ANNEX C

PERSONS WITH DISABILITY AFFAIRS OFFICE / FOCAL PERSON

Functionality Assessment Form

Year under Review : __________

Date of Submission : __________

Region : ___________
Province : ___________
City/Mun. : ___________

INDICATOR RATING REMARKS

Establishment 20%
Choose one:
a1. For Provinces, Cities, and 1st to 3rd income class
Municipalities, the PDAO is established through
Ordinance (20%)
- or -
a2. For 4th to 6th income class Municipalities, the
PWD FP is appointed by Executive Order (20%)
Accessibility 15%
Choose one:
a1. Physical location of PDAO is easily accessible to
Persons with Disabilities (5%)
- or -
a2. Physical location of PWD FP office/desk is easily
accessible to Persons with Disabilities (5%)
b. PDAO/FP has installed accessibility facilities/
devices such as:
o Ramps (1%)
o Support rails (1%)
o Reserved parking space for Persons with
Disabilities (1%)
o Wheelchair-friendly doors (1%)
o Wheelchair-friendly restrooms (1%)
o Braille (1%)
o Sign language interpreters (1%)
o Assistive signages (1%)
o Tactile tiles (1%)
o Others: ______________________ (1%)
Resources 10%
a. Furniture and Vehicle
o Tables and chairs (1%)
o Filing cabinet/ storage area (1%)
o Sofa bed, folding bed, or mat (1%)
o Availability of vehicle and/or transportation
expenses to convey Persons with Disabilities
(1%)
b. Equipment and Supplies
o Landline or mobile phone (1%)
o Computer, especially for PWD database
purposes (1%)
o Camera (0.5%)
 ANNEX C

o Voice Recorder (0.5%)

o First aid kit and other medicines (1%)

c. Monitoring Tools
 Logbooks
o Logbook for violations of Ras 7277,
9442, 10754 (0.5%)
o Logbook recording violence against
Persons with Disabilities (0.5%)
 Forms
o Feedback Form (0.5%)
Policies, Plans, and Budget 15%
a. PDAO/FP budget allocated in IRA (7.5%)
b. PDAO/FP PPAs integrated in AIP (7.5%)
Conduct of Meetings 5%
a. Regular conduct of public consultations by the
PDAO/FP with Persons with Disabilities in the
community on the formulation and implementation of
local policies for their well-being (2.5%)
b. Regular conduct of townhall meetings by the
PDAO/FP with Persons with Disabilities in the
community to get their views and concerns on local
and national issues affecting them (2.5%)
Partnership Initiatives 10%
a. PDAO/FP actively encourages and coordinates
with CSOs and the private sector in the conduct of
programs, initiatives, and activities that would engage
the participation of and provide benefit to Persons
with Disabilities (10%)
Accomplishments 25%
a. PDAO/FP has submitted the Annual
Accomplishment Report (choose one):
o in time (25%)
o 1 to 2 working days late (20%)
o 3 to 4 working days late (15%)
o 5 to 6 working days late (10%)
o 7 working days late and beyond (5%)
OVERALL RATING

LEVEL OF FUNCTIONALITY Indicate level below:

Basic 20% and below
Progressiv 21% to 50%
e
Mature 51% to 80%
Ideal 81% to 100%

Assessed by:
 ANNEX C

____________________
[Name]
[Position]