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Deafblind Census Form
Please take a few minutes to fill out this survey on the Deafblind community today. Deafblind South Africa require your help in identifying those who are Deafblind in and around your community. Please complete the following census for individuals who have BOTH vision AND hearing loss. (Diagnosed or Suspected). The information provided will be kept confidential. Thank you for your participation.
Deafblind South Africa
Full name and contact details of person completing the census on behalf of the Deafblind client:
Your answer
Personal Information of the Deafblind Individual
First Name
Your answer
Last Name
Your answer
Gender
Age
Your answer
Address, City, Province and Code
Your answer
Email
Your answer
Phone (if applicable)
Your answer
Race/Ethnicity
Your answer
Language
Your answer
Name of School (past and present)
Your answer
General Information
Etiology (Cause of Deafblindness)
Documented Vision Loss
Cortical Vision Impairment
Documented Hearing Loss
Other Impairments or Conditions:
Communication Choices
Education Information of Deafblind IndividualUntitled Title
Early Intervention Setting
Educational Setting
Exiting Education Status
Literacy Instruction
Living Setting Information of Deafblind IndividualUntitled Title
What is your current living arrangements?
Do you use any of the assistive devices?
Do you make use of any support services?
Additional Feedback
Please list any areas in which services are required in your community to ensure quality of life of a Deafblind individual.
Your answer
Would you like someone to contact you regarding your responses on this census?
Thank you for taking the time to fill out the census. Your participation is greatly appreciated.
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