First name
Email
ID Number
Residential Address
Current Employment Status UnemployedPart-timeFull-time
Place of Birth
Gender MaleFemale
Marital Status SingleMarried
Contact Number
Alternative Number
Age Group >18 Years<18-35 Years<35-50 Years<50-65 Years<65 Years
Are you directly linked to a domestic worker? YesNo
Contact Name of Domestic Worker
Last Name
Citizenship
Work Address
Number of People In the Household
Number of Children
Do you have any formal education? YesNo
Highest Standard/ Level Passed/ Completed
Year of completion
Name of Institution
Contact Number of Domestic Worker
Relationship with the Domestic Worker
Human Rights YesNo Remarks
Education and Skilling YesNo Remarks
Healthcare YesNo Remarks
Welfare YesNo Remarks
Are you aware of your rights as a domestic worker? YesNo Remarks
Are you in possession of a Letter of Appointment? YesNo Remarks
Are you registered for Unemployment Insurance Fund? YesNo Remarks
Is your employer contributing for Workmen’s Compensation on your behalf? YesNo Remarks
Are you satisfied with you current Conditions of Employment? YesNo Remarks
Are you satisfied with your Employer’s treatment in your workplace? YesNo Remarks
Have you experienced any human rights violation in your workplace? YesNo Remarks
General Remarks
Do you have any special skills that may assist you with generating extra income? YesNo Remarks
Are you interested in acquiring any new skills (over a period of 3-18 months) that may assist you with generating extra income? [radio-18 "Yes" "No"] Remarks
Are you interested in starting your own business and/or partnering with others to form business? YesNo Remarks
Do you have any health conditions requiring frequent access to health care services/facilities? YesNo Remarks
Are you able to access health care facilities to obtain necessary health care assistance? YesNo Remarks
Do you have any source of income? YesNo Remarks
Do you regard your living conditions as being sustainable? YesNo Remarks
Are you able to secure a meal/s on daily basis? YesNo Remarks
Do you require any special care and support? YesNo Remarks
Are you under anyone’s care and/or guardianship? YesNo Remarks
Are there any vulnerable minors under your care? YesNo Remarks
By clicking the "I Agree" button below, I, acknowledge that I consent to undergo a Needs Assessment conducted by SINA Foundation. I understand that this assessment is not a commitment or agreement between myself and SINA Foundation. I also acknowledge that, should I be deemed eligible for any assistance, I will enter into an Enrollment Agreement with SINA Foundation and will be bound by the Terms and Conditions set out therein. I agree
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