Thông tư 01/2015/TT-BLĐTBXH hướng dẫn về quản lý trường hợp với người khuyết tật do Bộ trưởng Bộ Lao động – Thương binh và Xã hội ban hành

MINISTRY OF LABOUR, WAR INVALIDS AND SOCIAL AFFAIRS
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SOCIALIST REPUBLIC OF VIETNAM
Independence – Freedom – Happiness
----------------

No.: 01/2015/TT-BLDTBXH

Hanoi, January 06, 2015

PP. MINISTER
DEPUTY MINISTER




Nguyen Trong Dam

Disabled person file number at local area:

………………………………………………………….

Case management file number: …………..

Name of substitute information provider (if any):

………………………………………………………….

Relationship with disabled person:

…………………………………………

Full name: ………………………….. Date of birth: ………………….. Sex: ..................................

ID number: ………………. Issued date: ……………….  Issuing authority: ……………….

Contact address: ……………….……………….……………….……………….……………….

Telephone number: ………………. Email: …………………………………………………….

Marital status: ……………….……………….……………….………….……………….……………….

Level of education: …………………… Professional qualification: ……………………………

School (if the disabled person is studying): ……………….……………….……………….……………….……………….……………….

Occupation (if the disabled person is in employment): ……………….……………….……………….……………….……………….…

Income of disabled person: ……………………………………………….

Services and policies from which the disabled person receives benefits: ……………………………………

……………………………………………………………………………………………………………

Support needs sorted according to the order of priority of disabled person: ……………………………………

……………………………………………………………………………………………………………

Typical type of disability: ……………………………………………………………………………

Severity of disability (if it is defined): ………………………………………………………………

Causes of disability: Congenital □    Accident □    Disease □    Other □

Features of disability: ……………………………………………….

……………………………………………………………………………………………………………

Working capacity: ……………………………………………………………………………………

Self-care ability in daily life of the disabled person: ……………………………………..

……………………………………………………………………………………………………………

Physical and mental health conditions, sentiment of disabled person: ……………………………………………….

……………………………………………………………………………………………………………

Full name of householder: ………………………….. Relationship with disabled person: …………………

Permanent residence: ……………………………………………… Telephone: ……………………..

Full name of caregiver: ………………… Relationship with disabled person: .…………………

Main job of caregiver: ……………………………………………………………

……………………………………………………………………………………………………………

Family members (give detailed information): …………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Position of disabled person in the family: ……………. Defendant □    Independent □

1. Family’s economic background: Poor □            Near poor □                    Not poor □

2. Sources of income:

a) Laborers: Number of main income earners: ………………………………………………………….

b) Income from employment: In cash ………………………………. In kinds: ………………………

c) Monthly financial support from the government: …………………………………………………

d) Other social support programs: …………………………………………………………

……………………………………………………………………………………………………………

3. Expenditures and family’s capacity to pay: ………………………………………………

a) Foods/foodstuffs

□ Capable of paying

□ Capable of paying but need support

□ Incapable of paying

□ Not identified

b) Clothing

□ Capable of paying

□ Capable of paying but need support

□ Incapable of paying

□ Not identified

c) Medical examination and treatment

□ Capable of paying

□ Capable of paying but need support

□ Incapable of paying

□ Not identified

d) Tuition expenditures

□ Capable of paying

□ Capable of paying but need support

□ Incapable of paying

□ Not identified

dd) Other expenditures: ……………………………………………………………………………………

……………………………………………………………………………………………………………

4. Accommodation conditions:  

a) Rented house □ Shelter □ Semi-permanent house □ Permanent house (grade of house:   ) Degraded □ Stable □

b) Convenient for daily activities of the disabled person: Passageways □      Restroom □       Floor of house □

5. Ability to take care of disabled person:

a. Care: A lot of care □        Not much □      None □

b. Care environment: Safe and clean □   Have problems □      High risk □

c. Capacity for care (Have knowledge and skills in caring for disabled person):            Thorough □  Basic □    None □

6. Support needs sorted according to the order of priority of disabled person: ……………………………………

……………………………………………………………………………………………………………

7. Other information 9if any): ……………………………………………………………………………

……………………………………………………………………………………………………………

Form of receiving case management service: 1) Emergency □  2) Long-term □

Date of receipt: ____________________ Place of receipt: _____________________________

Form of receiving case management service: 1) Emergency □  2) Long-term □

Date of receipt: ____________________ Place of receipt: _____________________________

Recommending party

Recommender/ case manager

______________________________

Head of unit: _________________

(signature and certification)

Reason:

Receiving party

Person receiving the case/ case manager

_________________________________

Head of unit: _________________

(signature and certification)

Comments:

No.

Evaluation aspects

Evaluation aspects

1

Livelihood support

□

2

Health care

□

3

Education, apprenticeship, employment

□

4

Family and social relations

□

5

Life skills

□

6

Community integration

□

7

Psychology, sentiment

□

8

Other needs

□

Earned by disabled person/ caregiver/ householder

Yes

No

Details (in cash and in kinds)

Income from employment

□

□

Emergency financial support

□

□

Monthly financial support

□

□

Social support from state budget

□

□

Benefits from other social support programs

□

□

 Capacity to pay

Spending  

Capable of paying (2 points)

Capable of paying but need support (1 point)

Incapable of paying (0 point)

Not identified (put x mark)

Spending on foodstuff/ foods and subsistence expenses

Tuition fees

Medical expenses

Other payables

Total points

Evaluation results a) Capable (> 7 points) □ b) Partially capable (4 points – 6 points) □ c) Incapable (≤ 3 points) □

Evaluating capacity to pay expenditures with family’s sources of income: (The payment of expenditures for disabled person is given priority)

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Evaluation results a) Capable (> 7 points) □ b) Partially capable (4 points – 6 points) □ c) Incapable (≤ 3 points) □

Evaluating capacity to pay expenditures with family’s sources of income: (The payment of expenditures for disabled person is given priority)

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Evaluation results a) Capable (> 7 points) □ b) Partially capable (4 points – 6 points) □ c) Incapable (≤ 3 points) □

Evaluating capacity to pay expenditures with family’s sources of income: (The payment of expenditures for disabled person is given priority)

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Evaluation results a) Capable (> 7 points) □ b) Partially capable (4 points – 6 points) □ c) Incapable (≤ 3 points) □

Evaluating capacity to pay expenditures with family’s sources of income: (The payment of expenditures for disabled person is given priority)

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Evaluation results a) Capable (> 7 points) □ b) Partially capable (4 points – 6 points) □ c) Incapable (≤ 3 points) □

Evaluating capacity to pay expenditures with family’s sources of income: (The payment of expenditures for disabled person is given priority)

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

 Evaluation level  

Aspects 

Good (2 points)

Average (1 point)

Poor (0 point)

Not identified (put x mark)

Whether design/set up/arrangement of house/ devices in house is convenient for moving in house of disabled person or not

Whether design/set up/arrangement of house/ devices in house is convenient for moving outside the house of disabled person or not

Whether disabled person may access to and use restroom or not

The safety of sources of drinking water and domestic water

Security of house where disabled person is living

Total points

Evaluation results a) Suitable (> 8 points) □ b) Partially suitable (4 points – 7 points) □ c) Unsuitable (≤ 3 points) □

Comments:

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Evaluation results a) Suitable (> 8 points) □ b) Partially suitable (4 points – 7 points) □ c) Unsuitable (≤ 3 points) □

Comments:

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Evaluation results a) Suitable (> 8 points) □ b) Partially suitable (4 points – 7 points) □ c) Unsuitable (≤ 3 points) □

Comments:

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Evaluation results a) Suitable (> 8 points) □ b) Partially suitable (4 points – 7 points) □ c) Unsuitable (≤ 3 points) □

Comments:

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Evaluation results a) Suitable (> 8 points) □ b) Partially suitable (4 points – 7 points) □ c) Unsuitable (≤ 3 points) □

Comments:

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Evaluation: a) Stable □  b) Have health problems □             c) High risk □          d) Not identified □

Description of symptoms and causes of disease (if point b/ point c/ or point d/ is applicable, give further explanation):

— …………………………………………………………………………………………………………

— …………………………………………………………………………………………………………

— …………………………………………………………………………………………………………

No.

Facility providing medical treatment and rehabilitation services

Name of disease

Inpatient/ outpatient treatment

Treatment period

Apply health insurance or not

1

□

2

□

3

□

4

□

5

□

Assessment of treatment results by disabled person/ his/her family or guardian:………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Assessment of treatment results by disabled person/ his/her family or guardian:………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Assessment of treatment results by disabled person/ his/her family or guardian:………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Assessment of treatment results by disabled person/ his/her family or guardian:………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Assessment of treatment results by disabled person/ his/her family or guardian:………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Assessment of treatment results by disabled person/ his/her family or guardian:………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

With the attendance of disabled person

Yes

Name of class/ school

Special education institution

□

Family-scale group of children

□

Preschool education

□

Primary school

□

Lower secondary school

□

Upper secondary school

□

College, higher education and post-graduate education

□

 Evaluation point 

Activities  

Capable (2 points)

Capable but need support (1 point)

Incapable  (0 point)

Not identified (put x mark)

Practice of life skills (communication, social interaction)

Identifying 24 letters of the alphabet

Writing full name and telephone of disabled person

Reading and understanding simple stories of grade 2

Reading and understanding books (at least books of grade-4 level)

Solving word problems and basic operations

Reading and understanding newspapers or magazines

Writing reports/ letters

Total points

Evaluation results a) Capable (> 13 points) □ b) Partially capable (7 points – 12 points) □ c) Incapable (≤ 6 points) □

Comments on study capacity of disabled person: ……………………………………………….

………………………………………………………………………………………………………………

Evaluation results a) Capable (> 13 points) □ b) Partially capable (7 points – 12 points) □ c) Incapable (≤ 6 points) □

Comments on study capacity of disabled person: ……………………………………………….

………………………………………………………………………………………………………………

Evaluation results a) Capable (> 13 points) □ b) Partially capable (7 points – 12 points) □ c) Incapable (≤ 6 points) □

Comments on study capacity of disabled person: ……………………………………………….

………………………………………………………………………………………………………………

Evaluation results a) Capable (> 13 points) □ b) Partially capable (7 points – 12 points) □ c) Incapable (≤ 6 points) □

Comments on study capacity of disabled person: ……………………………………………….

………………………………………………………………………………………………………………

Evaluation results a) Capable (> 13 points) □ b) Partially capable (7 points – 12 points) □ c) Incapable (≤ 6 points) □

Comments on study capacity of disabled person: ……………………………………………….

………………………………………………………………………………………………………………

  Disabled person/ caregiver

Yes

No

Name of vocational training institution

Provided with vocational training course

□

□

Provided with short-term vocational training course (career counseling and vocational training center)

□

□

Provided with professional vocational training course (Intermediate level or higher)

□

□

 Evaluation point 

Activities  

Capable (2 points)

Capable but need support (1 point)

Incapable  (0 point)

Not identified (put x mark)

Disabled person is capable of attending professional vocational training course

Disabled person is capable of attending short-term vocational training course

Disabled person is capable of self-learning

Disabled person has special skills

Total points

Evaluation results a) Suitable (> 7 points) □ b) Partially suitable (4 points – 6 points) □ c) Unsuitable (≤ 3 points) □

Comments on disabled person’s capacity to attend vocational training courses: ……………………………………………….

………………………………………………………………………………………………………………

Evaluation results a) Suitable (> 7 points) □ b) Partially suitable (4 points – 6 points) □ c) Unsuitable (≤ 3 points) □

Comments on disabled person’s capacity to attend vocational training courses: ……………………………………………….

………………………………………………………………………………………………………………

Evaluation results a) Suitable (> 7 points) □ b) Partially suitable (4 points – 6 points) □ c) Unsuitable (≤ 3 points) □

Comments on disabled person’s capacity to attend vocational training courses: ……………………………………………….

………………………………………………………………………………………………………………

Evaluation results a) Suitable (> 7 points) □ b) Partially suitable (4 points – 6 points) □ c) Unsuitable (≤ 3 points) □

Comments on disabled person’s capacity to attend vocational training courses: ……………………………………………….

………………………………………………………………………………………………………………

Evaluation results a) Suitable (> 7 points) □ b) Partially suitable (4 points – 6 points) □ c) Unsuitable (≤ 3 points) □

Comments on disabled person’s capacity to attend vocational training courses: ……………………………………………….

………………………………………………………………………………………………………………

Disabled person/ caregiver

Yes

No

Working place or activity where disabled person may participate in

Doing simple works, making contribution to family’s livelihood activities

□

□

Disabled person is employed or hired

□

□

Self-employed

□

□

 Evaluation point   

Activities  

Capable (2 points)

Capable but need support (1 point)

Incapable  (0 point)

Not identified (put x mark)

Opportunity to find job

Having stable income from employment

Accessing to suitable working environment and conditions

Having ability to self-organize production/business activities

Total points

Evaluation results a) Suitable (≥ 7 points) □ b) Partially suitable (4 points – 6 points) □ c) Unsuitable (≤ 3 points) □

Comments on disabled person’s capacity of finding job or self-organizing production/business activities: ……………………………………………….

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Evaluation results a) Suitable (≥ 7 points) □ b) Partially suitable (4 points – 6 points) □ c) Unsuitable (≤ 3 points) □

Comments on disabled person’s capacity of finding job or self-organizing production/business activities: ……………………………………………….

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Evaluation results a) Suitable (≥ 7 points) □ b) Partially suitable (4 points – 6 points) □ c) Unsuitable (≤ 3 points) □

Comments on disabled person’s capacity of finding job or self-organizing production/business activities: ……………………………………………….

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Evaluation results a) Suitable (≥ 7 points) □ b) Partially suitable (4 points – 6 points) □ c) Unsuitable (≤ 3 points) □

Comments on disabled person’s capacity of finding job or self-organizing production/business activities: ……………………………………………….

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Evaluation results a) Suitable (≥ 7 points) □ b) Partially suitable (4 points – 6 points) □ c) Unsuitable (≤ 3 points) □

Comments on disabled person’s capacity of finding job or self-organizing production/business activities: ……………………………………………….

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

No.

Person giving support to disabled person

Determining person giving support to disabled person

Description of support level for disabled person

Description of support activities for disabled person

1

Spouse

2

Parent

3

Sibling

4

Grandparent

5

Relative

6

Friend/neighbor

7

Social work staff

8

Social organization/ association

9

Teacher

10

Rehabilitation technician

11

Healthcare staff

12

Caregiver

13

Other

 Evaluation point 

Activities  

Capable (including use of assistive devices) (2 points)

Capable but need support from another person (1 point)

Incapable  (0 point)

Not identified (put x mark)

1. Move/ get around

2. Eat/ drink

3. Personal hygiene

4. Personal daily activities

5. Do family works

6. Listen and understand

7. Express desire

8. Study ability

Total points

Evaluation results: a) Live independently (> 15 points) □ b) Need support (7-14 points) □ c) Live dependently  (<6 points) □

Comments on main features that influence on communication skills and daily activities of disabled person:

…………………………………………………………………………………………………………….

…………………………………………………………………………………………………………….

Evaluation results: a) Live independently (> 15 points) □ b) Need support (7-14 points) □ c) Live dependently  (<6 points) □

Comments on main features that influence on communication skills and daily activities of disabled person:

…………………………………………………………………………………………………………….

…………………………………………………………………………………………………………….

Evaluation results: a) Live independently (> 15 points) □ b) Need support (7-14 points) □ c) Live dependently  (<6 points) □

Comments on main features that influence on communication skills and daily activities of disabled person:

…………………………………………………………………………………………………………….

…………………………………………………………………………………………………………….

Evaluation results: a) Live independently (> 15 points) □ b) Need support (7-14 points) □ c) Live dependently  (<6 points) □

Comments on main features that influence on communication skills and daily activities of disabled person:

…………………………………………………………………………………………………………….

…………………………………………………………………………………………………………….

Evaluation results: a) Live independently (> 15 points) □ b) Need support (7-14 points) □ c) Live dependently  (<6 points) □

Comments on main features that influence on communication skills and daily activities of disabled person:

…………………………………………………………………………………………………………….

…………………………………………………………………………………………………………….

Participation level

Evaluation contents

Regularly (2 points)

Occasionally (1 point)

Never (0 point)

Not identified (put x mark)

Participate in family activities

Participate in community and social activities with family

Participate entertainment activities with children of same age in community

Attend class by age at preschool

Total points

Evaluation results: a) Well participated (≥7 points) □ b) Limited (4 – 6 points) □   c) Have no chance (≤ 3 points) □

Evaluation results: a) Well participated (≥7 points) □ b) Limited (4 – 6 points) □   c) Have no chance (≤ 3 points) □

Evaluation results: a) Well participated (≥7 points) □ b) Limited (4 – 6 points) □   c) Have no chance (≤ 3 points) □

Evaluation results: a) Well participated (≥7 points) □ b) Limited (4 – 6 points) □   c) Have no chance (≤ 3 points) □

Evaluation results: a) Well participated (≥7 points) □ b) Limited (4 – 6 points) □   c) Have no chance (≤ 3 points) □

Comments on participation in activities by disabled person: …………………………………………….

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

Comments on participation in activities by disabled person: …………………………………………….

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

Comments on participation in activities by disabled person: …………………………………………….

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

Comments on participation in activities by disabled person: …………………………………………….

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

Comments on participation in activities by disabled person: …………………………………………….

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

Participation level

Evaluation contents

Regularly (2 points)

Occasionally (1 point)

Never (0 point)

Not identified (put x mark)

Participate in family activities

Participate in community and social activities with family

Make friends and participate in activities with friends of same age

Study at schools

Participate in Union/Team’s activities

Participate in favorite sports/arts activities

Total points

Evaluation results: a) Well participated (≥10 points) □ b) Limited (5 – 9 points) □   c) Have no chance (≤ 4 points) □

Evaluation results: a) Well participated (≥10 points) □ b) Limited (5 – 9 points) □   c) Have no chance (≤ 4 points) □

Evaluation results: a) Well participated (≥10 points) □ b) Limited (5 – 9 points) □   c) Have no chance (≤ 4 points) □

Evaluation results: a) Well participated (≥10 points) □ b) Limited (5 – 9 points) □   c) Have no chance (≤ 4 points) □

Evaluation results: a) Well participated (≥10 points) □ b) Limited (5 – 9 points) □   c) Have no chance (≤ 4 points) □

Comments on participation in activities by disabled person: ………………………………………….

………………………………………………………………………………………………………………

Comments on participation in activities by disabled person: ………………………………………….

………………………………………………………………………………………………………………

Comments on participation in activities by disabled person: ………………………………………….

………………………………………………………………………………………………………………

Comments on participation in activities by disabled person: ………………………………………….

………………………………………………………………………………………………………………

Comments on participation in activities by disabled person: ………………………………………….

………………………………………………………………………………………………………………

Participation level

Evaluation contents

Regularly (2 points)

Occasionally (1 point)

Never (0 point)

Not identified (put x mark)

Participate in family activities

Participate in community and social activities with family

Make friends and participate in activities with close friends

Study at schools

Participate in collective and community activities

Participate in favorite sports/arts activities

Total points

Evaluation results: a) Well participated (≥10 points) □ b) Limited (5 – 9 points) □   c) Have no chance (≤ 4 points) □

Evaluation results: a) Well participated (≥10 points) □ b) Limited (5 – 9 points) □   c) Have no chance (≤ 4 points) □

Evaluation results: a) Well participated (≥10 points) □ b) Limited (5 – 9 points) □   c) Have no chance (≤ 4 points) □

Evaluation results: a) Well participated (≥10 points) □ b) Limited (5 – 9 points) □   c) Have no chance (≤ 4 points) □

Evaluation results: a) Well participated (≥10 points) □ b) Limited (5 – 9 points) □   c) Have no chance (≤ 4 points) □

Comments on participation in activities of disabled person:

……………………………………………………………………………………………………………..

Comments on participation in activities of disabled person:

……………………………………………………………………………………………………………..

Comments on participation in activities of disabled person:

……………………………………………………………………………………………………………..

Comments on participation in activities of disabled person:

……………………………………………………………………………………………………………..

Comments on participation in activities of disabled person:

……………………………………………………………………………………………………………..

No.

Evaluation contents

Disabled person

Disabled person

Caregiver

Caregiver

Yes

No

Yes

No

1

Have optimistic spirit and life purpose

□

□

□

□

2

Sociable, know to care about and assist other people

□

□

□

□

3

Insomniac or sleeping soundly

□

□

□

□

4

Hot-tempered or becoming sluggish

□

□

□

□

5

Prolonged tiredness or fatigue

□

□

□

□

6

Feel useless or worthless

□

□

□

□

7

Ability to focus is reduced

□

□

□

□

8

Used to think of death, want to commit suicide or used to end life

□

□

□

□

9

Other difficulties

……………………………………………..

□

□

□

□

Comments on main contents that have positive and adverse impact on the life of disabled person:

………………………………………………………………………………

Comments on main contents that have positive and adverse impact on the life of disabled person:

………………………………………………………………………………

Comments on main contents that have positive and adverse impact on the life of disabled person:

………………………………………………………………………………

Comments on main contents that have positive and adverse impact on the life of disabled person:

………………………………………………………………………………

Comments on main contents that have positive and adverse impact on the life of disabled person:

………………………………………………………………………………

No.

Evaluation aspects

Problem determined

Strengths of disabled person/ family

Needs of disabled person/ family

Consulting specialists

Priority

1

Essential livelihood background

2

Health care and medical services

3

Education, apprenticeship and employment

4

Family and social relations

5

Independent life skills

6

Participation in community activities

7

Psychology and sentiment

General assessment:

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

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……………………………………………………………………………………………………………

General assessment:

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

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……………………………………………………………………………………………………………

General assessment:

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General assessment:

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General assessment:

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General assessment:

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Disabled person/ his/her family or guardian:

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Case manager:

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Signature:

Signature:

Date of collecting information: ………….

Date of providing information: ………….

No.

Evaluation aspects

Level of priority (1, 2, 3)

Specific objective need to be achieved

1

Livelihood support

2

Health care and medical services

3

Education, apprenticeship, employment

4

Family and social relations

5

Life skills

6

Community integration

7

Psychology, sentiment

8

Other needs

Objective number

Intervention/support activities

Performing period

Resource/ funding

Responsibility of relevant organizations, family and individual

Performing agency/ unit/ establishment

1st modification (date)

2nd modification (date)

3rd modification (date)

Disabled person/ family representative/ guardian
(signature and full name)

Case manager
(signature and full name)

Chairperson of commune-level people’s committee or head of social work service provider
(signature and seal)

Date of formulating plan:

Date of approval:

No.

Needs of intervention

Intervention/support activities

Period

Comments of agency/ unit/ establishment performing social intervention and support activities

Case manager

(Signature and full name)

Disabled person/ his/her family or guardian

Case manager

Chairperson of commune-level people’s committee/ head of social work service provider

Signature:

Signature:

Signature:

Date:

Date:

Date: