Republic of the Philippines

MARANGAS PWD ASSOCIATION

Marangas, Bataraza, Palawan

PERSONS WITH DISABILITY (PWD) GENERAL INTAKE SHEET

(Please answer appropriately and legibly)

Identifying Information

1. PWD Number 2. Date Issued:

_____________________________ __________________
l3.
NAME : (First Name) (Middle Name) (Last Name) Ext. Name

4 .ADDRE
SS
BATARAZA
(House No. & Street Name) (Barangay/District) (Municipality/City
)
PALAWAN MIMAROPA
(Province) ( Region )

17. OCCUPATION: Please Specify __________________________

18. MONTHLY INCOME: (In Philippine Peso )
________ 10,000 & above ________ 7,000-7,999 ________ 3,000-3,999 ______None
________ 9,000-9,999 ________ 6,000-6,999[ ________ 2,000-2,999
________ 8,000-8,999 ________ 5,000-5,999 ________ 1,000-1,999
________ 4,000-4,999 _______ 999 & below
19 . SOURCE OF INCOME : (Check all
applicable ) _________Own earnings,
salaries/wages
Pension: Source of Pension specify _________ amount ___________ _____None
Spouse Salary Business
Dependent on children/relatives/parents Others (Please
specify________________
RELIGION __Roman Catholic __Aglipay __Iglesia Ni Cristo __Protestant __Islam _ others ( please
specify________________________________
20. SOLO PARENT  Yes  No
22. IDINGENOUS PEOPLE GROUP: Please specify ____________________________________
23. TYPE OF DISABILITY: (1) ______ Deaf or Hard of Hearing (please specify -diagnosis of
Physician_______________________
(2)______ Intellectual Disability (please specify -diagnosis of
Physician____________________________
(3)______ Visual Disability (please specify -diagnosis of
Physician_________________________________
(4)______Learning Disability (please specify -diagnosis of
Physician_______________________________
(5)______Orthopedic Disability (please specify -diagnosis of
Physician____________________________
(6)______Mental Disability (please specify -diagnosis of
Physician_________________________________
(7)______Psychosocial Disability (please specify -diagnosis of
Physician___________________________
(8)______Physical Disability (please specify -diagnosis of
Physician________________________________
(9)______Speech and Language Impairment (please specify -diagnosis of
Physician_______________
24. CAUSE OF DISABILITY :
Congenital/Inborn please
( speficy
________________________________________
Aquired( please speficy
___________________________________________________
Cancer( please speficy
____________________________________________________
Chronic Illness ( please speficy
_____________________________________________
Injury(please speficy
______________________________________________________
Rare Desease (please speficy
_______________________________________________
Autism(please speficy
25. PROGRAM AND SERVICES RECEIVED? (Check all )
_____________________________________________________
applicable
Assistive Devices Supplemental Feeding _____ Housing
Scholarship Livelihood Assistance _____Skills/Livelihood Training
Day Care Service/ECCD Philhealth _____Microcredit
Pantawid Pamilya Pilipino Program Subsidized Rice _____others (please specify________
Social Pension Medical Assistance
26. FAMILY COMPOSITION
:
FAMILY COMPOSITION
NAME RELATIONSHIP INCOME
AGE CIVIL STATUSOCCUPATION
TO PWD

27. ASSETS & PROPERTIES: (Check all applicable) (Note if Single Asset of Immediate Family, if Married asset
) of family
.________ House ________ Fishponds/Resorts ________ Farmland
________ Lot ________ Commercial Building ________ Business
________ House & Lot ________ others, specify____________________________________
28. LIVING/RESIDING WITH: (Check all applicable )
________ Alone ________ Common Law Spouse
________ Spouse ________ Grand Parents
________ Parents ________ in Laws
________ Children ________ Relatives
________ Friends ________ others, specify ____________________________________
29. AREAS OF SPECIALIZATION/SKILLS: (Check all applicable )
________ Farming ________ Cooking
________ Teaching ________ Vocational (please
specify_________________________
________ Fishing ________ Arts
________ Dental ________ Engineering
________ Counseling ________ Organizing
________ Evangelization _______ Others, please specify
30 .INVOLVEMENT IN COMMUNITY ACTIVITIES: (Check all applicable)
________ Medical Service ________ Neighborhood Support Services
________ Community Service ________ Religious _______ Member of
association
________ Community Beautification ________ Counseling/referral _______ Affiliation
________ Community/Organizational Leader ________ friendly visit ________Others, specify
_______

31. PROBLEMS/NEEDS COMMONLY ENCOUNTERED: (Check all applicable)

32 . Economic
_______ Lack of income/resources ________ not employed
_______ Loss of income/resources ________ others, specify
_______ Skills/Capability Training ________ Livelihood opportunities
33. Social/Emotional
_______ Feeling of neglect & rejection _______ inadequate leisure/recreational activities
_______ Feeling of helplessness & worthlessness _______ PWD Friendly Environment
_______ Feeling of loneliness & isolation _______ others, specify ______________________
_______ Feeling of Discrimination

34. Health
With Maintenance: Yes ____ No ___ If yes, please specify __________________________
Concerns/Issues:
_______ Accessibility to Health Services
_______ High cost medicines
_______ Lack /No health insurance/s inadequate health services
_______ Lack of hospitals/medical facilities
_______ Lack of medical professionals
_______ Lack/No access to sanitation
_______ other, specify

35. Housing
_______ overcrowding in the family home _______ one room affair
_______ No permanent housing _______ Informal settlers
_______ longing for independent living/quiet atmosphere _______ Cost rent
_______ Light materials (cogon, nipa, anahaw) others (please specify)
_______ salvaged/makeshift materials
_______ Strong materials (galvanized iron, aluminum, tiles, concrete, brick, and stone)
36. Toilet Facility
_______ Water sealed, used exclusively by household _______ Open pit, used exclusively by
household
_______ Close pit, used exclusively by household _______ Others
37. Electricity  Yes  No
38. Main Source of Water
_______ Own use, faucet, community water system ____Shared, tubed/piped
well
_______ Shared, faucet, community water system ____Dug Well
_______ Own use, tubes/piped well ____Spring, river, stream,
etc.
_______ Rainfall ____Peddler
39. Community Service
Desire to participate _______ Skills/resources to share__________ others, specify
__________

40. Organization Information

__________________________ __________________ _______________________

Name of Organization Affiliated Address of Organization Contact Person and
Number

41. Identify Others Specific Needs

 42. Declaration: 43. Certification :

________________________
Printed Name and Signature or Thumb mark of Persons with Disability (PWD) Printed Name and Signature of Interviewer
/ Respondent
Date _____________________________
Date __________________________

DEPARTMENT OF HEALTH
Philippine Registry for Persons with Disability Version 4.0

Application Form
1. NEW APPLICANT RENEWAL Place 1”x1” Photo
Here
2. PERSONS WITH DISABILITY NUMBER (RR-PPMM-BBB-NNNNNNN) * 3. DATE APPLIED: * (mm/dd/yyyy)

4. PERSONAL INFORMATION *
LAST NAME: * FIRST NAME: * MIDDLE NAME: * SUFFIX:

5. DATE OF BIRTH: * (mm/dd/yyyy) 6. SEX: * Male Female

7. CIVIL STATUS: *
 Single  Married Separated  Widow/er Cohabitation (live-in)
8. TYPE OF DISABILITY: * 9. CAUSE OF DISABILITY: *
 Deaf or Hard of Hearing  Physical Disability (ORTHOPEDIC)  Congenital/Inborn Acquired
 Intellectual Disability  Psychosocial Disability  ADHD  Chronic Illness
 Learning Disability  Speech and Language Impairment
 Cerebral Palsy Cerebral Palsy
 Mental Disability  Cancer (RA 11215)
 Down Syndrome Injury
 Rare Disease (RA 10747)  Visual Disability
 Others, Specify_____ Others, Specify_____
10. RESIDENCE ADDR ESS *
House No. And Street:* Barangay:* Municipality:* Province:* Region:*
BATARAZA PALAWAN IV-B
11. CONTACT DETAILS
Landline No.: Mobile No.: E-mail Address:
12. EDUCATIONAL ATTAINMENT: * 13. STATUS OF EMPLOYMENT: * 14. OCCUPATION: *
 None  Employed  Managers
 Elementary Education  Unemployed  Professionals
 High School Education  Self-employed  Technician and Associate Professionals
 College  Clerical Support Workers
13a. CATEGORY OF EMPLOYMENT: *
 Postgraduate Program  Service and Sales Workers
 Government  Skilled Agricultural, Forestry and Fishery
  Non-Formal  Private Workers
Education
13b. TYPES OF EMPLOYMENT: *  Craft and Related Trade Workers
 Vocational  Permanent/Regular  Plant and Machine Operators and Assemblers
 Seasonal  Elementary Occupations
 Casual  Armed Forces Occupations
 Emergency  Others, specify: _______________________
15. ORGANIZATION INFORMATION:
Organization Affiliated: Contact Person: Office Address: Tel. Nos.:
FED. OF PWD ASSOCIATION
16. ID REFERENCE NO.:
SSS NO.: GSIS NO.: Pag-IBIG NO.: Phil Health NO.:
17. FAMILY BACKGROUND: LAST NAME FIRST NAME MIDDLE NAME
FATHER’S NAME:
MOTHER’S NAME:
GUARDIAN’S NAME:
18. ACCOMPLISHED BY: * LAST NAME FIRST NAME MIDDLE NAME
APPLICANT
GUARDIAN
REPRESENTATIVE

19. NAME OF CERTIFYING PHYSICIAN:

LICENSE NO:
20. PROCESSING OFFICER: *
21. APPROVING OFFICER: *
22. ENCODER: *
23. NAME OF REPORTING UNIT (OFFICE/SECTION): *

24. CONTROL NO: *

Republic of the Philippines

PROVINCE OF PALAWAN
MUNICIPALITY OF BATARAZA

MUNICIPAL HEALTH OFFICE

CERTIFICATION ON DISABILITY

This is to certify that_________________________________________Male/

Female, resident of _____________________________________________, Bataraza,
Palawan had voluntarily submitted himself / herself to this facility with regards to the nature
of his disability.

Based on the personal interview and medical assessment the undersigned

conducted, the patient has _____________________________________________, which
results in a person with ___________________________________________ as classified
in the Department of Health (DOH) Philippine Registry for Persons with Disability Version
4.0 Type of Disability.

/ _____ / Intellectual Disability /_____ / Physical Disability ( ORTHOPEDIC)

/ _____ / Learning Disability / _____ / Psychosocial Disability
/ _____ / Mental Disability / _____ / Visual Disability
/ _____ / Speech and Language Impairment / _____ / Deaf or Hard of Hearing
/ _____ / Cancer ( RA11215) / _____ / Rare Disease (RA10747)

This certification is issued on _____________________________ at place

_________________________________________ in compliance with the requirement in
the application/issuance of Person with Disability Identification Card (ID).

_______________________________
Revised as of August 1, 2021
Name of Physician
License Number_________________