Assessment - Alen Lewegen

Name of Disaster/Operation *

Date

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1. Assessing Agency Information

Organization doing the assessment (and collaborating organization):

Name of the Staff/Intake Person

Role in the community

Contact information

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2. Contact Information

Province/Region *

Sub city/Zone *

Woreda/Kebele

House Number #

Village Name *

Mailbox/Additional Description:

Where are you currently residing? *

Own Home
Transitional Housing
In Someone else’s Home
Emergency Shelter
Campsites
Others

Phone(Primary) *

Alternative contact Person/Phone *

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3. Personal Information

Caregiver's Name(Adult who is the parent/guardian of veteran's child(ren)) *

Gender *

Male
Female

Date of Birth *

Age

Primary Language *

Do you have an active Bank Account?

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4. Household Information

Did the child(ren)/ parent(s) served in military?

Which Branch?

Parent(s) death

Father
Mother
Both
None

Full Name of Deceased Parent(s)

Do you have a proof of death certificate?

Issued by:

Did the parent who serve in military

wounded
ill (Critical health Condition)
injured

Describe the injury

Availability of medicines/medical supplies

Adequate
Basic
Inadequate

Does the person pay for medical treatment?

Is treatment completed?

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If Child(ren) death, how old are the parent(s)? *

Over the age of 60 (60& 60+)
Age 55 and disability with Disability

How many child(ren) do you have 18 and over?

How many child(ren) do you have under the age of 18?

Do you care for a child with special needs (disability )?

If yes, how many?

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6.List All Household Members( important to include child(ren) caring for)

Full Name

Gender

Male
Female

Date of Birth

Age

Relationship to Caregiver

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6. Affirmation

I affirm that the information on this application is accurate. I affirm that the documentations provided is true and accurate. I acknowledge that approval is contingent upon the availability of resources. You are aware of this referral, and your information will be only shared with others to coordinate services, to make referrals to programs and benefits, and payment.

Signature of Staff/Intake Person

Caregiver (Caregiver Representative) Signature

Name of Caregiver Representative *

Phone

Parents/Children Photo

Click or drag files to this area to upload. You can upload up to 12 files.

Your Email *