Training to Strengthen Community-based Rehabilitation (CBR) through a

APPENDIX OF APPLICATION FORM
for
Training to Strengthen Community-based Rehabilitation (CBR) through a
Participatory Comprehensive Approach
Please submit all pertinent documents and your answers to this questionnaire
in typewritten form together with your Fellowship Application Form.
**This appendix is available at http://www.apcdproject.org/trainings/cbr04/
TITLE Mr.
Ms.
Mrs.
Dr.
GENDER
MALE
FEMALE
NAME (capital letters)
FAMIY NAME GIVEN NAME MIDDLE NAME
DATE OF BIRTH: (Day/Month/Year):
PASSPORT NUMBER:
PASSPORT EXPIRY DATE (Day/Month/Year):
HOME ADDRESS:
TELEPHONE NUMBER (Country Code/Area Code/Number):
FAX NUMBER (Country Code/Area Code/Number):
E-MAIL ADDRESS:
NAME OF THE ORGANIZATION:
ADDRESS:
TELEPHONE NUMBER (Country Code/Area Code/Number):
FAX NUMBER (Country Code/Area Code/Number):
E-MAIL ADDRESS:
Physical Disability
Hearing Disability
TYPE OF DISABILITY : Visual Disability
Intellectual Disability
Mental Disability
Other
DISABILITY
( IF ANY)
􀂆 YES
􀂆 NO
USAGE OF ASSISTIVE DEVICES : 􀂆 YES 􀂆 NO
DETAILS OF YOUR ASSISTIVE DEVICES:
Power/electronic wheelchair (􀂆 Wet battery 􀂆 Dry battery)
Wheelchair
Crutch(es)
White cane
Other ( )
NECESSITY OF A PERSONAL ASSISTANT FOR THE TRAINING:
􀂆 YES => (Details )
􀂆 NO
USAGE OF SIGN LANGUAGE (SL):
􀂆 English SL 􀂆 Other SL ( )
NECESSITY OF A SIGN LANGUAGE INTERPRETER FOR THE
TRAINING:
􀂆 YES => (Details )
􀂆 NO
DIETARY REQUIREMENTS (IF ANY)
I hereby certify that all the provided information is correct, accurate and complete to the best of my
knowledge.
In the event that I suffer injury, illness or death during the course of my participation in the
program/course, I shall hold the Royal Thai Government, the Government of Japan, Japan
International Cooperation Agency (JICA) and/or the Asia-Pacific Development Center on
Disability (APCD) harmless and without any liability whatsoever for compensation towards
myself, my legal representatives and/or my heirs. Should I cause any person loss of property,
injury, illness or death during the course of my participation in the program/course, I shall be fully
responsible and liable for the said person without reference whatsoever to the Royal Thai
Government, the Government of Japan, JICA and/or APCD.
SIGNATURE OF NOMINEE…………………………………………………………
PRINTED NAME OF NOMINEE ( )
DATE:
QUESTIONNAIRE
*Please submit your answers to the following questions as a part of the “Appendix of the
Application Form”.
Q.1 What does “CBR” mean to you?
Q.2 Please give an overview of the CBR program which you are responsible for and/or
involved in. (e.g., Activities, Problems, Outcomes, Networks, Human Resource
Development)
Q.3 What do you think about your CBR program? (Briefly explain its strengths and
weaknesses.) What do you plan to do to improve the situation of your CBR program?
Q.4 What do you think about “CBR” in your country in general? (Briefly explain its
strengths and weaknesses.)
Q.5 What factors do you think contribute to the success of CBR?