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ANNEX


Preliminary trainee selection questionnaire

No

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Day

Month

Year


PERSONAL HISTORY AND EDUCATION



Name (Mr., Ms, title)

Family name

Age

Date/month/year of birth

Nationality

Religion

Education

Year finished education

Name of school

Special ability

Occupation

Address No. Street

Village

Sub-district / district

Province

Marital status

If married, name of spouse

Spouse age

Spouse occupation

Income (candidate)

Income (spouse)

Number of children


Who takes care of the children?





FAMILY HISTORY

Father's given name

Father's family name

Age

Alive or deceased

Occupation

Income (per day/per month/per year)

Mother's given name

Mothers' family name

Age

Alive or deceased

Occupation

Income (per day/per month/per year)

Status of marriage of parents

New marriage


How many brothers and sisters (grand father, grand mother on each side of the family, and other relatives)?

Name of brothers and sisters

Age

Occupation







HISTORY OF DISABILITY

What is your disability?

Cause?

Since when?

Where did you receive rehabilitation?


What is the ability of the body at the moment of the interview?

How are the eyes used, how does the candidate drink... use his/her hands?

Left-handed or right-handed?

How much weight can the candidate lift?

Can he or she stand or not?

For how long?

Can he or she walk or not? How far?

Use of prosthesis / orthotic / wheelchair.

Can he or she sit or not?

If yes, for how long?

If lower part of the body has no feeling, can he/she control bladder and bowel movements?



HISTORY OF WORK

What was the last occupation?

Position?

Where is location of work?

Salary?

When did candidate give up this occupation?

Reason for leaving?

INFORMATION ON TRAINING

Where did you learn about training? Why do you want to join the training?

Where did you apply?

When did you apply?

Do you know when the training will start?

Are you available during that time?

What does your family say about the training?

What does your community say about training?

Do you wish to set up a micro-enterprise after the training?

What would be your preferred occupation?

STATUS OF HOUSE AND LAND

What are your family duties?

What is your financial situation? Do you have any debts?

Can you travel by yourself?

Do you own land?

Size of land?

Can the land be used to start enterprise after training?

Space available for enterprise?

COMMENTS OF INTERVIEWER




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