Annex No. 7

Community Services for Returnees Welfare Needs Assessment

Serial No.________________________

1. Name:_________________________________________________

2. Address: _______________________________________________
________________________________________________________
____________________________ Telephone:___________________

3. Date of Birth: __/__/__ 4. Sex: M/F 5. Marital Status: M/S/D/SP/O

6. Education:

A. Formal Education:_____________________________________
B. Informal Education:____________________________________
C. Other Training:________________________________________
_______________________________________________________

7. Work Experience: (Last job held)_____________________________
__________________________________________________________
(Other jobs)________________________________________________
__________________________________________________________

8. Family Composition:

Name:	Rel:	Age:	Sex:	Remarks:
1.
2.
3.
4.
5.
6.
Special Problems:______________________________________ _____________________________________________________

9. Housing:

A. Current Address:____________________________________________
_____________________________________________________________
B. No. of Persons Living Together:_________ C. No. of Rooms:_________
D. Rel. with Householder:_______________________________________
_____________________________________________________________
E. Problems if Any:_____________________________________________
_____________________________________________________________
_____________________________________________________________
F. Other Information:___________________________________________
_____________________________________________________________
_____________________________________________________________

10. Legal/Security:

A. Applied for Indemnity:	Y/N	If YES, has it been granted:	Y/N
B. Applied for I.D.:	Y/N	If YES, application No._________________________
C. Dependents Born in Exile:	Y/N	If YES, give details.

Name:	Date of Birth	Place of Birth	Remarks, Birth Certificate

F. Births Registered in Country of Origin: Y/N
If YES, give details:
_______________________________________________________________
_______________________________________________________________

11. Health:

A. Special Health Problems:		Y/N
Orthopaedic		Chronic Illness		Blindness
Mental Illness		Addiction		Other
Give Details:______________________________________________________ ________________________________________________________________ ________________________________________________________________

B. Needs for Regular Medical Attention: Y/N If YES, give details:__________
________________________________________________________________
C. Hospitalization: Y/N If YES, give details:____________________________
________________________________________________________________
D. Other Help Needed:_____________________________________________
________________________________________________________________

12. Education:

Name:	Level	Institution	Language	Remarks

13. Other Problems Encountered:

1.____________________________________________________________
2.____________________________________________________________
3.____________________________________________________________

14. Plan of Action:

1.____________________________________________________________
2.____________________________________________________________
3.____________________________________________________________

15. Action Taken

1.____________________________________________________________
2.____________________________________________________________
3.____________________________________________________________

Signature: _____________________________ Date:_____________________

Approved by: __________________________ Date:_____________________