PROFESSIONAL INTEGRATION

OF PERSONS WITH DISABILITIES - HUAMBO

A / IDENTIFICATION OF THE BENEFICIARY

Name:

Key contact (name, address and telephone, relationship): ………......

Sex: M F Date of birth or age: ………………......

School level:………......

Studying? Wishes to continue his/her studies? Wishes to resume his/her studies? ......

Place of residence(district, sub-district, address or landmark):…………………………………………….…......

……………...... …......

Member of an association: ANDA ASADEF Other:...... None

Type of disability
 Hearing
Aesthetic
Intellectual
Speech
 Physical
 1LL
 2LL
 1UL
 2 UL
 LL/UL
 Psychological
Visceral and chronic
Visual
 Other
 I don’t know / Cause of disability
 Inborn
 Acquired
 Mine
Shooting, bomb, other explosives
Disease Which?…………………………
 Accident
Lack of medical care
(conventional mine) / When did the disability occur?
......
How?
......

What are the applicant’s mobility aids (technical devices)?

wheelchair tricycle crutches walking framewalking stickprosthesis orthosisorthopedic shoesglasses othersnone

Demobilised in Bicesse  Lusaka  Luena

Marital status: single cohabitation married widowed separated

Living: alone with his/her own family with relatives at his children’s/other family members’ with friends in an institution

Family status: grand-father/grand-mother father/mother child other

Family composition:

Number / M / W / Total
Adults
Children – number of children of the beneficiary
Seniors

The applicant receives or has received assistance from an institution (MINARS, etc.)?: …………………………….…......

  1. Applicant’s current occupation/activity: ……………………………………………………………………

Where?………………………………………………………………………………………………

Since when? …………………………………………………

Does the applicant live on this activity/ provide for his/her family? …………………………………………………………

Type of products/services sold: ………………………………………………………………………

Competition in the same district? ………………………………………………………………………………

Does the applicant work alone or with other persons? ………………………………………………………………………

  1. Since when is he/she not working?

……………………………………………………………………………

Is the applicant looking for a particular job? ……………………………………………………………

If the applicant does not know what to do:

What types of activities has the applicant already done? …………………………………………………………………………………

What does he/she want to do to improve his/her life? …………………………………………………………………………

What does he/she know or is able to do? ………………………………………………………………………………………………………………………………………

  1. What training programmes did he/she already attend? (type, duration, place)?

………………………………………………………………………………………………………………………………………

  1. What is the applicant’s professional project?

- Attend training? 

- Join a micro-enterprise for apprenticeship? 

- Continue to work in the same activity? 

- Change economic activity?  for what?

Professional field:

Reasons for this?

- The applicant does not have any professional project

  1. How could the association help him/her?

......

Comments/ summary of the interview

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

How was the applicant detected?

following an awareness-raising intervention within his/her community or in another institution

through the radio

through a friend or relative

through local authorities in his/her district

through an administration department (eg. MINARS)

through another association

he/she was not aware of this type of services before joining the association

he/she already knew the association and its services

other

DECISION

Applicant not shortlisted

Cause of refusal:

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Second appointment to be organised

Date: ______