Identification Form (HI example, Indonesia programme)
IDENTIFICATION FORM
DATE:
NAME OF Community Disability Worker (CDW):
PLACE OF ASSESSMENT: c in home c in social center______
PERSONAL DATA
PATIENT NAME:
AGE:
GENDER:
PARENTS NAME (if under 16):
STATUS (Married or not):
ADDRESS (with kecamatan, desa):
CONTACT TELEPHONE NUMBER:
HEALTH
Medical history (hospitalizations, birth complications, accident, fractures, treatments to date, past and present health issues, etc ):
Physical impairment c YES c NO
Description (can’t walk because can’t move legs, has pain, etc.):
Sensorial impairment c YES c NO
Description (blind, deaf, etc.):
Intellectual impairment c YES c NO
Description:
Mental illness c YES c NO
Description:
ENVIRONMENT
SOCIAL
Number of people in the house and relationships:
Main caregiver if needs (specify when):
Links with neighbors / community members:
ECONOMICAL
Main source of revenue (who and what livelihood activity):
PwD social card: c YES c NO
Other:
Economic status: c Poor c Moderate c Comfortable
PHYSICAL
House description (on steel, level, wooden, concrete):
Access to the house from the street (concrete, sand path, stones):
Presence of steps/stairs outside and inside the house: c YES; where?______
c NO
Material of floor surface:
Situation of the house in the community:
Proximity of services (health center, school, community center, church, etc.):
OCCUPATION
EDUCATION
Education level, ongoing studies:
(If kid) Is the person going to school: c YES c NO
Explain: (name of school, what level if he is, or if not why doesn’t he go):
LIVELIHOOD
Is the person working: c YES c NO
Explain:
Employment history:
Has the person ever received trainings c YES c NO
Other skills:
Interests:
LEISURES (community activity, sports, etc.)
Description of the PWDs social activities:
Is the person satisfied with her present activities? c YES c NO
Explain:
ACTIVITY OF DAILY LIVING
MOBILITY
- Walking indoors c Able alone c Able with help c Unable
Explain:
If unable to walk: c carried c wheelchair c Rolling
- Go to the bathroom c Able alone c Able with help c Unable
Explain:
- Go to the kitchen c Able alone c Able with help c Unable
Explain:
- Go to the living room c Able alone c Able with help c Unable
Explain:
- Go to bedroom c Able alone c Able with help c Unable
Explain:
- Walking outdoors c Able alone c Able with help c Unable
Explain:
If unable to walk c carried c wheelchair c Rolling
Type of transportation able/ unable to use (bus, motorcycle, car):
Places in community that are not accessible to him (market, puskesmas, public buildings, mosq, etc.):
PRAYING:
SELF CARE
- Use the toilet c Able alone c Able with help c Unable
Explain:
- Bathing c Able alone c Able with help c Unable
Explain:
- Dressing c Able alone c Able with help c Unable
Explain:
- Eating / drinking c Able alone c Able with help c Unable
Explain:
DOMESTIC ACTIVITIES
- Food preparation c Able alone c Able with help c Unable
Explain:
- House cleaning c Able alone c Able with help c Unable
Explain:
- Washing clothes c Able alone c Able with help c Unable
Explain:
- Washing dishes c Able alone c Able with help c Unable
Explain:
Main difficulties & needs, according to the person:
Comments/remarks by social agent:
Objectives of the person:
PERSONAL PLAN
Goal (what) / Action (who, how) / Date (when)------
Document from the CD-ROM Personalised social support, Handicap International, 2009