ISF - Individual Survey Form (for handicapped children)
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Family name of child: ______________________________
First name: ________________________________________
Male or female: ____________________________________
Year of birth: _____________________________________
Home address/location: ____________________________
____________________________________________________
____________________________________________________
1. When is the child seen by a doctor/other professional?
Answer:
2. What type of medicine has been used for the child's present
condition?
Answer:
3. Describe the disability:
Answer:
4. Social Background/Status:
Answer (Yes or No):
§ Does the child play and get along with other children?
§ Does the child help with household/odd job activities?
§ Does the child go to school?
§ Does the child cooperate with the rehabilitation process?
§ Does the child participate in local community activities?
§ Is the child happy?
§ Does the child feel part of the family/community?
§ Is the youngster active (financially) to become self-supporting?
§ Can the parents secure the (basic) daily needs?
§ Can the parents pay for any medical expenses/surgery?
§ Does the family support the rehabilitaion process?
§ Can the child eat and drink by himself/herself?
§ Does the child wash him/herself?
§ Can the child dress him/herself?
§ Can the child manage toilet activities by himself/herself?
§ How does the child move inside/outside the house?
§ Can the child see?
§ Can the child hear?
§ Can the child talk?
§ How does the child communicate?
§ How are the child's mental activities?
§ How is the child's other health condition?
(other than disability)
§ Who takes care of the child?
§ Caretaker's relation to the child:
§ Source of income:
§ How many other children does the caretaker supports/helps?
§ Describe the living condition (housing, land, food that is grown
on the land, cattle, poultry)
§ The mediator is directly responsible for the correct use of the
financial assistance of SLF. Who would be responsible for
the aftercare?
DO NOT send this form to SLF if evaluation is not finished. SitD will do
first hand evaluation.
A CbR (Community-based Rehabilitation) is an assistance program for
disabled and handicapped children aged 0 up to 25 years of age. This is
done through a mediator/worker who is already based in a community and is
already involved in a particular community work. One can also act as a
mediator without any experience in ministries like this, but needs to
work with SitD. Our partner organization, Stichting Liliane Fonds, will
provide a subsidy funding for the treatment, surgery, rehabilitation or
therapy of such needy children. Mediators relate with parents, relatives
and neighbors of the child, and eventually the community around gets
involved as well.
