Pwd screening form (blank form)

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Pwd screening form (blank form)

  1. 1. PWD screening form with guidelines for completion Information about the person doing the screening PwD's Personal Information Name: Sex: M M F Age: Marital Status: Unmarried U Married Widowed Separated Divorced Parent/spouse’s name: Address: Who is the contact person or carer for the PWD?(if required) Name and Telephone Number: How many people live in the house and who are they? Is this person’s house located in a disaster prone area? No ? Yes Y Flood prone area F Landslide prone area Fire (near to jungle) Earthquake E Profile of the PwD: Does the person have difficulty seeing? Are they totally blind? Yes A No Comments: No N YesY → Does the person have difficulty hearing? Are they totally deaf? Yes A No Comments : No N YesY → Does the person have difficulty speaking? a) Are they completely unable to speak? Yes a No Comments: No N YesY b) Do they also have difficulty understanding? Yes b No → Comments : Has the person difficulty hearing and seeing?
  2. 2. Is the person completely deaf and blind? Yes I No No N YesY Comments: → Does the person use an aid or need assistance to communicate with others? Braille B Hearing aid Sign language S Lip reading Comments : No N YesY → Does the person have any difficulty walking or moving? Can they walk a short distance? (about 10 metres) Yes C No Can they sit by themselves? Yes C No Comments : No N YesY → Does the person have difficulty using their arms or hands? Can they hold things in their hands? Yes C No Comments : No N YesY → Does the person use an aid or assistance to move around? Walking stick W White cane Crutches Wheelchair 1 person 1 2 people Prosthesis r Callipers a Other (describe): No N YesY → Comments: Does the person have difficulty understanding, remembering or learning new things? Comments : No N YesY → Does the person ever have behavioural difficulties?
  3. 3. Comments : No N YesY → Does the person have difficulty doing self-care activities? Do they need assistance to: Wash Yes W No Go to the toilet Yes G No Dress Yes D No No N YesY Eat Yes E No → Extra comments: What is the person’s occupation? Student S Office worker Daily Labourer Farmer Housewife H Self-employed S Part-time employed Unemployed Other Comments: Where does the person spend most of their day? School/work S In their home In the field Other Comments: Additional comments or recommendations from the person or their family: To be answered by the community worker: Does this person know anything about disasters and what to do if a disaster happens? Yes No Comments: Is this person interested in receiving training in disaster preparedness? Yes No If yes, what training would they like to receive?
  4. 4. Will this person be able to attend this training outside his/her house? Yes No N/A If no, can training be provided at his/her house? Will this person have additional needs during and after disaster? Communication systems: Yes: No Details: Early warning system: Yes: No Details: Search/Rescue/Evacuation: Yes: No Details: Shelter: Yes: No Details: Medical support: Yes: No Details: Aids and assistive devices: Yes: No Details: Additional comments or needs:

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