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APPENDIX OF APPLICATION FORM
FOR
Training of Information and Communication Technology for Visually Impaired Persons

Please submit all pertinent documents and your answers to this questionnaire in typewritten form together with your Fellowship Application Form.
**This appendix is available at http://www.apcdproject.org/trainings/2005/vip/

TITLE Mr.
Ms.
Mrs.
Dr. 		NAME (captical letter)  
GENDER MALE
FEMALE 		FAMILY NAME GIVEN NAME MIDDLE NAME
BIRTH DATE (Day/Month/Year):

PASSPORT NUMBER:

PASSPORT EXPIRY DATE (Day/Month/Year):

HOME ADDRESS:

 

TELEPHONE NUMBER (Country Code/Area Code/Number):

FAX NUMBER (Country Code/Area Code/Number):

NAME OF THE ORGANIZATION:

 

ADDRESS:

 

TELEPHONE NUMBER (Country Code/Area Code/Number):

FAX NUMBER (Country Code/Area Code/Number):

 

E-MAIL ADDRESS:

Page break

DISABILITIES
(IF ANY)

YES.
NO.

TYPE OF DISABILITIES Physical Disability
Hearing Disability
Visual Disability
Intellectual Disability
Mental Disability
Other
  USAGE OF ASSISTIVE DEVICES: YES NO
DETAIL OF YOUR ASSISTIVE DEVICES:
  1. Power/electronic wheelchair ( Wet battery Dry battery)
  2. Wheelchair
  3. Crutch (es)
  4. White cane
  5. Other (                                )
NECESSITY OF A PERSONAL ASSISTANT FOR THE TRAINING:
  1. YES => (Details)
  2. NO
NECESSITY OF A SIGN INTERPRETER FOR THE TRAINING:
  1. YES => (Details)
  2. NO
DIETARY REQUIREMENT (IF ANY)

I hereby certify that all the provided information is correct, accurate and complete to the best of my knowledge.

In the event that I suffer injury, illness or death during the course of my participation in the program/course, I shall hold the Royal Thai Government, the Government of Japan, Japan International Cooperation Agency (JICA) and/or the Asia-Pacific Development Center on Disability harmless and without any liability whatsoever for compensation towards myself, my legal representatives and/or my heirs. Should I cause any person loss of property, injury, illness or death during the course of my participation in the program/course, I shall be fully responsible and liable for the said person without reference whatsoever to the Royal Thai Government, the Government of Japan, Japan International Cooperation Agency (JICA) and/or the Asia-Pacific Development Center on Disability.

 

 

SIGNATURE OF NOMINEE

PRINTED NAME OF NOMINEE (________________________________)

DATE:

QUESTIONNAIRE

Q1. Please kindly share your organization's plan for computer training for VIP by specifying target group, software to teach, number of students, number of computers, etc (this plan would be carefully screened for your selection so that please provide planned training as detail as possible)
Your answer is here
Q2. Please briefly explain your work responsibility in line with the computer training above.
Your answer is here
Q3. Why do you think computer training is necessary for VIPs in your country?
Your answer is here
Q4. How much of the software or assistive devices listed below can you use?
Software or Assistive Devices Expert Very Good Good Little Never
Screen Reader          
Screen Magnifier*          
Making website*          
Braille Production*          
Talking Book Production*          
MS Office          

*Please specify your favorite software

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