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close this bookRefugee Emergencies. A Community-Based Approach (UNHCR, 1996, 142 p.)
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Annex No. 6

Assessment Form for a Person who is Disabled or Chronically Ill

(Complete a separate form for each member of a family who is disabled or chronically ill.)

Case No:________________

Principal Applicant's Name:__________________________________________

1. Name of person who is disabled or chronically ill:_______________________

(underline family name)

Sex: female male Year of Birth:_____________________________________

2. Has lived:

with family

with friends since:

with relatives




3. If the disabled or chronically ill person lives with someone who is registered separately, provide the full name of the head of that family:
(underline family name)

4. Does this person have an illness that has lasted more than three months? yes no
If "yes", give the name of the illness and explain how it affects this person.

5. This person has difficulty (mark any boxes that apply):

using his/her legs


using his/her hands or arms



because of acting sometimes in a strange way


with fits

other (specify)________________________________________________________

6. Describe this disability:

7. Explain how and when the disability began:_____________________________

8. The list below includes activities required for normal daily living.

Mark the Immediate Assistance box for any activities that the person is not now able to do and with which he/she does not have someone to help.

Mark the Training box beside any activity the person cannot do without assistance. This will show areas where rehabilitation training may be helpful.

Immediate Assistance


obtaining food, water, fuel (cross out any that do not apply)

preparing food

eating food

washing himself/herself


cleaning his/her house

preventing injuries to parts of his/her body that have no feeling

moving around inside his/her house and immediate living area

moving around outside his/her living area

going to the toilet or latrine


going to school

understanding what is said to him/her

expressing thoughts, needs and feelings

taking part in family activities

taking part in community activities

other (describe)____________________________________

9. Explain how the person previously has been able to accomplish any of the tasks for which immediate assistance is needed:

10. If a change in the location where the person is living or any special adaptations in or around the house (such as handrails or a ramp) would help in meeting daily needs, please explain:

11. If the person is an adult, indicate any:

previous occupation_______________________________________________
current occupation________________________________________________

12. Describe any assistance this person needs to establish or improve an occupation:

13. Has the person ever regularly taken medicine to cure or control illness or disability?



If "yes", explain who told the person to take this medicine, where it was obtained, when the person started taking it and whether the person is still taking it:

14. Describe any other rehabilitation training or medical treatment the person has had for the illness or disability. Explain who provided this treatment, where it was provided, when it began and whether it is still being provided:

15. Add any further details that may be useful to those arranging assistance for this person:



Name of the Interviewer

Organization of Interviewer

Date of Interview

17. Plan for Immediate Action

The space below is to be used by medical, rehabilitation and social services staff to indicate what action should be taken in regard to this case.

Action Required

To be Carried Out by

Recommended by


Immediate assistance with ____________________________________________


Further assessment of________________________________________________


General medical examination __________________________________________


Specialized medical examination________________________________________
(specify type): ______________________________________________________

Additional Comments:_________________________________________________

18. Rehabilitation Plan

1. The rehabilitation goal for the refugee is:_________________________

2. This goal should be achieved by what date?_______________________

3. If the refugee requires medical treatment, explain what treatment is needed and who will provide it:

4. Describe any rehabilitation training that is required and who is responsible for it:

5. Explain what role the refugee and/or the refugee's family will play in this training: