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		alone	mm	yy

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		speaking
	using his/her hands or arms		learning
	seeing		because of acting sometimes in a strange way
	hearing		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	Training
		obtaining food, water, fuel (cross out any that do not apply)
		preparing food
		eating food
		washing himself/herself
		dressing
		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
		working
		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?

yes	no

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:
__________________________________________________________________

16.	______________________________________________________________
	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	Date
	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:
_____________________________________________________________