AAP CARES

DATE
NAME
AGE
GENDER
EDUCATION
NUMBER OF FAMILY MEMBERS
18 & ABOVE: YesNo
PHONE
ADDRESS
WARD

FACILITIES SO FAR

What are the facilities and services extended thus far?
Ration KitsSanitizationHealth check-uphealth screeningAny Other
Who has approached you with these facilities?
BBMPRWANGOAny Other
Do you or any of your family member have any major health issues?
Is any medical appointment scheduled over the next month? Is there anything the
Household needs at this time with regard to health care?
Do you know/ have your heard about the AAP Cares Initiative?
Have you availed any facility? If so, what is it? OximeterSanitizationPersonal protection(masks)Assistance in case of hospitalizationAny other
What do you like about this initiative?
Do you have any suggestions to improve the Initiative?
Would you spread the message about the AAP Cares Initiative with yourfriendsneighboursfamilycolleagues?

INVOLVEMENT WITH AAP

Do you think this AAP Cares Initiative should be continued, in the days to come?YesNo
Would you like to be part of this Intitiative? YesNo
How would you like to contribute to or be involved with this Initiative?
Kiosk ManagementTime (volunteering) DonationsLeadMobilizeAwareness BuildingInformation DisseminationCapacity Building
How many hours in a week can you volunteer?