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Ministry of Social Security, National Solidarity and Reform Institutions

This document contains a questionnaire to collect information about disabled persons in Mauritius to assist with the country's disability management system. The questionnaire collects basic information such as name, address, contact details, as well as details about the type of disability, education/employment history, and responsible party for minors. All information collected is kept strictly confidential.

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Irshaad Ally Ashrafi Golapkhan
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
163 views

Ministry of Social Security, National Solidarity and Reform Institutions

This document contains a questionnaire to collect information about disabled persons in Mauritius to assist with the country's disability management system. The questionnaire collects basic information such as name, address, contact details, as well as details about the type of disability, education/employment history, and responsible party for minors. All information collected is kept strictly confidential.

Uploaded by

Irshaad Ally Ashrafi Golapkhan
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Ministry of Social Security, National Solidarity and Reform Institutions

MAURITIUS DISABILITY MANAGEMENT SYSTEM

QUESTIONNAIRE

This questionnaire should be filled by the disabled respondent or proxy; or helped by a relative or
friend. All information in this questionnaire will be kept in STRICT CONFIDENTIALITY. Tick where
appropriate (√).

BASIC INFORMATION OF DISABLED PERSON

1. Surname: ………………………………………………………………………………

2. First Name(s): ………………………………………………….. Gender: Male Female

3. Date of Birth: ……………… National Identity Card Number: ………………………………………

4. Marital Status:

Single: Divorced: Separated:

Married: Widow: Living Together:

5. Postal Address: ………………………………………………………………………………

6. Phone number(s):- Residence: ……………………… Mobile:……………………………

7. Email Address (optional) …………………………………………………………………

DISABILITY INFORMATION

IMPAIRMENT (Tick as appropriate) √ DETAILS OF IMPAIRMENT

Physical

Intellectual

Hearing

Visual

Communication

Skin

Fits

Cancer

Lungs

Cardiac

Lupus
High Support Needs

Autism

Multiple

Other (s) – please specify

1. Cause(s) of disability:

By Birth Disease Accident Other

For ‘Other’, please specify: ……………………………………………………………………

2. Since when disabled? ……………………………………………………………………

3. Use of Assistive Devices (e.g: hearing aid, manual wheelchair and so on)

Yes No

If ‘Yes’, name the assistive device(s) used: ………………………………………………………

4. Mobility Level (whether can climb stairs, travel alone, travel by public transport,
others) ………………………………………………………………………………………………………………

5. Are you bed-ridden? Yes No

QUALIFICATIONS AND EMPLOYMENT HISTORY

1. Academic Qualifications details

CPE
YEAR………………………………….. RESULT:………………………………………
SC/GCE O LEVEL: RESULT:………………… YEAR:……………. SITTING: …………..
SUBJECTS GRADE SUBJECTS GRADE
1.……………………… ………… 5.……………………… …………

2.……………………… ………… 6. …………………… …………

3.………………………… …………. 7. …………………….. …………

4.………………………… ………… 8. ……………………… …………


HSC/GCE A LEVEL:
RESULT:…………………… YEAR:…………… SITTING:………….

SUBJECTS GRADE SUBJECTS GRADE


PRINCIPAL SUBSIDARY
………………………… ………… ………………… …………

………………………… ………… …………………. ………….

………………………… …………
2. Technical/Vocational Qualification Details
Institution Qualification Subjects Year Level/Result

3. Professional Qualification Details

Year School/Institution Results (specify if


Course
attended In Study)

4. Outline your employment/placement history (if any)

Status
Date of
Year Duties/ Date of Reasons (placement,
Employer’s Name Resignation
Appelation Joining for leaving contract,
(if applicable)
permanent)

RESPONSIBLE PARTY INFORMATION (for minors)

1. Name: ………………………………………………………………………………

2. Relationship with the disabled respondent: ……………………

3. NIC……………………………………Phone Number (Res):…………………Mobile: ………………

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