Disability is not a sin, not a curse let us wipe out the wrong concept
Has to be filled up in both Bengali & English language
 Phonetic  Bijoy  Avro
[ Introductory Part : Personal Information of the Person With Disability (PWD). Please fill up NID or BRIS. ]

Permanent Address

Present Address

স্থায়ী ঠিকানা

বর্তমান ঠিকানা

[ Section-1: Social & Rehabilitation ]
(1) Male
(2) Female
(3) Third Gender
(1) Unmarried
(2) Married
(3) Divorced
(4) Widow
(5) Widower
(6) Polygamy
(7) Separated
(1) Islam
(2) Hinduism
(3) Buddhism
(4) Christianity
(9) Others
(1) Village
(2) City
(3) Slum
(1) Plain land
(2) Haour
(3) Coastal
(4) Island
(5) Hill
(6) Forest
(9) Others
(1) Illiterate
(2) Literate
(3) P.S.C./Class Five
(4) J.S.C./Class Eight
(5) S.S.C.
(6) H.S.C.
(7) Graduate
(8) Post-graduate
(10) Special Education
(9) Others
(1) Congenital
(2) Accident
(3) Illness
(4) Wrong Treatment
(9) Others
(1) No
(2) Physical
(3) Mental
(4) Sexual
(5) Social
(6) Teasing
(9) Others
(1) Did not receive
(2) Disability Stipend
(3) Stipends
(4) Microcredit
(5) Training
(6) Visual Aids
(7) Rehabilitation allowance
(8) Health Care
(10) Counseling
(11) Rehabilitation Services
(9) Others
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
[ Section-2 : Occupation & Income ]
(1) Not Applicable
(2) Agriculture
(3) Business
(4) Government Services
(5) NGO Services
(6) Teaching
(7) Doctor
(8) Engineering
(10) Law
(11) Domestic Work
(12) Day Labourer
(13) Begging
(14) Artist
(15) Jobless
(16) Study
(9) Others
(1) Not Applicable
(2) No Income
(3) Below 24,000 Tk
(4) Between 24,000-48,000 Tk
(5) Between 48,000-72,000 Tk
(6) Between 72,000-1,08,000 Tk
(7) Between 1,08,000-2,40,000 Tk
(8) 2,40,000 Tk and Above
[ Section-3 : Disability related ]
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No