous month | _______ |
People new this month | +_______ |
Total in community Rehabilitation Programme this month |
_______ |
People discharged | -_______ |
People to continue next month | _______ |
Number of people who made at least one step of progress
during this month:
Evaluating Community Based Rehabilitation :
Guidelines for Accountable Practice
By Dr. Tizun Zhao, Joseph K.F. Kwok Ph.D, J.P.