Joint circular No. 37/2012/TTLT-BLDTBXH-BYT-BTC-BGDDT dated December 28, 2012, on determination of impairment levels by Impairment Assessing Council

• Official number: 37/2012/TTLT-BLDTBXH-BYT-BTC-BGDDT
• Legislation Type: Joint circular
• Organization: The Ministry of Education and Training, The Ministry of Finance, The Ministry of Health, Bộ Lao động - Thương binh và Xã hội
• Signer: Nguyen Thi Xuyen, Nguyen Trong Dam, Nguyen Thi Nghia, Nguyen Thi Minh
• Issued Date: 28/12/2012

MINISTRY OF LABOR, WAR INVALIDS AND SOCIAL AFFAIRS - THE MINISTRY OF FINANCE - THE MINISTRY OF HEALTH - THE BOARD OF DIRECTORS -------	SOCIALIST REPUBLIC OF VIETNAM Independence - Freedom - Happiness ---------------
No. 37/2012/TTLT-BLĐTBXH-BYT-BTC-BGDĐT	Hanoi, December 28, 2012

JOINT CIRCULAR

ON DETERMINATION OF IMPAIRMENT LEVELS BY IMPAIRMENT ASSESSING COUNCIL

Pursuant to the Law on the disabled dated June 17, 2010;

Pursuant to the Decree No. 28/2012/NĐ-CP dated April 10, 2012 by the Government providing instructions on the implementation of a number of articles of the Law on the disabled (hereinafter referred to as 28/2012/NĐ-CP);

The Minister of Labor, War Invalids and Social Affairs, the Minister of Health, the Minister of Finance and the Minister of Education and Training promulgate the Joint-Circular providing for the determination of impairment levels made by Impairment assessing Council.

Chapter 1.

GENERAL PROVISIONS

Article 1. Entities and scope of application

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This Joint-Circular provides for the operations of the Impairment assessing Council (hereinafter referred to as Council); methods for determining and re-determining the impairment levels; documents, procedures and process for determining impairment levels; issuance, replacement, re-issuance, revocation of Impairment certificate; expenditure of the determination of impairment levels.

2. Regulated entities of this Joint-Circular include:

a) Disability services;

b) Impairment assessment Council;

c) Members of Impairment assessing Council;

d) The disabled;

dd) Legal representatives of the disabled.

Chapter 2.

OPERATIONS OF THE COUNCIL, METHODS FOR DETERMINING IMPAIRMENT LEVELS

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1. The Impairment assessing Council is established under the decision of the Presidents of the People’s Committees of communes and contains members according to the provisions in clause 2 Article 16 of the Law on the disabled.

2. The Council is operated according to the provisions in clauses 3 and 4 Article 16 of the Law on the disabled.

3. The Council is responsible for determining types and levels of impairment; re-determining impairment levels of the disabled who experienced an event that modifies the impairment level.

4. Responsibilities of the Council’s members:

a) Chairperson of the Council is responsible for organizing and presiding over the operation of the Council;

b) Civil servants of communes who are in charge of labor, war invalids and social affairs issues are responsible for:

- Receiving application papers and application documents;

- Providing the disabled with guidance on completing documents;

- Making records on the content of the Council’s sessions;

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- Carrying out other tasks assigned by the Chairperson of Council.

c) Heads of the medical stations of communes are responsible for:

- Providing the Council with medical information pertaining to the disabled;

- Carrying out other tasks assigned by the Chairperson of Council.

d) Any members of the Council is responsible for participating in the impairment level determination process, participating in all concluding sessions of the Council, contributing opinions and carrying out tasks assigned by the Council.

5. When the Council is established or when there is change in Council's members, Presidents of People’s Committees of communes are responsible for giving promulgate Decisions on establishment, replacement or addition of Council’s members.

6. Council’s tenure is the same as the one of People’s Committees of communes.

7. Councils may use the seals of People’s Committees of communes.

Article 3. Methods for determining impairment type and impairment levels

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a) Determination of impairment type for children under 6/under age 6:

Any members of the Council shall observe directly the specific signs of children with disabilities, interview the legal representatives of such children and use “Impairment determination form for children under 6” prescribed in Form No. 02 enclosed herewith to determine the impairment type of children with disabilities.

Members of the Council evaluate only 03 types of impairment: mobility impairment, vision impairment and mental impairment.

b) Determination of impairment type for the disabled aged 6 or older:

Any members of the Council shall observe directly the specific signs of the disabled, interview the disabled or their legal representatives and use “Impairment determination form for the disabled aged 6 or older” prescribed in Form No. 03 enclosed herewith to determine the impairment type of the disabled.

2. Determination of impairment levels:

a) Determination of impairment levels for children under 6:

Any members of the Council shall observe directly the specific signs of children with disabilities, interview the legal representatives of such children and use “Impairment assessment form for children under 6” prescribed in Form No. 04 enclosed herewith to determine the impairment levels of children with disabilities.

b) Determination of impairment level for the disabled aged 6 or older:

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Chapter 3.

APPLICATION, PROCEDURES FOR DETERMINATION OF IMPAIRMENT LEVELS AND ISSUANCE OF THE IMPAIRMENT CERTIFICATE

Article 4. Application for determination, re-determination of impairment levels

1. Application for determination of impairment levels shall include:

a) An application form using the Form No. 01 enclosed herewith.

b) Copies of medical documents proving the impairment: medical records, examination papers, and relevant documents (if any)

c) A copy of the conclusion of Medical Examination Council on self-care ability, level of working ability reduction applied to the disabled having been issued with the conclusion of Medical Examination Council before the day on which the Decree No. 28/2012/NĐ-CP takes effect.

2. Application for re-determination of impairment levels shall include:

a) An application form using the Form No. 01 enclosed herewith.

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Article 5. Procedures for determination and re-determination of impairment levels

1. The disabled person or his/her legal representatives who wish to determine impairment levels shall submit 01 application conformable to the provisions in Article 4 of this Joint-Circular to People’s Committees of the communes where the disabled live (family register or ID card shall be presented in order for the receiving officials to check the information on the application form).

2. Within 30 days from the day on which the application form for determination of impairment levels is received, Presidents of People’s Committees of communes shall:

a) Convene the members, send the notification of the time and location for determination to the disabled or their legal representatives:

b) Determine the types and levels of impairment of the disabled person according to the methods and contents prescribed in Article 3 of this Joint-Circular; draw up documents and records of conclusion of the impairment levels determination of the applicant according to the assessment using Form No. 06 enclosed herewith.

If the disabled person has been issued with the conclusion of the Medical Examination Council on self-care ability, level of working ability reduction before the day on which the Decree No. 28/2012/NĐ-CP by the Government takes effect, the Council shall base on the conclusion of the Medical Examination Council to determine the impairment levels according to the provisions in clause 3 Article 4 of the Decree No. 28/2012/NĐ-CP.

3. The determination of impairment levels shall be performed at a People’s Committee of communes or at a medical station. If a disabled person is impossible to reach the determination location specified in the notification prescribed in point a Clause 2 of this Article, the determination shall be carried at his/her residence.

4. With regard to the cases specified in clause 2 Article 15 of the Law on the disabled, the Council shall issue the applicant with a letter of introduction, list the cases and request the Medical Examination Council to take over (via the Department of Labor, War Invalids and Social Affairs)

Article 6. Procedures for the issuance of impairment certificate

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2. With regard to the cases undertaken by Medical Examination Council, Presidents of People’s Committees of communes shall base on the Certificate of impairment using Form No. 07 enclose herewith according to the conclusion of Medical Examination Council about types and levels of impairment.

Article 7. The Certificate of impairment

1. The Certificate of impairment shall ensure the sufficiency of information prescribed in clause 1 Article 19 of the Law on the disabled.

2. The Certificates of impairment shall be printed on rectangular hard papers, size of 9 cm x 12 cm, on a blue background. The contents shall be typed in Times New Roman font (according to the Vietnamese character sets TCVN-6909/2001) according to Form No. 07 enclosed herewith.

3. According to the guidance in Clauses 1 and 2 of this Article, People’s Committees of provinces shall provide guidance, produce forms of the Certificate of impairment and distribute them to communes, wards and towns in local area.

Article 8. Replacement, re-issuance and revocation of the certificate of impairment

1. The procedures for replacement of the Certificate of impairment shall be followed in the following cases:

a) The Certificate of impairment is damaged and no longer usable;

b) Children with disabilities turn 6.

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a) Types or levels of impairment are changed;

b) The Certificate of impairment is lost.

3. In case the Certificate of impairment is issued but the type and level of impairment on the certificate is found untruthful by the inspecting agency, then the Certificate shall be revoked. 

Article 9. Procedures and process for the replacement, re-issuance and revocation of the Certificate of impairment

1. The disabled person or his/her legal representative who requests replacement or re-issuance of the Certificate of impairment shall submit 01 application form using the Form No. 01 enclosed herewith and submit it to People’s Committees of communes where the disabled reside.

People’s Committees of communes shall reissue the Certificate and revoke the old Certificate concurrently.

2. 05 working days later, based on the remained document, Presidents of People’s Committees of communes shall decide whether to replace or re-issue the Certificate of impairment. Particularly for the change of type or level of impairment, the replacement and re-issuance shall be carried out in accordance with the provisions in Articles 5 and 6 of this Joint-Circular.

3. In case the Certificate of impairment is issued but the type or level of impairment is untrue, then based on the petition of the inspector/examiner agency, Presidents of People’s Committees of communes shall revoke and replace the Certificate with the Certificate conformable to the real type and level of impairment.

Chapter 4.

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Article 10. Fund

1. Funding for the determination of impairment levels and issuance of the Certificate of impairment is derived from the annual budget estimate of communes according to the provisions in the Law on State budget and the guiding documents.

2. Funding for the determination of impairment level and issuance of the Certificate of impairment is obtained, allocated, used, managed and settled according to the provisions in the Law on State budget, the Law on Accounting, the guiding documents and the provisions in Article 11 of this Joint-Circular.

Article 11. Spending targets and amount

1. Spending on the determination of types and levels of impairment and the issuance of the Certificate of impairment, including:

a) Spending on stationery; printing of the forms of Certificate of impairment, indexes; purchase of records and documents serving the managing activities. The actual spending according to estimate approved by competent authorities.

b) Spending on the sessions of Impairment assessing Council for:

- Chairperson of the Council: not exceeding VND 70,000 per person per time;

- Council members: not exceeding VND 50,000 per person per time;

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c) Spending on medical examination: according to the provisions of the Circular No. 93/2012/TT-BTC dated June 5, 2012 by the Ministry of Finance providing for amount, the collection, management and use of medical examination expense.

2. Spending on propagating relevant documents and writings serving the determination of impairment levels; spending on training and cultivating professional skill for members of the Council to adopt the regulations on funding for social protection beneficiaries according to applicable regulations.

Chapter 5.

ORGANIZATION OF IMPLEMENTATION

Article 12. The reporting activities

Responsibilities of People’s Committees of communes

Making a collective list of the disabled who have been issued with the Certificate of impairment and periodically submitting it to the Department of Labor, War Invalids and Social Affairs before the June 15 and December 15 of years according to the Form No. 08 enclosed herewith.

b) Responsibilities of Department of Labor, War Invalids and Social Affairs

Making a collective list of the disabled who have been issued with the Certificate of impairment and periodically submitting it to the Services of Labour, War Invalids and Social Affairs before the June 30 and December 30 of years according to the Form No. 09 enclosed herewith.

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Making a collective list of the disabled who have been issued with the Certificate of impairment and periodically submitting it to the Ministry of Labor, War Invalids and Social Affairs before January 15 and July 15 of years according to the Form No. 10 enclosed herewith.

Article 13. Implementation

1. This Joint-Circular takes effect on February 10, 2013

2. The provisions pertaining to the disabled in the Joint Circular No. 24/2010/TTLT-BLĐTBXH-BTC dated August 18, 2010 expires since the day on which this Joint-Circular takes effect.

Article 14. Responsibilities

1. Relevant Ministries, regulatory bodies, People’s Committees of provinces according to functions and tasks shall monitor the implementation of this Joint-Circular.

2. Difficulties that arise during the implementation of this Circular should be reported to the Ministry of Labor, War Invalids and Social Affairs, the Ministry of Finance, the Ministry of Health and the Ministry of Education and Training for consideration and solution.

PP. THE MINISTRER OF HEALTH
THE DEPUTY MINISTER





Nguyen Thi Xuyen

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PP. THE MINISTER OF EDUCATION AND TRAINING
THE DEPUTY MINISTER




Nguyen Thi Nghia

PP. THE MINISTER OF FINANCE
THE DEPUTY MINISTER





Nguyen Thi Minh

Form No. 01

(Enclosed with the Joint-Circular No. 37/2012/TTLT-BLĐTBXH-BYT-BTC-BGDĐT dated December 28, 2012)

SOCIALIST REPUBLIC OF VIETNAM
Independence - Freedom – Happiness
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APPLICATION FORM FOR IDENTIFIACATION, RE-DETERMINATION OF IMPAIRMENT LEVELS AND ISSUANCE, REPLACEMENT, RE-ISSUANCE OF CERTIFICATE OF IMPAIRMENT

Dear:

Chairperson of Impairment assessing Council of commune…………………………………….
District:………………………….
Province……………………….

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Full name of the disabled person/representative of the disabled:…………………………………………………………….

ID number………………………………………

Name of the disabled:……………………………………………..Male/Female:………….

Date of birth:……………………..

Hometown……………………………………………………………….

Permanent address…………………………………………………………

Commune…………………………….district………………………………………

Province……..……………………………………………………………….

Summary of personal situation……………….....…………………………………………

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I hereby apply for:

- Determination/re-determination of impairment levels;

- Issuance/replacement/re-issuance of the Certificate of impairment.

These following documents are enclosed herewith (if any):

The impairment assessment form.

Ÿ Document/Decision/Paper from Medical Examination Council

Ÿ Confirmation papers of medical agency (Hospital/Medical center of districts)

Ÿ Confirmation/Dispensing book/Medical record of mental illness

Ÿ Conclusion record of the Social benefit approval council.

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…………….,date………………..
Signature of the applicant

Form No. 02

(Enclosed with the Joint-Circular No. 37/2012/TTLT-BLĐTBXH-BYT-BTC-BGDĐT dated December 28, 2012)

PEOPLE’S COMMITTEE OF COMMUNE………………….
IMPAIRMENT ASSESSING COUNCIL
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SOCIALIST REPUBLIC OF VIETNAM
Independence - Freedom – Happiness
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Part A

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Full name:

Date of birth:

Gender: Male/Female

Permanent address:

Province

Father’s name:

Mother’s name:

Full name of representatives of the children (specifically the relationship with the children):

ID number of the representative:                                Date of issue:                 Place of issue:

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No.

Type of impairment

Affirmative

Negative

1. Mobility impairment

1

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Loss of arm(s) or immovability of arm(s)

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Loss of leg(s) or immovability of leg(s)

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2. Vision impairment

4

Blindness or loss of an eye

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5

Frequent convulsions

Conclusion:

Type of impairment:

Note: The Council shall request the Medical Examination Council to take over the determination of cases having signs other than the signs specified above.

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…………….,date………………..
Signature of the assessing official

Part B

GUIDANCE ON IMPAIRMENT DETERMINATION FORM FOR CHILDREN UNDER 6:

1. Introduction

- This Form is for the determination of impairment types for children under 6.

+ The Impairment determination form  includes 5 signs of the 03 types of impairment: mobility impairment, vision impairment and mental impairment.

+ The determination of hearing and speech impairment; intellectual disability and other types of impairment of children under 6 requires deep professional knowledge. Therefore, the Council may transfer the cases having signs of such types to Medical Examination Council for determining.

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+ Observing directly the unusual signs of the child with disabilities.

+ Interviewing the carers about unusual signs of the child with disabilities.

2. Guidance on Impairment determination form:

Assessing official shall determine every sign in the  impairment determination form type for children under 6:

- If a sign of a type of impairment is confirmed, such children will be considered suffering the corresponding type of impairment including mobility impairment or vision impairment or mental impairment.

- If a child is considered suffering from multiple types of impairment, all such types shall be specified in the conclusion of the Impairment determination form. For instance, a child may suffer from 2 or 3 types of impairment: mobility impairment, vision impairment and mental impairment.

- After determining the type of impairment, impairment level of children shall be identified.

- The Council shall request the Medical Examination Council to take over the determination of cases having signs other than the signs specified in the  Impairment determination form or there are difficulties in determining the type of impairment.

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(Enclosed with the Joint-Circular No. 37/2012/TTLT-BLĐTBXH-BYT-BTC-BGDĐT dated December 28, 2012)

PEOPLE’S COMMITTEE OF COMMUNE………………….
IMPAIRMENT ASSESSING COUNCIL

SOCIALIST REPUBLIC OF VIETNAM
Independence - Freedom - Happiness

Part A

IMPAIRMENT DETERMINATION FORM FOR CHILDREN AGED 6 OR OLDERAGED 6 OR OLDER:

Full name:

Date of birth:

Gender: Male/Female

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Province

Father’s name:

Mother’s name:

Name of wife/husband:

Full name of representatives of the disabled (specifically the relationship with the disabled):               

ID number of the representative:                Date of issue:         Place of issue:

The signs of impairment on the disabled Put “X” in the “Affirmative” column for the appropriate signs

No.

Type of impairment

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Negative

1. Mobility impairment

1

Difficulties in activities like sitting, standing and walking

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Weakness, paralysis, or limited movements of arms, legs, back, neck

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Malformation of arms, legs, back, neck

2. Hearing and speech impairment

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Difficulty or inability to speak

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Difficulties in hearing or inability to hear

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Malformation of ears, nose and mouth

3. Vision impairment

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 Difficulties in seeing or inability to see objects

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8

Difficulties in differentiating colors or inability to differentiate colors

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Malformation of eye zone

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4. Mental impairment

10

The patient usually stay alone, never talk to anyone or care about anything.

11

The patient have unusual behaviors like being roused, angry or causelessly fear or have self-harming behaviors including head-banging, hand-biting

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12

The patient suddenly stop all activities to gaze at something without blink, convulse limbs, lips or suddenly fall out, convulse, foam at mouth and have no response to sound

5. Intellectual disability

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The patient have difficulties in recognizing family or in communicating compared with people at the same age

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The patient is sluggish, doltish or unable to do even a simple thing compared with people at the same age) in spite of being instructed.

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The patient have difficulties in studying (reading, writing and calculating) compared with people at the same age because of mental retardation

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6. Other disabilities

16

Reduction in ability to perform the activities in studying and working because of anesthesia despite being treated for 3 months.

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Reduction in ability to perform the activities in studying and working because of ? despite being treated for 3 constant months.

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Reduction in ability to perform the activities in studying and working because of  other reasons

Conclusion:

Type of impairment:

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…………….,date………………..
Signature of the assessing official

Part B

GUIDANCE ON IMPAIRMENT DETERMINATION FORM FOR THE DISABLED AGED 6 OR OLDER

1. Introduction

This Form is for determination of impairment type for the disabled aged 6 or older: This form is based on disability determination questions by the World Health Organization (WHO) and is modified according to:

- The division of impairment type in the Law on the disabled of Vietnam.

- The concepts of disability of the WHO

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The Impairment determination form includes 18 signs of the 6 types of impairment: mobility impairment, hearing and speech impairment, vision impairment, mental impairment, intellectual disability and other disabilities.

2. Methods for determining impairment type

The assessing official shall combine 2 following methods:

- Observing directly the unusual signs of the disabled in daily life.

Interviewing the disabled or their carers about signs and their abilities

3. Guidance on Impairment determination form:

Assessing official shall examine every sign specified in the Impairment determination form for children aged 6 or older:

- If one of three signs of a type of impairment is confirmed, such children will be identified as the corresponding type of impairment.

- A disabled person may suffer from 1 or multiple types of impairment If a child is identified suffering from multiple types of impairment, all such types shall be specified in the conclusion of the Impairment determination form,. For instance, a disabled person may suffer from 2 or 3 types of impairment: mobility impairment, hearing and speech impairment, vision impairment, intellectual disability...

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Form No. 04

(Enclosed with the Joint-Circular No. 37/2012/TTLT-BLĐTBXH-BYT-BTC-BGDĐT dated December 28, 2012)

PEOPLE’S COMMITTEE OF COMMUNE………………….
IMPAIRMENT ASSESSING COUNCIL
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SOCIALIST REPUBLIC OF VIETNAM
Independence - Freedom – Happiness
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IMPAIRMENT ASSESSMENT FORM FOR CHILDREN UNDER 6

Full name:

Date of birth:

Gender: Male/Female

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Father’s name:

Mother’s name:

Full name of representatives of the disabled (specifically the relationship with the disabled):

ID number of the representative:                Date of issue:         Place of issue:

The impairment assessment table Observing directly the unusual signs of the children with disabilities and put “X” in the “Affirmative” column for the appropriate signs

Conditions

Signs (DÙNG DANH TỪ)

Affirmative

Negative

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Full body flaccid paralysis or spastic paralysis

Loss of arms

Loss of legs

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Loss of an arm and a leg

Blindness or loss of eyes

Very usual suffering from convulsions (at least 15 fits per month)

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2. Serious impairment

 Immovability of arms or legs

Loss of an arm

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Blindness in one eye

Loss of an eye

Usual suffering from convulsions usually (from 4 to 14 fits per month)

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Conclusion:

Note: If a child has signs other than those signs above and the Council fail to determine the impairment levels, the Council shall note “Undetermined" in the conclusion and transfer such case to the Medical Examination Council.

…………….,date………………..
Signature of the assessing official

Part B

GUIDANCE ON IMPAIRMENT ASSESSMENT FORM FOR CHILDREN UNDER 6:

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This form is for the assessment of extremely serious impairment and serious impairment of the children with disabilities who are under 6 according to 3 types of impairment: mobility impairment, vision impairment and mental impairment. This form is based on:

- The division of type and level of impairment in the Law on the disabled of Vietnam.

-  Development features of the children

2. Methods for determining the impairment level for the children under 6

The assessing official shall combine 2 methods:

- Observing directly the unusual signs of the children with disabilities. This is the main method for determining the impairment level.

- Interviewing the carers about unusual signs specified in the form.

The assessing official shall determine the impairment level of children according to the information from observation and interview.

3. Guidance on Impairment assessment form for children under 6:

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- Extremely serious impairment: if the disabled child have 6 following signs: be flaccid or rigid all over; lack arms; lack legs; lack an arm and a leg; be blind in eyes or lack eyes; suffer from convulsions very usually (at least 15 fits per month)

- Serious impairment: if the disabled child have 6 following signs: immovability of arms or legs; loss of an arm; loss of a leg; blindness in one eye; loss of an eye; usual suffering from convulsions (from 4 to 14 fits per month);

4. Rules for assessment

- In case there is unreliable information in the assessing process, the Council shall carry out a re-assessment to come to an accuracy conclusion

- If a child is identified suffering 1 of 3 types of impairment (mobility impairment, vision impairment and mental impairment) and has signs other than those specified in Form No. 02 part A, the Council shall transfer such case to Medical Examination Council for accuracy conclusion.

Form No. 05

(Enclosed with the Joint-Circular No. 37/2012/TTLT-BLĐTBXH-BYT-BTC-BGDĐT dated December 28, 2012)

PEOPLE’S COMMITTEE OF COMMUNE………………….
IMPAIRMENT ASSESSING COUNCIL
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Part A

IMPAIRMENT ASSESSMENT FORM FOR THE DISABLED AGED 6 OR OLDER

Full name:

Date of birth:

Gender: Male/Female

Permanent address:

Province

Father’s name:

Mother’s name:

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Full name of representatives of the disabled (specifically the relationship with the disabled):       

ID number of the representative:        Date of issue:     Place of issue:

The signs of impairment on the disabled Score the appropriate signs

Ability

Activities

Able to do (2 pts)

Able to do with help (1 pt)

Unable to do (0 pt)

Undetermined (put an “X” in the box)

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2. Eating and drinking

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4. Personal hygiene (including brushing, face washing, bathing and showering...)

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6. Hearing and understanding what people say

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8. Participating in housework like folding clothes, sweeping, washing dishes, cooking,

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Extremely serious impairment: 0 - 4 pts

Serious impairment: 5 - 11 pts

Mild impairment: at least 12 pts

Note: If the Council fail to identify the impairment level, the Council shall put an “X” in the column “Undetermined" for corresponding criterion.

…………….,date………………..
Signature of the assessing official

Part B

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1. General introduction:

This form is for the assessment of impairment type for the disabled aged 6 or older:

The Impairment assessment form is based on:

- The division of type and level of impairment in the Law on the disabled of Vietnam.

- Definition and characteristics of each type of impairment

- Activities of daily living of a normal person in Vietnamese social conditions.

- Instruments for screening, diagnosing, assessing of impairment of developed countries (USA, Japan, UK...)

2. Methods for determining impairment level

The assessing official shall combine 2 methods:

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- Interviewing the disabled or their carers about the abilities to perform the activities specified in the form.

The assessing official shall determine the ability level of each activity of the disabled according to the information from observation and interview.

3. Guidance on the impairment assessment form:

The form consist of 8 simple activities serving daily living. For each activity, the assessing official shall determine the ability of the disabled according to 3 levels:

- “Able to do”: the disabled person is able to perform the activity independently without need for help.

- “Able to do with help”: the disabled person is able to perform independently some small steps in the activity; or the disabled person is able to perform the activity with some help. Such help include 2 kinds:

+ Instruments: a disabled person can perform an activity with help of instruments such as stick, splints, crutch, prosthesis, hearing aid, optical aid...

+ Helpers: a disabled person can only perform an activity with help of other persons.

- “Unable to do”: The disabled person is totally unable to perform any steps of the activity, totally depended on helpers. The assessing official shall determine the ability level of the disabled according to their performance in each activity.

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√ If the activity is evaluated “able to do”: write 2 pts in the corresponding box.

√ If the activity is evaluated “able to do with help”: write 1 pt in the corresponding box.

√ If the activity is evaluated “unable to do”: write 0 pt in the corresponding box.

√ If ability level is not identifiable, put an “X” in the corresponding box.

* The activities are evaluated as follows:

Activity 1 - “Walking":

- Able to do: If the disabled person can walk without difficult and without help.

- Able to do with help: if the disabled person has difficulties in walking or need stick, splints, crutch, prosthesis or helpers.

- Unable to do: if the disabled person is immobilized or needs to use wheelchair or has to be carried by another person.

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- Able to do: If the disabled person can perform independently the activity including taking bowls, picking and spooning, chewing without difficult and without help

- Able to do with help: if the disabled person has difficulties in chewing and swallowing or needs help in eating process like spoon rice, finding food or holding bowls.

- Unable to do: if the disabled is totally unable to pick up food or spoon/pick up food to eat by himself/herself.

Activity 3 - “Toilet hygiene”:

- Able to do: If the disabled person can perform independently the activity including moving to the toilet without difficult and without help.

- Able to do with help: if the disabled person has difficulties when going to the toilet or has difficulties in urination or defecation that needs help from another person or instruments.

- Unable to do: if the disabled person is totally unable to control their urination or defecation and always need help from another person.

Activity 4 - Personal hygiene (including brushing, face washing, bathing and showering...)

- Able to do: If the disabled person can person can perform independently the activity including moving to bathroom, using personal hygiene items with no need of help.

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- Unable to do: if the disabled person is totally unable to perform the personal hygiene and always needs help from another person.

Activity 5 - “Dressing”:

- Able to do: If the disabled person can perform the activity without difficulties including taking clothes, sitting down, standing up during the changing process without difficulties and without help.

- Able to do with help: if the disabled have difficulty when

- Unable to do: if the disabled person is totally unable to perform the dressing and always needs help from other person.

Activity 6 – “Hearing and understanding what the people say”

- The assessing official may request the disabled person to do two of the following activities (the assessing official may ask the disabled person's family member to utter the question to avoid misunderstanding due to being unfamiliar with voice): Show me the chair!; Give me the book!; Take me the glass of water!; Stand up!; Sit down!; Go to the kitchen and bring me a bowl!; Do you know this....? (point at the member of his/her family)...

- Able to do: If the disabled person can hear and independently perform the activities according to the request without any help.

- Able to do with help: if the disabled person has difficulty in hearing and understanding the requests and needs help from another person or instrument like hearing-aid.

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Activity 7 – “Express wishes and thinking in speech”;

The assessing official may request the disabled person to answer two of the following questions (the assessing official may ask the disabled person's family member to avoid misunderstanding): Have you had meal?  Would you like to drink something? What do you want? How long have you been in this condition? ...

- - Able to do: If the disabled person can answer clearly, fluently without any help.

- Able to do with help: if the disabled person has difficulty in answering the questions and need to use sign, stutter, lisp, double Dutch or need help from another person.

- Unable to do: if the disabled is totally unable to understand and answer.

Activity 8 – “Participating in housework like folding clothes, sweeping, washing dishes, cooking”:

Ask the disabled person or his/her carer if he/she can do two of the listed activities (folding clothes, sweeping, washing dishes, cooking...)

-  Able to do: If the disabled person can do without difficult and without help.

- Able to do with help: if the disabled person can perform partially the activity or need help to complete the activity.

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After assessing, total score of the 8 activities shall be calculated. Conclusion:

Extremely serious impairment: 0 - 4 pts

Serious impairment: 5 - 11 pts

Mild impairment: at least 12 pts

4. Rules for assessment

- In case there is information suspicious in the assessing process, the Council shall arrange a re-assessment to come to an accuracy conclusion

- If a disabled person has a sign that is evaluated “Undetermined”, the Council shall transfer such case to the Medical Examination Council for an accuracy conclusion.