FDPF Standard Members Form – FDPF DATA HUB

Fiji Disabled Peoples Federation

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Title of the document FDPF STANDARD FORM FOR MEMBERS.

Please fill in our Member Drive Form,

1. Full Name

2. Gender

3. Birthdate

or Age

4. Birth Registration Number

5. Address

6. Province

7. District

8. Phone Contact

9. Other Phone Contact

10. OPD (s) Currently Belong To

If other which OPDs

11. Cause of Disability

12. Type of Disability1. Amputee Above Knee2. Amputee Below Knee3. Double Amputee4. Upper Limb Amputee5. Birth Deformity6. Blind7. Cerebral Palsy8. Deaf9. Frail Old Age10. Hard of Hearing11. Paraplegia12. Psycho Social Disability13. Polio14. Quadriplegia15. Spinal Bifida16. Stroke17. Visual Impaired18. Juvenile Rheumatoid Arthritis19. Intellectual DisabilityChoose up to 5

13. Marital Status

14. Are You a Single Parent

If Yes. How many dependent children

15. Do they live with you

16. Ethnicity

If Others ethnicity , Please state it here

Government Initiatives

17. Poverty Benefit Scheme

18. Disability Allowance Scheme

19. Social Pension Scheme

20. Care and Protection Scheme

21. Bus Fare Concession

Receive Other Assistance From

22. Faith Based Organisation

23. Community Based Organisation

24. Family or Neighbors

25. Disability Based Organisation

26. Community Based/NGO s in your area

27. Can you live Independently or Need a Carer

28. Assistive Device Have and Use:1. Commode2. Crutches3. Eye Glasses Distance4. Eye Glasses Reading5. Hearing Aid6. Hoist7. Hospital Bed8. Quadrapod9. Shower Chair10. Walker11. Walking Cane12. Wheelchair13. White Cane (Blind)

29. Do you require Medical Consumables1. Catheters2. Uridomes3. Diapers4. Urine Bag5. Micro Pore TapePlease choose at least 2

30. Do You Work

31. Are you able to work

32. What Stops You From Work if You Are Able to Work

33. Educational Level

34. Are You Able to Attend School

35. What Stops You From Schooling if You Are Able to attend School

36. Is Your Home Accessible

37. Is the Bathing and Toilet Accessible

38. Is the outside environment accessible

39. Outside Environment

40. Do you have an accessible evacuation center

41. Do you take medication or receive regular medical treatment for your impairment

Washington Question

42. Vision

43. Hearing

44. Walking Stairs

45. Remembering Concentration

46. Washing Dressing

47. Communicating

Branch Belong To

Use of Transportation

Mode Of Transport1. Public Bus2. Minivan/Minibus3. Taxi4. Private Car (Owned by you or Family)5. Water Taxi6. Walking7. OtherPlease select at least 3

If others mode of transport

How often do you use transport1. Daily2. 2-3 times a day3. Once a week4. Less than a week

What is the main purpose of your travel?1. Work/Employment2. Education3. Healthcare4. Shopping/Errands5. Social/Community Activities6. Others

If others purpose of travel

Barriers face when using transport1. Lack of accessible vehicles (ramps, lifts, space for wheelchair)2. Cost too high3. Unsafe or unfriendly drivers/attendants4. Poor infrastructure (no footpaths, bus shelters)5. Discrimination or Stigma6. No nearby transport service7. Long waiting time8. Inaccessible bus stops or terminal9. Others

If Others barriers

What improvement would you like to see in transportation for persons with disabilities

Any other comments or experiences youd like to share with the use of transportation??

Your Feedback Matters. How user-freindly is this Form? What suggestions do you have to improve its accessibility or clarity for different disability groups?

Applicant Consent *

I certify that my answers are true and complete to the best of my knowledge. I acknowledge that the information
may be used for statistical purposes or shared with other organizations.

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