Disability Resource Centre: Voluntary Disability Disclosure Form

GENERAL INFORMATION

Layout

Name *

Marital Status *

Gender *

Male
Female
Others

Student ID Number

Nationality *

Gender *

Date of Birth *

II. CONTACT DETAILS

Layout

Phone *

Email *

Mobile *

Mailing Address *

Functional Assessment

To be completed by the applicant.

(Adopted from the 2016 UNICEF/ Washington Group functioning and disability questions”.)

Please put a circle around the appropriate answer:

There are three related questions for Question 1 as some people tend to have more than one health condition.

Question 1. Do you have any health conditions? *

Question 1.1 – a) What is your main health condition? (Select One) *

Poor or no vision
Poor or no hearing
Speech problem
Physical/mobility problem (e.g. can’t 5. walk, hold pen)
Down’s Syndrome
Intellectual disability or slow learner
Other

other *

Question 1.1 – b) What is the cause of your health condition? (Read out options – Select one) *

Existing at birth
Illness/Disease
Don’t know
Other (Please Specify)

Other (Please Specify) *

Question 1.1 – c) How much does this condition bother you? *

1) Not at all
2) A little
3) A lot

Please explain if your answer is 2 or 3 *

Question 1.2 – a) Do you have any other health conditions? What are they? (Select Yes or No) *

	Yes	No
Poor or no vision	YesPoor or no vision Yes	NoPoor or no vision No
Poor or no hearing	YesPoor or no hearing Yes	NoPoor or no hearing No
Speech problem	YesSpeech problem Yes	NoSpeech problem No
Physical/mobility problem (eg can't walk, hold pen)	YesPhysical/mobility problem (eg can't walk, hold pen) Yes	NoPhysical/mobility problem (eg can't walk, hold pen) No
Down's Syndrome	YesDown's Syndrome Yes	NoDown's Syndrome No
Intellectual disability or slow learner	YesIntellectual disability or slow learner Yes	NoIntellectual disability or slow learner No
Asthma	YesAsthma Yes	NoAsthma No
Cerebral Palsy (CP)	YesCerebral Palsy (CP) Yes	NoCerebral Palsy (CP) No
Fits/epilepsy	YesFits/epilepsy Yes	NoFits/epilepsy No
Heart or kidney problem	YesHeart or kidney problem Yes	NoHeart or kidney problem No
Other	YesOther Yes	NoOther No

Question 1.2 – b) What is the cause of your health condition? (Read out options – Select one) *

Existing at birth
Illness/Disease
Accident
Don’t know
Other (Please specify)

Other (Please specify) *

Question 1.2 – c) How much does this condition bother you? (Read out options) *

1) Not at all
2) A little
3) A lot

Please explain if your answer is 2 or 3: *

Question 1.3 – a) Do you have any other health conditions? (If yes, write down) *

What are they? *

Poor or no vision
Poor or no hearing
Speech problem
Physical/mobility problem (eg can’t walk, hold pen)
Down’s Syndrome
Intellectual disability or slow learner
Asthma
Cerebral Palsy (CP)
Fits/epilepsy
Heart or kidney problem
Other ( Chest pains)

other *

Question 1.3 – b) What is the cause of your health condition? (Read out options – select one) *

Existing at birth
Illness/Disease
Accident
Don’t know
Other (Please specify)

Other (Please specify) *

Question 2.0 – Do you wear glasses or contact lenses? Yes/ No *

Question 2.1 – a) When wearing your glasses or contact lenses, do you have difficulty seeing? Would you say you have: no difficulty, some difficulty, a lot of difficulty or could not do at all? *

No difficulty
Some difficulty
Lot of difficulty
Could not do at all

Please explain if your answer is some difficulty, a lot of difficulty or cannot do at all: *

Question 2.1 – b) Do you have difficulty seeing without glasses or contact lenses? Would you say: no difficulty, some difficulty, a lot of difficulty or could not do at all? *

No difficulty
Some difficulty
Lot of difficulty
Could not do at all

Please explain if your answer is some difficulty, a lot of difficulty or cannot do at all: *

Question 3 – Do you have difficulty hearing sounds like peoples’ voices or music? Would you say: no difficulty, some difficulty, a lot of difficulty or could not do at all? *

No difficulty
Some difficulty
Lot of difficulty
Could not do at all

Please explain if your answer is some difficulty, a lot of difficulty or cannot do at all: *

Question 3.1 – a) Do you use a hearing aid? *

Question 3.1 – b) When using your hearing aid, do you have difficulty hearing sounds like peoples’ voices or music? Would you say you have: no difficulty, some difficulty, a lot of difficulty or could not do at all? *

No difficulty
Some difficulty
Lot of difficulty
Could not do at all

Please explain if your answer is some difficulty, a lot of difficulty or cannot do at all: *

Question 4 – Do you use any equipment or assistive device? *

Question 4.1 – If yes, what type of assistive device(s) do you use? (Tick all applicable options) *

Hand powered tricycle
Wheelchair
Crutches
Walking stick
Walking frame
Hearing aid
White cane
Glasses
Magnifier
Orthotic devices (to support legs, arms or spine)
Artificial limbs
Communication boards (e.g. a board which people use to point to and express themselves)
Other (Please specify)

Other (Please specify) *

Question 4.2 – a) Without equipment or assistance, do you have difficulty walking on level ground or climbing stairs? Would you say: some difficulty, a lot of difficulty or could not do at all? *

No difficulty
Some difficulty
Lot of difficulty
Could not do at all

Please explain if your answer is some difficulty, a lot of difficulty or cannot do at all: *

Question 4.2 – b) Using equipment or assistance, do you have difficulty walking on level ground or climbing stairs? Would you say: some difficulty, a lot of difficulty or could not do at all? *

No difficulty
Some difficulty
Lot of difficulty
Could not do at all

Please explain if your answer is some difficulty, a lot of difficulty or cannot do at all: *

Question 5 – Do you have difficulty with self-care such as feeding, dressing, bathing, getting on and off the bed and independently moving around the room? Would you say: no difficulty, some difficulty, a lot of difficulty or could not do at all? *

No difficulty
Some difficulty
Lot of difficulty
Could not do at all

Please explain if your answer is some difficulty, a lot of difficulty or cannot do at all: *

Question 6 – Do you use a ‘Carer’ or ‘personal assistant’ as any time? *

Please explain when and why the assistance is required? *

Layout

Signature *

Clear Signature

Date *