Personal InformationASSESSMENT QUESTIONNAIRE OF THE DISASTER VICTIMS' NEEDS
Date of Birth
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Address Sex
Living Situation
___Single ___Couple ___Family ___Other ___Dependent Children
___Other Dependents
Evacuation
How long did the evacuation last?
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Relocation? ___Yes ___No
If yes, where?
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Losses
Did you lose persons or things which were important to you? ___Yes ___No
If yes, who or what were they?
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Natural Support Network
Yes No
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Have you received support from your family, friends, people in your group? |
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Was this support sufficient? |
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Was this support helpful? |
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Are you still receiving support? |
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If so, is this support sufficient? |
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If so, is this support helpful? |
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Did this incident create difficulties? |
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In your daily life? If so, what are they? |
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In your relationships (couple, family…)? If so, what are they? |
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In regard to your children's behavior? If so, what are they? |
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In regard to your work? If so, what are they? |
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In regard to financial matters? If so, what are they? |
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On the social level? If so, what are they? |
Reactions Caused By The Incident
Do you have reactions that you did not have before the incident and which are persisting? If so, has there been an increase or a decrease in these symptoms during the last two weeks?
Yes No Increase Decrease
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More nervous |
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More worried |
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More irritable |
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More impatient |
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More withdrawn |
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Difficulty sleeping |
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Nightmares |
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Loss or increase in appetite |
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Headaches |
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Difficulty concentrating |
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Increased alcohol consumption |
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Other reactions |
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If so, what are they? |
Do you have someone with whom it is easy for you to talk with? ___Yes ___No
State of Health
How has your health been since the incident?
___Good ___Average ___Has deteriorated
Were you obliged to go to see a doctor? ___Yes ___No
How is the health of your spouse and children?
___Good ___Average ___Has deteriorated
Did they have to visit a doctor? ___Yes ___No
Degree of Intensity of the Effect on the Person
If we were to describe the moment you were emotionally affected by the incident as the number 10 on a scale of 0 to 10, what number would you apply to your state today? _______
Activities Offered By The Red Cross And Others
Yes No
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Have you participated in the activities offered by the Red Cross or by the community following the incident? |
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Have these activities helped you? How? ___To experience the incident better ___To understand ___To manage the stress better ___Other (Please specify) _______________________________________________ ____________________________________________________________________ |
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If you are still having difficulties, would you be interested in receiving assistance? If so, what type of assistance? ___Private interview ___Small group with professionals ___Other (Please specify) _______________________________________________ |
What type of activities would you like us to organize?
___Incident Debriefing Session ___Conference on the cause of the disaster
___Relaxation Session ___Community Activity ___Other Suggestions:
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