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Cod operator date personale nr.

2092

CENTRUL DE RECUPERARE SI REABILITARE A PERSOANELOR CU DIZABILITATI CONDORUL BACAU


Str. Condorilor, nr. 2., Bacau
E-mail: condorulbacau@gmail.com
Tel. / fax: 0234/ 585 028

Chestionar pentru identificarea unor forme de abuz sau exploatare a persoanei cu dizabiliti n
comunitate

Nume i prenume beneficiar.................................................................................


Data nasterii..............................................................
Diagnostic.............................................................................................................

1. Te simi n siguran (acas/ instituie, etc.)? DA NU

Exemple de a te simi n siguran:

Nimeni nu ip la tine

Nimeni nu te lovete

Te simi bine

Te simi respectat

Oamenii te ncurajeaz s vorbeti cnd ai ceva de spus

Nu eti obligat s faci ce nu vrei

Eti bucuros

Nu te temi de nimeni

2. i s-a vorbit acas/ n instituie despre despre abuz, intimidare, ameninri ? DA NU

3. Ai fost vreodat ameninat, btut, maltratat n vreun fel? DA NU

Dac DA, poi spune cum ai fost abuzat, cine a fost vinovat, unde a avut loc i ce s-a ntmplat dup:
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Data completarii........................................................
Funcia, numele i semntura persoanei care aplic chestionarul...
Semntura beneficiar..
Cod operator date personale nr.2092

CENTRUL DE RECUPERARE SI REABILITARE A PERSOANELOR CU DIZABILITATI CONDORUL BACAU


Str. Condorilor, nr. 2., Bacau
E-mail: condorulbacau@gmail.com
Tel. / fax: 0234/ 585 028

Chestionarul pentru identificarea unor forme de abuz sau exploatare de ctre persoanele pe care le
viziteaz beneficiarul

Nume i prenume beneficiar.................................................................................


Data nasterii..............................................................
Diagnostic.............................................................................................................

1. Te simi n siguran cand esti vizitat de catre(numele


persoanei care efectueaz vizita, grad de rudenie etc.)? DA NU

Exemple de a te simi n siguran:

Nimeni nu ip la tine

Nimeni nu te lovete

Te simi bine

Te simi respectat

Oamenii te ncurajeaz s vorbeti cnd ai ceva de spus

Nu eti obligat s faci ce nu vrei

Eti bucuros

Nu te temi de nimeni

2. i s-a vorbit acas/ n instituie despre despre abuz, intimidare, ameninri ? DA NU

3. Ai fost vreodat ameninat, btut, maltratat n vreun fel? DA NU

Dac DA, poi spune cum ai fost abuzat, cine a fost vinovat, unde a avut loc i ce s-a ntmplat dup:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Data completarii........................................................
Funcia, numele i semntura persoanei care aplic chestionarul...
Semntura beneficiar..