DEPARTMENT OF HEALTH Philippine Registry For Persons with Disability Version 3.0, Application Form 7, PERSONS WITH DISABILITY NUMBER (RR-PPMIMF-BBB-NNNNNNN) | 2. DATE APPLIE temvédivent '3. PERSONAL INFORMATION * Poca Sat 4. DATE OF BIRTH: * AGE: * wane rassnnnnnubay | 5. RELIGION: 6. ETHNIC GROUP: 7.SEK* &. CIVIL STATUS: * 9, BLOOD TYPE: © Male Q Single Q Married OAr OABE OBF OOF © Female Separated © Widow/er © Cohabitation (live-in) On On 08 00 10. TYPE OF DISABILITY: * 1. CAUSE OF DISABILITY: U1 Deaf or Hard of Hearing EdPhysical Disability OD Acquired 1 Intellectual Disability Lipsychosocial Disability DD Cancer DD Learning Disability Dispeech and Language Impairment || 1 Chronic iliness 1 Mental disability Divisual disability DD Congenital/inborn 11 orthopedic Disability OF injury Or Rare Disease Autism 12. RESIDENCE ADDRESS * House No. And Street” | Barangay Maridpaliv® Province 13, CONTACT DETAILS Candle No obi Na al dress 14, EDUCATIONAL ATTAINMENT: * | 15, STATUS OF EMPLOYMENT: © 16. OCCUPATION: ‘© None © Employed © Managers © Elementary Education © High School Education © College © Postgraduate Program © Non-Formal Education © Vocational © Unemployed © Self-employed 15a, CATEGORY OF EMPLOYMENT: * © Government © Private 15b. TYPES OF EMPLOYMENT: * © Permanent/Regular © Seasonal © Casual © Emergency O Professionals © Technician and Associate Professionals © Clerical Support Workers Service and Sales Workers © Skilled Agricultural, Forestry and Fishery Workers © Craft and Related Trade Workers © Plant and Machine Operators and Assemblers © Elementary Occupations © Armed Forces Occupations © Others, specify 17. ORGANIZATION INFORMATION: ‘Organization Afilated: ‘Contact Perio ‘Otis Adress Tel No 18. ID REFERENCE NO. SSSNOE GEIENO, PagiBIGNO? Phas NO. 19. FAMILY BACKGROUND: LAST NAME, FIRST NAME MIDDLE NAME FATHER’S NAME: MOTHER'S NAME: ‘GUARDIAN’S NAME: 720. ACCOMPLISHED BY: * 20a. NAME OF REPORTING UNIT: 21. REGISTRATION NUMBER:Instructions for Philippine Registry for Persons with Disability (PRPWD) Version 3.0 Form ‘NO._| FIELD NAME INSTRUCTION and DEFINITION ] | Registration No. | This sa system- generated number assigned by the PRPWD software. Once the Person with Disability data is encoded into the system, copy the system -generated number and write into the box ofthe Application Form, Z| ae “The date when the form was accomplished must be entered in this portion, The formats “mm/S6/yw" 3 Persona Write the last name, frst name and middle name inthe appropriate space provided. Information | note: adele name is default to "N/A" because iis required fel. Ifthe Person with Disbityhosa mide name, remove the ‘W/A" and write the mdale name, | Bithdste | Weite the birthdate ofthe Person with Disailiy Ta the format of “mm Gd yyw" (ea luly 1, 1970 should be wwetten 28 07/01/1970). The birthdate should not be later than the current date/registration date. I the birthdate snot provided, write the “Age” ofthe Person with Disability 5 | felon ‘Write the religion on the space proved inthe form, Note Lit for thi fil i bulls tothe system. | FheGroup [Write the spectic Ethnic Group on the space provided in he form test for this is bun tothe system. 7 [se Check the appropriate box forthe sex of the Person with Dsabiy &. | ewIstatus | Check the appropriate box for the cwl status of the Person with Disability. Not legally separated 6 sll considered as "Married 3,__| Blood Type | Check the appropriate bax Tor the Blood type of the Person with Disobiy. 10, | Treat Check the aperopriate box/es forthe Type/sof Oli. One or more ems ean Be checked Torts ald Disabity | Deaf oF Hard of Hearing ~ refers to people with hearing iss, imps litle or no hearing anging rom mild to severe. Hearings, also known as hearing inparment means the compete o partial ssa the aby to hear fom ane or both cars with 26 dB or greater hearing threshold averaged a frequencies 0.5, 1,2, klohert IntelectulDizobilty-signiarly reduced aolty to understand new or comple information an to learn and apply new sil. Learning Disabil - perzons who, although normal in sensory, emtional and intellectual ables, ext disorders In perception, lstering thinking reading, writing, speling, and arthmetc “Mental Disability - ssbiity resuting trom organic brain syndrome and or mental iless (psychotic or non-psyehotic disorder) Orthopedic Disabil -cizabit inthe normal functioning ofthe joints, musces, and lms Physical Disability - ary impairment which imi the function oimbsor fine or gross moter ay Psychosocial Dizabity- any acauired behavioral cognitive, emotional or sil impsirment that limits one o more aetties necessary to eectve interpersonal transactions and other ciliing processor acts today living sch 38 but not limited to deviney or antisocial Bera. Speech and Language Impairment - ane or more speecylanguage disorders of voice, articulation, rhythm anor the receatve and expressive processes of language. Visual Disability person with sua sabi (impairment) fone whoa impaiement of sal unetoning even alter eatment and/or standard reactive conection, anghas visual city Inthe better ee of les than 6/18 for low sion and 3/60 for lind, ora visual fle of less tan 10 degrees from te point of ration. certain evel of sual Impairments define as legal Blindness. On is egally Blind when you best corected antral vial aut n your beter ee 6/60 on worse or your side viton 20 degrees or lesin the beter ee, Ti | Cameo? Check the appropriate box/es forthe Causes of Dalit. One or more tems con be checked for this eld Dsabity ‘Acquired ~is a csbity that has developed during the persons atime ~ that as rest of an accident o ies rath {han a lsabily te person was som wih Concer Cancorrefr oa genetic tem for large group af dzoases tha can aft any pat of he body. Other ams sed lremalgnant tumors and veopisams. One defining feature of eancar te rap creation af abnormal ale hat row Dyan ‘har usal boundaries, and which can hen imvade adoring pars ofthe body ar spread fo tr organs Chronic illness» describes a group of health conditions that lst along ime. It may get slowy worse overtime or may become nermanent or may lata ceath.tmay cause permanent change tothe body and willcertiny affect the person's avalty of fe This i slo true to persons slagnoses with Cancer or Rare Disease. Thus, Chron nesses may case disbity, hence, is considered no sabi Congenital inborn cisease present a bi Injury «An ijory the physical damage that results when a human body is suddenly a riely subjected to intolerable tevels of ene-y. canbe abodly lesion resulting rom acute exposure to energy in amounts that exces the threshold of physologcal tolerance ort can be an impairment of function resuting from alack of one or ore wal elements (ea, "water, warmth), asin rowning, tangatonorfeesing, The time between exposure tothe energy andthe appesrance of an injury is short. (INJURY SURVEILLANCE GUIDELINES, Publened in conjunction with the Centers for Olsease Control ana revention, dant, USA, bythe Worl Heath Organization, 2003) ore Disease ‘ers ‘0 csorders such aa shorted metabo dsrders and other diseases with siniar ar occurence a8 ‘ocognzedby tho DOH upon recommendation fhe NI but oxladng catastrophe (oe thaateing, soul bang ‘Sretous ond donc fone of more requenly oocuting daeasee, GE [Residence] Write the Person wth Disobiltys permanent address House No, and Street, Barangay, Munlcpalty/Gty, Province and Aderess Region Note: House No, and Street name shouldbe encoded in the system, but the Region, Province, Muncipaty/Cty and Barangay are crea bult-n to the system: jst clk the appropriate Region, Province, Muncipaly/Cy, and Barangay af the Peron wth Disability [Ea [CGonteat betas Write the Teephone No, Mabie No, andE ral adress of Whe Person wth Dab WavaiableTE, | Educational] Check the approprate orle for the highest education atalned by the Person with DoBIiy, Attainment Ts, | status of (Check the appropriate circle for the working status ofthe Person with Disabliy. One Wem must be chasen in Employment | this field Employed - persons nthe labor force who were reported either at work ar with aj or business although not at work: 2) At Work -those who dd some work, even for one hour during the reference period 1b) With a Job or Business but not at Work those who have a job or business eventhough not at work during the reference petiod because of temporary illness/inury, vacation or other leave of absence, bad weather or strike/labor Aspute or other reasons Likewise, persons who are expected to report for work o to start operation ofa farm or business enterprise within too weeks fom the date of the enumerator’ visit are considered employed ‘Unemployed = includes al persons who are 15 years olé and aver as of thei ast bithday and are reported as 1} without work, Le, had no jb or business during the basic survey reference period; AND, 2) current avalabe for work, e, were avallaole and wiling to take up workin paid emaloyment or set. employment during the basic survey reference period, and/or would be avalable and willing to take up workin paid employment or self-employment within two weeks after the interview date; AND, 3) seeking wort, Le, had taken specific steps to look for 3 job or establish a business during the basc survey reference petiod; OF not seeking work due tothe folowing reasons: (a) tred/beieve no work avaiable, Le, the dscouraged "workers who laoked for work within the last sic months prior t the interview dete; (2) awaiting results of previous job aplication (c) temporary illness/dsabilty; 4) bad weather; an (e) waiting fr renire/job recall Self-employed - isan independent contractor or sole proprietor who reports income-earned in own business. The person works for him/herself ata variety of trades, professions, and occupations rather than working for an employe. T5a. | Category of —] Check the approprate cxcle for the Category of Employment ofthe Person with Dsabity Employment | Permanent/Regular - the directly employed; work for an employer and are paid directly by that employer; permanent/regular employees do not have 3 predetermined ene date of employment; permanent employees are often eligible to switch ob postions within thei companies ‘Seasonal- he term seasonal employment refers to open postions inan organization that are avalable for only a portion of the year; seasonal employments a form of temporary employment, whereby the workload occurs only during certain times ofthe year Casual - employees are employees who do not have regular or systematic hours ef worker an expectation of continuing work typical casual employee is employed ona daly basis when the nee arses, Emergency ~ means any work performed for the purpose of preventing oF alleviating the physical traums or property damage threatened or caused by an emergency; emergency work means work which could not be covered by a weckly employee because of extenuating cumstances sb, | WReror ‘heck the appropriate crcl forthe Type of Employment af the Person with DBaBiiy. Employment TE, | Occupation | Check the appropriate cre Tor the Occupation of the Person with Diobiliy. 1 not slated in the choice, check “Others” then specify T7._| Ogantaton —] Weke the organvation formation of the Person with Drabilty mclading the nanve of organtation affliated, contact Information | person, office address, and telephone number, If one, leave it blank TE, | 1D Reference | Write the SSS, GSS, PAG-SIG, and Philippine Heath Insurance Number f avaiable No. 75, | fami ‘Waite the names ofthe father, mother and guaran ofthe Person with DRabillyn Wie pace prOWde Background 20. Accompished | Personnel completing the form must be entered on this required Feld By Wa | Nameot Tor the isang affce, wits the name af your offee Reporting Unit Zi] Registration | This wa sytem generated number ater the information have been encoded and slbmitted in Ue system, Numer