THIS FORM SHALL BE ANSWERED BY (OR FOR) PEOPLE WITH DISABILITIES.

PLEASE FILL OUT THIS FORM AND SUBMIT TO THE NATIONAL COMMISSION ON DISABILITY.

Personal Information

Your First Name
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Other Name
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Sex
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Your Last Name
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Date of Birth:
Select a date
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Your National ID Number
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Age:
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Region
  • - select a region -
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
- select a region -
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Are you a Guyanese National?
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Other Nationality:
If you are not Guyanese what is your nationality
Your Nationality
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Lot and Street:
Lot and Street
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Town and Village:
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Type of Residence:
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Home Phone Number:
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Mobile Number:
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Your Email Address
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Disabilities

Source or Cause of Disability and Age Disability was diagnosed.
If you have more than one, add it using the + button after the disability fields.
Disability Type
  • - select a option -
  • Attention deficit and Hyperactivity Disorder (ADHD)
  • Autism
  • Blind
  • Cerebral Palsy
  • Deaf
  • Down Syndrome
  • Hearing Impaired
  • Learning Disability (Dyslexia, understanding)
  • Mental Health Issues
  • Orthopaedic Impairment (difficulty moving, reaching, Kneeling, grouching, gripping, holding objects)
  • Schizophrenia
  • Speech Impairment
  • Tasting, Smelling, or Feeling ( Physical Touch)
  • Visually Impaired (even if wearing glasses)
- select a option -
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Field is required!
Cause or Source of Disability
  • - select a option -
  • (1) Born with Disability
  • (2) Acquired disability by disease
  • (3) Violence
  • (4) Acquired disability due to an accident at Work
  • (5) Acquired disability due to a Vehicular accident
  • (6) Acquired disability due to an accident while at Home or at Recreation
  • (7) Not Sure
- select a option -
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Age Disability Diagnosed
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Other Disability:
List any other disabilities along with the cause/source and age diagnosed
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Additional Information

Kindly indicate if you currently attend school
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Your age when you first attended school:
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Your age when you left school:
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What type of school did you attend?
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Do you need schooling?
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Type of classes needed:
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Currently Employed:
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Your Profession:
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Do you require training to be employed?
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Training Required:
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What are your sources of material and financial support?
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Do you use any assistive aid for your disability?
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Field is required!
What assistive aids do you use?
Wheelchair, hearing aid etc.
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Field is required!
Do you need any assistive aid for your disability (e.g. wheelchair, hearing aid, walking aid)?
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Field is required!
Assistive Aids Needed:
wheelchair, hearing aid, walking aid etc.
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Field is required!
Are you a member of any disability organization/s? If so state which:
Organization Name
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Field is required!
Submit