Scribd
Upload
294 views2 pages

NCPWD Data Collection Form

This document is a data collection form for beneficiaries and caregivers of the NCPWD COVID-19 intervention program. It collects basic information such as name, ID number, contact details, disability details, and geographical location. For caregivers, it also collects their name, ID number, contact details and relationship to the beneficiary. Beneficiaries or caregivers must declare that the information provided is accurate. The form is then recommended by a local chief and processed by disability officers at the county and regional levels.

Uploaded by

JOSEPH MWANGI
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
294 views2 pages

NCPWD Data Collection Form

This document is a data collection form for beneficiaries and caregivers of the NCPWD COVID-19 intervention program. It collects basic information such as name, ID number, contact details, disability details, and geographical location. For caregivers, it also collects their name, ID number, contact details and relationship to the beneficiary. Beneficiaries or caregivers must declare that the information provided is accurate. The form is then recommended by a local chief and processed by disability officers at the county and regional levels.

Uploaded by

JOSEPH MWANGI
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

NCPWD COVID-19 INTERVENTION

BENEFICIARY / CAREGIVER DATA COLLECTION FORM

NOTE: If the PWD is the PRIMARY RECIPIENT fill in Part 1


If the Caregiver is the PRIMARY RECIPIENT fill in Part 1 and 2

1. BENEFICIARY BASIC INFORMATION

Name (In Full) ________________________________________________________________

I.D. No. (Where applicable _________________________ Sex ______________________

Nature of Disability _________________________ Disability Reg. No. ________________

Telephone No.: _________________________ (Mobile numbers provided should be


those registered by the beneficiary, therefore matching with their full names and
identity card numbers)

Mobile Service Provider _______________________________ (Safaricom, Airtel,


Telkom)

2. CAREGIVER BASIC INFORMATION (PWDs requiring a caregiver must provide


a valid Kenyan ID and active telephone number of the caregiver.)

Name (In Full) ________________________________________________________________

I.D. No. _________________________________ Sex _________________________________

Telephone No.: _________________________ (Mobile numbers provided should be


those registered by the caregiver, therefore matching with their full names and
identity card numbers)

Mobile Service Provider _______________________________ (Safaricom, Airtel,


Telkom)

Relation to the Beneficiary ____________________________ (Parent, Guardian,


Family member, etc)

1
3. GEOGRAPHICAL DATA/PHYSICAL ADDRESS

County ___________________________________________________________________
Constituency _______________________________________________________________
Location __________________________________________________________________
Sub-Location _____________________________________________________________

4. DECLARATION (Beneficiary/Caregiver)

I, _______________________________________hereby declare that the information


given above is true to the best of my knowledge.

Sign/Thumb Print______________________ Date________________________

5. RECOMMENDED BY (AREA CHIEF/ASSISTANT CHIEF)

Name ________________________________ Signature & Stamp: ___________________

Date: _________________________________

6. OFFICIAL USE (Form Acted on By Regional Coordinator and County Disability


Services Officer):

COUNTY DISABILITY SERVICES OFFICER REGIONAL COORDINATOR DISABILITY SERVICES


Name: Name:
Signature: Signature:
Date: Date:

You might also like