Questionnaire on Survivor’s Needs Research
for Social Reintegration & Rehabilitation
7 Injuries
7.1
& Their Consiquenses
Injuries:
Cerebral trauma
Spinal cord trauma
Fractures ________________________
Avulsion (localization) ______________________________
Paralysis/Paresis __________________________
Fragment’ injuries (local-ion & number) _____________________
7.2
Injuries’ Consequences:
7.3
Complaints:
7.4
Disfunctions of:
hearing
digestive tract
basic-motional apparatus
respiratory system
nervous system
endocrine system
urology system
7’
Others:
genital system
8 Medical
Not extracted (local-ion & #) __________________________
Operations lived through _______________________________________________________
eyesight
cardiovascular system
Burn ____________________
care:
Resurgery _______________________
General
Fragments’ extraction
Neurosurgery
Recovery _______________________
Bones
Wound care
Eye surgery
Plastic __________________________
Adhesions’ separation
Bandaging the
residual limb
8.1
Surgery:
8.2
Treatment/
Consultation of:
8.3
8’
traumathologist
oculist
neurologist
gastroenth-st
physiotherap-st
prosthetist
general surgeon
otologist
dome-doctor
nephrologyst
pulmonologist
orthopedist
neurosurgeon
therapeutist
cardiologist
urologist
stomatologist
Diagnostics:
Electroencephalography
X-ray
Ultrasonography
others
Others:
9 Physical
rehabilitation:
9.1
Prosthetics:
Below-knee
Replacement prosthetics
Above-knee
of Foot/fing.
Prosthesis’s fitting
Repeat prosthetics
9.2
Providing with prosthetic-orthopedic products:
9.3
Physical Therapy:
9.4
Occupational Therapy
Treatment in sanatorium
Trainings in:
9’
10 Social
Below-elbow
Armchair
Above-elbow
Repair service prosthetics
Wheelchair
Remedial gymnastics
Activities of Daily Living
of Hand/fingers
Crutches
Walking-stick
Gait training
Use of upper extremity prostheses
Others
adaptation:
10.1
Hearing:
10.2
Sight:
Aero-phonic techniques
Braille
Printings in special type
Special-purpose tape recorders
11 Psychosocial
Peer support
Signs and lips language
Technical means of communication
Soniferous books
Loupes
Lens
Subject guides
Spectacles
Eye-stick
care:
Education of survivor’s families in care
Social Support Group’s visits
Participation in Support Groups
Mine Risk Education activity
Participation in Associations of Mine Survivors
Created by ANAMA as an annex to IMSMA’s “Victim” Form
Mine Victim Assistance activity
Create family
(February-2004)
Locator code: 56/91 /03/
Page 1 of 2
Questionnaire on Survivor’s Needs Research
for Social Reintegration & Rehabilitation
12 Economic
13.1
assistance:
13.2
Treatment
13.3
Medicaments
13.5
Medical & domestic services at:
home
Public assistance
stationary institutions
13.4
Payment for habitation & public service
13.6
Technical & others means for rehab-on
13.7
Assignment of lands for:
13.8
Loans (specify aim): _____________________________________________________________
13.9
Grants (specify aim): ____________________________________________________________
agricultural works
housing construction
Small business start up:
13.14
Procurement of ware and food products (specify):
13’
sports
13 Professional
Repair of a house
13.11
Provision of housing
13.12
Provision of car
Obtaining of raw produce & production’ distribution
13.13
food products
13.10
social amenities
Allotment of empty quarters
industrial
economic
Others:
Rehabilitation 13.1Profession: Previous ________________________ Present ____________________
Other skills _______________________________________________________________________
13.2
Unemployed
Employment:
Place & field of work _____________________________________________________________________________________________
______________________________________________
Skills in the following professional fields:
13.3 Agriculture
13.6 Art:
Plumbing
Husbandry
Olericulture
Electric works
Pottery
Sculpture
Mechanization
Viniculture
Welder’s work
Hammered work
Beaux-arts
Radiotechnics
Woodcarving
Music _______________
Car repair
Shoemaking
13.4 Industry/Technique:
Stock raising
Aviculture
13.7
13.5 Crafts:
Floriculture
Carpentry
Beekeeping
Metalwork
Mechanics
Tailoring
Fruit-growing
House painting
Driving
Prostheses production
Preferable field of activity:
Art __________________
Bussines ______________
Economy ______________
Construction __________________
Education: 14.1At present:
Uneducated
14.2
Desire to get:
Paraprofessional (speciality): __________________
Secondary
At home
Primary
Special (in malformation cases)
Secondary
Training courses:
Computer
Language
Veterinary
___________________________________________________
Sports:
Exercisers
Gymnastics
Additional information:
16.3
Pension
16.6
In care of parents
16.9
17
16.4
16.1
High
High (speciality): ________________
Accounting
Others:
Swimming
Running
Boxing
Football
Weight-lifting
Chess
Shooting
Wrestling
Volleyball
Table games
Degree of disablement: _______
Income (monthly, in AZM): _______________
16.7
Paraprofessional ______________
Assistance to parents in visiting education of disabled children
14.3
15 Fitness
Since ___________________
Others ______________________________________________
14
16
Poetry
13’Others:
16.5
Dwelling-space (sq.m): _________
16.2
Disablement:
total
Different sports
15’Others:
partial
temporary
Monthly Family Income (in AZM): ______________________
16.8 Small
holdings or other household area (ha) _____________
Family members (and ages): ______________________________________________________________________________________
Remarks of mine/UXO survivor or his/her witness: _______________________________________________________
____________________________________________________________________ Signature: __________________ ( ________________ )
18
For interviewers:
Recommendable for honorary duties
Awareness on laws of disabled people (put value): ______
In need
Degree of disablement to be changed
Talented in (field): _________________________________
Remarks: ____________________________________________ Contacts: ___________________________________________________
Created by ANAMA as an annex to IMSMA’s “Victim” Form
(February-2004)
Locator code: 56/91 /03/
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