Application Form: Philippine Registry For Persons With Disabilities Version 4.0
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DEPARTMENT OF HEALTHPhilippine Registry For Persons with Disabilities Version 4.0 Application Form1. NEW APPLICANT RENEWAL * Place 1”x1” Photo Here
2. PERSONS WITH DISABILITY NUMBER (RR-PPMM-BBB-NNNNNNN) * 3. Date Applied *(mm/dd/yyyy)
4. PERSONAL INFORMATION * LAST NAME: * FIRST NAME: MIDDLE NAME: * SUFFIX: * *
5. DATE OF BIRTH: * (mm/dd/yyyy 6. SEX: * FEMALE MALE7. CIVIL STATUS: * Single Separated Cohabitation (live-in) Married Widow/er8. TYPE OF DISABILITY: * 9. CAUSE OF DISABILITY: * Deaf or Hard of Hearing Psychosocial Disability Congenital / Inborn Acquired Intellectual Disability Speech and Language Impairment Autism Chronic Illness Learning Disability Visual Disability ADHD Cerebral Palsy Mental Disability Cancer (RA11215) Physical Disability (Orthopedic) Rare Disease (RA10747) Cerebral Palsy Injury Down Syndrome10. RESIDENCE ADDRESS *House No. and Street:* Barangay:* Municipality:* Province:* Region:*
11. CONTACT DETAILSLandline No.: Mobile No.: E-mail Address:
12. EDUCATIONAL ATTAINMENT: * 14. OCCUPATION: * None Senior High School Managers Kindergarten College Professionals Elementary Vocational Technicians and Associate Professionals Junior High School Post Graduate Clerical Support Workers Service and Sales Workers13. STATUS OF EMPLOYMENT: * 13 b. TYPES OF EMPLOYMENT: * Skilled Agricultural, Forestry and Fishery Workers Employed Permanent / Regular Craft and Related Trade Workers Unemployed Seasonal Plant and Machine Operators and Assemblers Self-employed Casual Elementary Occupations Emergency Armed Forces Occupations13 a. CATEGORY OF EMPLOYMENT: * Others, specify: _______________________ Government Private15. ORGANIZATION INFORMATION:Organization Affiliated: Contact Person: Office Address: Tel. Nos.:
16. ID REFERENCE NO.:SSS NO.: GSIS NO.: PAG-IBIG NO.: PSN NO.: PhilHealth NO.:
17. FAMILY BACKGROUND: LAST NAME FIRST NAME MIDDLE NAME FATHER’S NAME MOTHER’S NAME: GAUARDIAN:18. ACCOMPLISHED BY: * LAST NAME FIRST NAME MIDDLE NAME APPLICANT GUARDIAN REPRESENTATTIVE19. NAME OF CERTIFYING PHYSICIAN: LICENSE. NO.:20. PROCESSING OFFICER: *21. APPROVING OFFICER: *22. ENCODER *23. NAME OF REPORTING UNIT: (OFFICE/SECTION)*24. CONTROL NO.: *
Revised as of August 1, 2021 DEPARTMENT OF HEALTH Philippine Registry For Persons with Disabilities Version 4.0 Application FormInstructions for Philippine Registry for Persons with Disabilities (PRPWD) Version 4.0 Form NO. FIELD NAME INSTRUCTION and DEFINATION 1 New Applicant and Check the appropriate box based on the definition. Renewal New Applicant: to account the information of the new applicant Renewal: for possible update of information of the individual (address, type of disability, contact details, etc.) 2 Registration No. Region, Province, City/Municipality and Barangay is system-generated number, but the sequential number should be assigned by the Issuing Office. Once the Person with Disability report is encoded into the system, copy the system- generated number and write into the box of the Application Form. 3 Date Applied The date when Persons of Disability applied, must be entered on this portion. The format is “mm/dd/yyyy” 4 Personal Information Write the last name, first name, middle name in the appropriate space provided.by the Issuing Office Note: Middle name is default to “N/A” because it is a required field. If the Person with Disability have a middle name, remove the “N/A” and write the middle name. 5 Birthdate Write the birthdate of the Person with Disability in the format of “mm/dd/yyyy” (e.g. July 1, 1970 should be written as 07/01/1970). The birthdate should not be later than the current date/registration date. 6 Sex Check the appropriate circle for the sex of the Person with Disability. 7 Civil Status Check the appropriate circle for the civil status of the Person with Disability. Not legally separated is still considered as “Married” 8 Type of Disability Check the appropriate box/es for the Type/s of Disability sustained by the Person with Disability. One or more items can be checked for this field. Deaf or Hard of Hearing - refers to people with hearing loss, implies little or no hearing/ranging from mild to severe. Hearing loss, also known as hearing impairment means the complete or partial loss of the ability to hear from one or both ears with 26 dB or greater hearing threshold, averaged at frequencies’ 0.5, 1, 2, 4 kilohertz. Intellectual Disability - a significantly reduced ability to understand new or complex information and to learn and apply new skills. Learning Disability - persons who, although normal in sensory, emotional and intellectual abilities, exhibit disorders in perception, listening, thinking, reading, writing, spelling, and arithmetic. Mental Disability - disability resulting from organic brain syndrome and or mental illness (psychotic or non-psychotic disorder) Physical Disability - is a restriction of ability due to any physical impairment that affects a person’s mobility, function, endurance or stamina to sustain prolonged physical ability, dexterity to perform tasks skillfully and quality of life. Causes may be hereditary or acquired from trauma, infection, surgical or medical condition and include the following disorders, namely: (1) Musculoskeletal or orthopedic disorders (2) Neurological disorders (3) Cardiopulmonary disorders (4) Pediatric and congenital disorders Psychosocial Disability - any acquired behavioral, cognitive, emotional or social impairment that limits one or more activities necessary to effective interpersonal transactions and other civilizing process or activities to daily living such as but not limited to deviancy or anti-social behavior. Speech and Language Impairment - mean one or more speech/language disorders of voice, articulation, rhythm and/or the receptive and expressive processes of language. Visual Disability - A person with visual disability (Impairment) is one who has impairment of visual functioning even after treatment and/or standard refractive correction, and has visual acuity in the better eye of less than (6/18 for low vision and 3/60 for blind), or a visual field of less than 10 degrees from the point of fixation. A certain level of visual impairment is defined as legal blindness. One is legally blind when your best corrected central visual acuity in your better eye is 6/60 on worse or your side vision is 20 degrees or less in the better eye. Cancer (RA 11215) - Cancer refers to a genetic term for a large group of diseases that can affect any part of the body. Other terms used are malignant tumors and neoplasms. One defining feature of cancer is the rapid creation of abnormal cells that grow beyond their usual boundaries, and which can then invade adjoining parts of the body and spread to other organs; Rare Disease (RA10747) -refers to disorders such as inherited metabolic disorders and other diseases with similar rare occurrence as recognized by the DOH upon recommendation of the NIH but excluding catastrophic (i.e., life threatening, seriously debilitating, or serious and chronic) forms of more frequently occurring diseases. 9 Cause of Disability Check the appropriate box/es for the Cause/s of Disability sustained by the Person with Disability. This field can be multiple checking. Acquired – is a disability that has developed during the person's lifetime – that is as a result of an accident or illness rather than a disability the person was born with. Chronic illness - describes a group of health conditions that last a long time. It may get slowly worse over time or may become permanent or may lead to death. It may cause permanent change to the body and
Revised as of August 1, 2021 DEPARTMENT OF HEALTH Philippine Registry For Persons with Disabilities Version 4.0 Application Form will certainly affect the person’s quality of life. This is also true to persons diagnose with Cancer or Rare Disease. Thus, Chronic illnesses may cause disability, hence, it is considered not a disability. Congenital/Inborn - disease is present at birth Injury - An injury is the physical damage that results when a human body is suddenly or briefly subjected to intolerable levels of energy. It can be a bodily lesion resulting from acute exposure to energy in amounts that exceed the threshold of physiological tolerance, or it can be an impairment of function resulting from a lack of one or more vital elements (i.e. air, water, warmth), as in drowning, strangulation or freezing. The time between exposure to the energy and the appearance of an injury is short. (INJURY SURVEILLANCE GUIDELINES, Published in conjunction with the Centers for Disease Control and Prevention, Atlanta, USA, by the World Health Organization, 2001) Autism: refers to a range of conditions characterized by some degree of impaired social behavior, communication and language, and a narrow range of interests and activities that are both unique to the individual and carried out repetitively. ADHD (Attention Deficit hyperactivity Disorder): is a disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Cerebral Palsy: is a complex motor. disorder at the level of the central. nervous system. It is caused by. irreversible brain lesions occurring Down Syndrome: is a genetic disorder in which some, or all, of a person's cells have an extra chromosome.10 Residence Address Write the Person with Disability’s permanent address - House No. and Street, Barangay, Municipality/City, Province and Region Note: House No. and Street name should be encoded in the system, but the Region, Province, Municipality/City and Barangay is already built–in to the system; just click the appropriate Region, Province, Municipality/City, and Barangay of the Person with Disability11 Contact Details Write the Telephone No., Mobile No., and E-mail address of the Person with Disability if available.12 Educational Check the appropriate circle for the highest education attained by the Person with Disability. Attainment13 Status of Check the appropriate circle for the working status of the Person with Disability. One item must be chosen Employment in this field. Employed - persons in the labor force who were reported either at work or with a job or business although not at work: a) At Work - those who did some work, even for one hour during the reference period. b) With a Job or Business but not at Work - those who have a job or business even though not at work during the reference period because of temporary illness/injury, vacation or other leave of absence, bad weather or strike/labor dispute or other reasons. Likewise, persons who are expected to report for work or to start operation of a farm or business enterprise within two weeks from the date of the enumerator's visit are considered employed. Unemployed - includes all persons who are 15 years old and over as of their last birthday and are reported as: 1) without work, i.e., had no job or business during the basic survey reference period; AND, 2) currently available for work, i.e., were available and willing to take up work in paid employment or self-employment during the basic survey reference period, and/or would be available and willing to take up work in paid employment or self-employment within two weeks after the interview date; AND, 3) seeking work, i.e., had taken specific steps to look for a job or establish a business during the basic survey reference period; OR not seeking work due to the following reasons: (a) tired/believe no work available, i.e, the discouraged workers who looked for work within the last six months prior to the interview date; (b) awaiting results of previous job applications; (c) temporary illness/disability; (d) bad weather; and (e) waiting for rehire/job recall. Self-employed - is an independent contractor or sole proprietor who reports income-earned own business. The person works for him/herself at a variety of trades, professions, and occupations rather than working for an employer.13 a Category of Check the appropriate circle for the Category of Employment of the Person with Disability. Employment Permanent/Regular - the directly employed; work for an employer and are paid directly by that employer; permanent/regular employees do not have a predetermined end date of employment; permanent employees are often eligible to switch job positions within their companies Seasonal - the term seasonal employment refers to open positions in an organization that are available for only a portion of the year; seasonal employment is a form of temporary employment, whereby the workload occurs only during certain times of the year
Revised as of August 1, 2021 DEPARTMENT OF HEALTH Philippine Registry For Persons with Disabilities Version 4.0 Application Form Casual - employees are employees who do not have regular or systematic hours of work or an expectation of continuing work; a typical casual employee is employed on a daily basis when the need arises Emergency - means any work performed for the purpose of preventing or alleviating the physical trauma or property damage threatened or caused by an emergency; emergency work means work, which could not be covered by a weekly employee because of extenuating circumstances13 b Types of Check the appropriate circle for the Type of Employment of the Person with Disability. Employment14 Occupation Check the appropriate circle for the Occupation of the Person with Disability. If not stated in the choice, check “Others” then specify. Major Group 1. Managers - workers in this group plan, direct, coordinate and evaluate the overall activities of enter prises,governments and other organizations, or of organizational units within them, and formulate and review their policies, laws, rules and regulations. Major Group 2. Professionals - workers in this group increase the existing stock of knowledge, apply scientific or artistic concepts and theories, teach about the foregoing in a systematic manner, or engage in any combination of these activities. Major Group 3. Technicians and associate professionals - workers in this group perform mostly technical and related tasks connected with research and the application of scientific or artistic concepts and operationalmethods, and government or business regulations. Major Group 4. Clerical support workers ·workers in this group record , organize, store, compute and ret rieve information related , and perform a number of clerical duties in connection with money- handling operations , travel arrangements, requests for information, and appointments. Major Group 5. Service and sales workers - worker s in this group provide personal and protective services related to travel, housekeeping, catering, personal care, or protection against fire and unlawful acts , or demonstrate and sell goods in wholesale or retail shops and similar establishments, as well as at stalls and on markets. Major Group 6. Skilled agricu ltural, forestry and fishery workers - workers inthis group grow and harvest field or tree and shrub crops,gather wild fruits and plants, breed, tend or hunt animals, produce a variety of animal husbandry products, cultivate, conserve and exploit forests,breed or catch fish and cultivate or gather other forms of aquatic lifeinorder to provide food, shelter and income for themselves and their households. Major Group 7. Craft and related trades workers - work ers in this group apply spec ific knowledge and skills in the fields to construct and maintain buildings, form metal, erect metal structures, set machine tools, or make, fit,maintain and repair machinery, equipment or tools, carry out printing work, produce or process foodstuffs, textiles, or wooden, metal and other articles, including handicraf t goods. Major Group 8. Plant and machine operators and assemblers - workers in this group operate and monitor industrial and agricultural machinery equipment on the spot or by remote control , drive and operate trains, motor vehicles and mobile machinery and equipment, or assemble products from compone nt parts according to str ict specifications and procedures. Major Group 9. Elementary occupations - occupations in this group involve the performance of simple and routine tasks which may require the use of handheld tools and considerable physical effort. Major Group 10. Armed forces occupations - this major group includes all jobs held by members of the armed forces.Members of the armed forces are those personnel who are currently serving in the armed forces, including auxiliary services, whether on a voluntary or compulsory basis, and who are not free to accept civilian employment and are subject to military discipline. Included are members of the army, navy, air force and other military services, as well as conscri pts enrolled for military training or other service for a specified period.15 Organization Write the organization information of the Person with Disability including the name of organization Information affiliated, contact person, office address, and telephone number. If none, leave it blank16 ID Reference No. Write the SSS, GSIS, PAG-IBIG, PNS, and Philippine Health Insurance Number if available17 Family Background Write the name of the father, mother and or Guardian of the Person with Disability in the space provided.18 Accomplished By Check the appropriate circle, who accomplished the form weather Applicant, Guardian and or Representative. Then write the name who accomplished the form in the space provided
Revised as of August 1, 2021 DEPARTMENT OF HEALTH Philippine Registry For Persons with Disabilities Version 4.0 Application Form 19 Name of Certifying Write the name of physician who issued the Medical Certificate on the Person with Disability and write Physician the license no. 20 Processing Officer: Write the name of the processing officer who check the requirements submitted by Person with Disability 21 Approving Officer: Write the name of the approving officer who validate and approve the requirements submitted by Person with Disability 22 Encoder: Write the name of the encoder who enter the information of the Person with Disability 23 NAME OF REPORTING For the issuing office, Automatic generation of the system based on the User account UNIT:(OFFICE/SECTION) 24 Control No.: Write the number assigned by the Issuing Office Control number should be assigned by each Issuing offices (MSWDO/CMSWDO/PDAO)Sources defintion of terms are the following: Republic Act 10747, MOP of ONEISS, Department Admnistrative 2013-0005 and Amedment Department Admnistrative 2013-0005-A, Republic Act 11215, Philippine Standard Occupational Classification Of 201 2. Work Health Organization (thru online searching) DOLE 2019 guideline (thru online searching)
Revised as of August 1, 2021