Box to Be Filled-In by the Data Collector at the Beginning of the Interview

Ministry of Health National Rehabilitation HANDICAP Center INTERNATIONAL QUANTITATIVE SURVEY FORM FOR DISABLED CHILDREN AND ADULTS Box to be filled-in by the data collector at the beginning of the interview

Name of village District Province/Prefecture NSC code (ppddvvv)

Name - Data Collector Signature Date of interview

1. Individual and Family Information 1.1 First name : Family name : Age : Sex M F Father's First Name & Family Name : Mother's First Name & Family Name :

Present Address : Group: House Number: 1.2 Name of the person answering the survey if other than the child or adult who is disabled

1.2. If someone other than the disabled child or adult is answering, what is the relationship of this 1 person to the disabled person? family member non-family member (ex: friend, other neighbor) 1.3 Married Single Divorced Widow(er) Separated Child (under 12) 1.4 Who do you live parents relatives non- live alone with? relatives 1.5 How many people are there in the family (living in the same How many adults : house)? How many children:

2. Disability Information 2.1 Physical Disability (check all that apply) 2.1. above knee one leg above knee both legs below knee one leg 1 below knee both legs one arm above elbow both arms above elbow one arm below elbow both arms below elbow foot hand cleft lip and/or cleft palate polio club foot cerebral 2.1. palsy leprosy paralysis ( 1 arm 2 arms 1 leg 2 legs Entire) 2.2 Sensory Disability (check all that apply) problem to hear: cannot hear can hear a little problem with the eyes: blind low vision 2.3 Other Disability (check all that apply) epilepsy psychological problem (unusual behavior) difficulty to understand and learn (slow other, describe clearly : development) 2.4 How did you become disabled? at birth disease UXO accident war Other 3. Mobility Aids 3.1 Do you have a no good bad not make no* prosthesis? yes * * use use yourself 3.2 Do you have an no good bad not make no* orthosis? yes * * use use yourself 3.3 Do you have no good bad not make no* wheelchair? yes * * use use yourself 3.4 Do you have no good bad not make no* crutches? yes * * use use yourself

4. Educational Information 4.1 Can you read and write Lao? yes no 4.2 Have you ever attended school? no yes currently at school left school finished primary school 4.3 Have you ever attended a school that is part of the Integrated Education Project? never attended currently attending left a school 4.4 If you left school or never attended school, why? not accessible not allowed not useful 4.5 What is your highest completed level of education? none (no level primary1-5 lower secondary upper secondary completed) 1-3 1-3 vocational education first level middle level high level/university 4.6 If you attend or attended vocational education, what kind of vocational education? mechanic radio/tape refrigerator/air fan/television recorder conditioner repair repair repair animal raising welding weaving sewing/tailoring hair dressing basket making carpentry

motorcycle/bicycle repair other

5. Social Situation 5.1 What kind of activities are you able to do? Feed yourself (eating and drinking)? yes no Keep yourself clean (washing and dressing)? yes no Communicate with other children and adults? yes no Stay mostly inside the home? yes no Stay mostly outside around the village? yes no Help and participate in family activities? yes no 5.2 Who helps you when you have a problem in daily activities? uncle/aunt relatives no one grand parents

neighbors husband or mother father not necessary wife brother/sister 5.3 Where is your house located? center of near the market near the near the near the village school pagoda health center near the road near the rice far from all the above mentioned places fields 5.4 Do you meet with other children or adults in the community?

who? neighbors relatives friends good * means good condition bad* means bad condition no* means did not make yourself 5.5 Where do you meet? school temple office of the village market at work outside playing house 5.6 If you are deaf, how do you communicate? speech gestures sign language drawings or writing

6. Economic/Work Situation (Adults Only)

6.1 Have you had a job in the past 12 months? (check all that apply) no yes, rice farming fish what raising kind of growin job? g fruit radio selling/ repair vegeta buying motorc ble ycle gardeni repair ng hair sewing/ weavin dressin gover tailorin g g nment g staff private unable staff military to work work at home doing domestic chores other 6.2 Do you own your house? yes no 6.3 Do you rent a house? yes no 6.4 Have your own land? yes no 6.5 Do you own animals? no yes, fish pigs, what pond pou buffaloes, kind? ltry or cows 6.6 What kind of equipment do you own? no equipment yes, bicycle car what mo kind? tor cyc le truck tractor boat

oxc art 6.7 How much do you earn per month? less than between more than 50,000 kip 50,000 - 100,000 kip 100,000 kip 6.8 Do you receive any money/support from any organization or service? no yes, from gove N whom? rnme G nt O 6.9 How much money per month? less than between more than 50,000 kip 50,000 - 100,000 kip 100,000 kip 6.1 Do you receive any material support? 0 no yes , what ri kind? c fabr e ic hoe

s h o v el other 7. Attitudes 7.1 Because of your disability, do you have problems with others? no problem yes, with par whom/ s ents what? p o u s e access to services

fr ie n d s 7.2 How do you think other people in your community look at you? afraid ad u f mir n e e c e o l m p fo it rt y a bl e equal to a non- disable d

7.3 What would you like to do most?(tick one) study work receive tools learn a skill have land have better house receive rehabilitation services meet with other people in your community nothing 7.4 What can be done to improve your livelihood? (tick one) improve house help to find a job rehabilitation aid help to go to school help to meet other children and adults provide medicine nothing else needed

7.5 Who do you think is the best person to help you? yourself chief of the village family health worker village committee schools & teachers government neighbors organizations Rehabilitation no one necessary Center group of other disabled children and adults Is there anything else you would like to tell us?

Comments by interviewer: