DEPARTMENT OF HEALTH

Philippine Registry For Persons with Disabilities Version 4.0

Application Form
1.  NEW APPLICANT  RENEWAL * Place 1”x1”
Photo Here

2. PERSONS WITH DISABILITY NUMBER (RR-PPMM-BBB-NNNNNNN) * 3. Date Applied *(mm/dd/yyyy)

4. PERSONAL INFORMATION *
LAST NAME: * FIRST NAME: MIDDLE NAME: * SUFFIX: *
*

5. DATE OF BIRTH: * (mm/dd/yyyy 6. SEX: *

 FEMALE  MALE
7. CIVIL STATUS: *
 Single  Separated  Cohabitation (live-in)  Married  Widow/er
8. TYPE OF DISABILITY: * 9. CAUSE OF DISABILITY: *
 Deaf or Hard of Hearing  Psychosocial Disability  Congenital / Inborn  Acquired
 Intellectual Disability  Speech and Language Impairment  Autism  Chronic Illness
 Learning Disability  Visual Disability  ADHD  Cerebral Palsy
 Mental Disability  Cancer (RA11215)
 Physical Disability (Orthopedic)  Rare Disease (RA10747)
 Cerebral Palsy  Injury
 Down Syndrome
10. RESIDENCE ADDRESS *
House No. and Street:* Barangay:* Municipality:* Province:* Region:*

11. CONTACT DETAILS

Landline No.: Mobile No.: E-mail Address:

12. EDUCATIONAL ATTAINMENT: * 14. OCCUPATION: *

 None  Senior High School  Managers
 Kindergarten  College  Professionals
 Elementary  Vocational  Technicians and Associate Professionals
 Junior High School  Post Graduate  Clerical Support Workers
 Service and Sales Workers
13. STATUS OF EMPLOYMENT: * 13 b. TYPES OF EMPLOYMENT: *  Skilled Agricultural, Forestry and Fishery Workers
 Employed  Permanent / Regular  Craft and Related Trade Workers
 Unemployed  Seasonal  Plant and Machine Operators and Assemblers
 Self-employed  Casual  Elementary Occupations
 Emergency  Armed Forces Occupations
13 a. CATEGORY OF EMPLOYMENT: *  Others, specify: _______________________
 Government
 Private
15. ORGANIZATION INFORMATION:
Organization Affiliated: Contact Person: Office Address: Tel. Nos.:

16. ID REFERENCE NO.:

SSS NO.: GSIS NO.: PAG-IBIG NO.: PSN NO.: PhilHealth NO.:

17. FAMILY BACKGROUND: LAST NAME FIRST NAME MIDDLE NAME

FATHER’S NAME
MOTHER’S NAME:
GAUARDIAN:
18. ACCOMPLISHED BY: * LAST NAME FIRST NAME MIDDLE NAME
 APPLICANT
 GUARDIAN
 REPRESENTATTIVE
19. NAME OF CERTIFYING PHYSICIAN:
LICENSE. NO.:
20. PROCESSING OFFICER: *
21. APPROVING OFFICER: *
22. ENCODER *
23. NAME OF REPORTING UNIT: (OFFICE/SECTION)*
24. CONTROL NO.: *

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 DEPARTMENT OF HEALTH
Philippine Registry For Persons with Disabilities Version 4.0
Application Form
Instructions for Philippine Registry for Persons with Disabilities (PRPWD) Version 4.0 Form
NO. FIELD NAME INSTRUCTION and DEFINATION
1 New Applicant and Check the appropriate box based on the definition.
Renewal New Applicant: to account the information of the new applicant
Renewal: for possible update of information of the individual (address, type of disability, contact details, etc.)
2 Registration No. Region, Province, City/Municipality and Barangay is system-generated number, but the sequential number should be
assigned by the Issuing Office. Once the Person with Disability report is encoded into the system, copy the system-
generated number and write into the box of the Application Form.
3 Date Applied The date when Persons of Disability applied, must be entered on this portion. The format is “mm/dd/yyyy”
4 Personal Information Write the last name, first name, middle name in the appropriate space provided.by the Issuing Office
Note: Middle name is default to “N/A” because it is a required field. If the Person with Disability have a middle name,
remove the “N/A” and write the middle name.
5 Birthdate Write the birthdate of the Person with Disability in the format of “mm/dd/yyyy” (e.g. July 1, 1970 should be written as
07/01/1970). The birthdate should not be later than the current date/registration date.
6 Sex Check the appropriate circle for the sex of the Person with Disability.
7 Civil Status Check the appropriate circle for the civil status of the Person with Disability. Not legally separated is still
considered as “Married”
8 Type of Disability Check the appropriate box/es for the Type/s of Disability sustained by the Person with Disability. One or
more items can be checked for this field.
Deaf or Hard of Hearing - refers to people with hearing loss, implies little or no hearing/ranging from mild
to severe. Hearing loss, also known as hearing impairment means the complete or partial loss of the ability
to hear from one or both ears with 26 dB or greater hearing threshold, averaged at frequencies’ 0.5, 1, 2,
4 kilohertz.
Intellectual Disability - a significantly reduced ability to understand new or complex information and to
learn and apply new skills.
Learning Disability - persons who, although normal in sensory, emotional and intellectual abilities, exhibit
disorders in perception, listening, thinking, reading, writing, spelling, and arithmetic.
Mental Disability - disability resulting from organic brain syndrome and or mental illness (psychotic or
non-psychotic disorder)
Physical Disability - is a restriction of ability due to any physical impairment that affects a person’s
mobility, function, endurance or stamina to sustain prolonged physical ability, dexterity to perform tasks
skillfully and quality of life. Causes may be hereditary or acquired from trauma, infection, surgical or
medical condition and include the following disorders, namely: (1) Musculoskeletal or orthopedic
disorders (2) Neurological disorders (3) Cardiopulmonary disorders (4) Pediatric and congenital disorders
Psychosocial Disability - any acquired behavioral, cognitive, emotional or social impairment that limits
one or more activities necessary to effective interpersonal transactions and other civilizing process or
activities to daily living such as but not limited to deviancy or anti-social behavior.
Speech and Language Impairment - mean one or more speech/language disorders of voice, articulation,
rhythm and/or the receptive and expressive processes of language. Visual Disability - A person with
visual disability (Impairment) is one who has impairment of visual functioning even after treatment and/or
standard refractive correction, and has visual acuity in the better eye of less than (6/18 for low vision and
3/60 for blind), or a visual field of less than 10 degrees from the point of fixation. A certain level of visual
impairment is defined as legal blindness. One is legally blind when your best corrected central visual acuity
in your better eye is 6/60 on worse or your side vision is 20 degrees or less in the better eye.
Cancer (RA 11215) - Cancer refers to a genetic term for a large group of diseases that can affect
any part of the body. Other terms used are malignant tumors and neoplasms. One defining feature
of cancer is the rapid creation of abnormal cells that grow beyond their usual boundaries, and
which can then invade adjoining parts of the body and spread to other organs;
Rare Disease (RA10747) -refers to disorders such as inherited metabolic disorders and other
diseases with similar rare occurrence as recognized by the DOH upon recommendation of the
NIH but excluding catastrophic (i.e., life threatening, seriously debilitating, or serious and chronic)
forms of more frequently occurring diseases.
9 Cause of Disability Check the appropriate box/es for the Cause/s of Disability sustained by the Person with Disability. This
field can be multiple checking.
Acquired – is a disability that has developed during the person's lifetime – that is as a result of an
accident or illness rather than a disability the person was born with.
Chronic illness - describes a group of health conditions that last a long time. It may get slowly worse over
time or may become permanent or may lead to death. It may cause permanent change to the body and

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 DEPARTMENT OF HEALTH
Philippine Registry For Persons with Disabilities Version 4.0
Application Form
will certainly affect the person’s quality of life. This is also true to persons diagnose with Cancer or Rare
Disease. Thus, Chronic illnesses may cause disability, hence, it is considered not a disability.
Congenital/Inborn - disease is present at birth
Injury - An injury is the physical damage that results when a human body is suddenly or briefly subjected
to intolerable levels of energy. It can be a bodily lesion resulting from acute exposure to energy in amounts
that exceed the threshold of physiological tolerance, or it can be an impairment of function resulting from
a lack of one or more vital elements (i.e. air, water, warmth), as in drowning, strangulation or freezing.
The time between exposure to the energy and the appearance of an injury is short. (INJURY SURVEILLANCE
GUIDELINES, Published in conjunction with the Centers for Disease Control and Prevention, Atlanta, USA,
by the World Health Organization, 2001)
Autism: refers to a range of conditions characterized by some degree of impaired social behavior,
communication and language, and a narrow range of interests and activities that are both unique to the
individual and carried out repetitively.
ADHD (Attention Deficit hyperactivity Disorder): is a disorder marked by an ongoing pattern of
inattention and/or hyperactivity-impulsivity that interferes with functioning or development.
Cerebral Palsy: is a complex motor. disorder at the level of the central. nervous system. It is caused by.
irreversible brain lesions occurring
Down Syndrome: is a genetic disorder in which some, or all, of a person's cells have an extra chromosome.
10 Residence Address Write the Person with Disability’s permanent address - House No. and Street, Barangay, Municipality/City,
Province and Region
Note: House No. and Street name should be encoded in the system, but the Region, Province,
Municipality/City and Barangay is already built–in to the system; just click the appropriate Region,
Province, Municipality/City, and Barangay of the Person with Disability
11 Contact Details Write the Telephone No., Mobile No., and E-mail address of the Person with Disability if available.
12 Educational Check the appropriate circle for the highest education attained by the Person with Disability.
Attainment
13 Status of Check the appropriate circle for the working status of the Person with Disability. One item must be chosen
Employment in this field.
Employed - persons in the labor force who were reported either at work or with a job or business
although not at work:
a) At Work - those who did some work, even for one hour during the reference period.
b) With a Job or Business but not at Work - those who have a job or business even though not at
work during the reference period because of temporary illness/injury, vacation or other leave of
absence, bad weather or strike/labor dispute or other reasons.
Likewise, persons who are expected to report for work or to start operation of a farm or business
enterprise within two weeks from the date of the enumerator's visit are
considered employed.
Unemployed - includes all persons who are 15 years old and over as of their last birthday and are
reported as:
1) without work, i.e., had no job or business during the basic survey reference period; AND,
2) currently available for work, i.e., were available and willing to take up work in paid employment or
self-employment during the basic survey reference period, and/or would be available and willing to take
up work in paid employment or self-employment within two weeks after the interview date; AND,
3) seeking work, i.e., had taken specific steps to look for a job or establish a business during the basic
survey reference period; OR not seeking work due to the following reasons: (a) tired/believe no work
available, i.e, the discouraged workers who looked for work within the last six months prior to the
interview date; (b) awaiting results of previous job applications; (c) temporary illness/disability; (d) bad
weather; and (e) waiting for rehire/job recall.
Self-employed - is an independent contractor or sole proprietor who reports income-earned own
business. The person works for him/herself at a variety of trades, professions, and occupations rather than
working for an employer.
13 a Category of Check the appropriate circle for the Category of Employment of the Person with Disability.
Employment Permanent/Regular - the directly employed; work for an employer and are paid directly by that employer;
permanent/regular employees do not have a predetermined end date of employment;
permanent employees are often eligible to switch job positions within their companies
Seasonal - the term seasonal employment refers to open positions in an organization that are available
for only a portion of the year; seasonal employment is a form of temporary employment, whereby the
workload occurs only during certain times of the year

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 DEPARTMENT OF HEALTH
Philippine Registry For Persons with Disabilities Version 4.0
Application Form
Casual - employees are employees who do not have regular or systematic hours of work or an expectation
of continuing work; a typical casual employee is employed on a daily basis when the need arises
Emergency - means any work performed for the purpose of preventing or alleviating the physical trauma
or property damage threatened or caused by an emergency; emergency work means work, which could
not be covered by a weekly employee because of extenuating circumstances
13 b Types of Check the appropriate circle for the Type of Employment of the Person with Disability.
Employment
14 Occupation Check the appropriate circle for the Occupation of the Person with Disability. If not stated in the choice,
check “Others” then specify.
Major Group 1. Managers - workers in this group plan, direct, coordinate and evaluate the overall
activities of enter prises,governments and other organizations, or of organizational units within them,
and formulate and review their policies, laws, rules and regulations.
Major Group 2. Professionals - workers in this group increase the existing stock of knowledge, apply
scientific or artistic concepts and theories, teach about the foregoing in a systematic manner, or
engage in any combination of these activities.
Major Group 3. Technicians and associate professionals - workers in this group perform mostly
technical and related tasks connected with research and the application of scientific or artistic
concepts and operationalmethods, and government or business regulations.
Major Group 4. Clerical support workers ·workers in this group record , organize, store,
compute and ret rieve information related , and perform a number of clerical duties in
connection with money- handling operations , travel arrangements, requests for information,
and appointments.
Major Group 5. Service and sales workers - worker s in this group provide personal and protective
services related to travel, housekeeping, catering, personal care, or protection against fire and
unlawful acts , or demonstrate and sell goods in wholesale or retail shops and similar establishments,
as well as at stalls and on markets.
Major Group 6. Skilled agricu ltural, forestry and fishery workers - workers inthis group grow and
harvest field or tree and shrub crops,gather wild fruits and plants, breed, tend or hunt animals,
produce a variety of animal husbandry products, cultivate, conserve and exploit forests,breed
or catch fish and cultivate or gather other forms of aquatic lifeinorder to provide food, shelter and
income for themselves and their households.
Major Group 7. Craft and related trades workers - work ers in this group apply spec ific
knowledge and skills in the fields to construct and maintain buildings, form metal, erect metal
structures, set machine tools, or make, fit,maintain and repair machinery, equipment or tools, carry
out printing work, produce or process foodstuffs, textiles, or wooden, metal and other articles,
including handicraf t goods.
Major Group 8. Plant and machine operators and assemblers - workers in this group operate and
monitor industrial and agricultural machinery equipment on the spot or by remote control , drive
and operate trains, motor vehicles and mobile machinery and equipment, or assemble products
from compone nt parts according to str ict specifications and procedures.
Major Group 9. Elementary occupations - occupations in this group involve the performance of
simple and routine tasks which may require the use of handheld tools and considerable physical
effort.
Major Group 10. Armed forces occupations - this major group includes all jobs held by members of
the armed forces.Members of the armed forces are those personnel who are currently serving in the
armed forces, including auxiliary services, whether on a voluntary or compulsory basis, and who
are not free to accept civilian employment and are subject to military discipline. Included are
members of the army, navy, air force and other military services, as well as conscri pts enrolled for
military training or other service for a specified period.
15 Organization Write the organization information of the Person with Disability including the name of organization
Information affiliated, contact person, office address, and telephone number. If none, leave it blank
16 ID Reference No. Write the SSS, GSIS, PAG-IBIG, PNS, and Philippine Health Insurance Number if available
17 Family Background Write the name of the father, mother and or Guardian of the Person with Disability in the space provided.
18 Accomplished By Check the appropriate circle, who accomplished the form weather Applicant, Guardian and or
Representative. Then write the name who accomplished the form in the space provided

Revised as of August 1, 2021

 DEPARTMENT OF HEALTH
Philippine Registry For Persons with Disabilities Version 4.0
Application Form
19 Name of Certifying Write the name of physician who issued the Medical Certificate on the Person with Disability and write
Physician the license no.
20 Processing Officer: Write the name of the processing officer who check the requirements submitted by Person with Disability
21 Approving Officer: Write the name of the approving officer who validate and approve the requirements submitted by Person
with Disability
22 Encoder: Write the name of the encoder who enter the information of the Person with Disability
23 NAME OF REPORTING For the issuing office, Automatic generation of the system based on the User account
UNIT:(OFFICE/SECTION)
24 Control No.: Write the number assigned by the Issuing Office
Control number should be assigned by each Issuing offices (MSWDO/CMSWDO/PDAO)
Sources defintion of terms are the following: Republic Act 10747, MOP of ONEISS, Department Admnistrative 2013-0005 and
Amedment Department Admnistrative 2013-0005-A, Republic Act 11215, Philippine Standard Occupational
Classification Of 201 2. Work Health Organization (thru online searching) DOLE 2019 guideline (thru online searching)

Revised as of August 1, 2021

 FUNCTIONAL ASSESSMENT
Musculoskeletal, Orthopedic, Mobility Visual Impairment
001___Weak, paralyzed left leg 001___Total visual impairment, left
002___Weak, paralyzed right leg 002___Total visual impairment, right
003___Weak, paralyzed both legs 003___Total visual impairment, both
004___Underdeveloped left leg 004___Partial visual impairment, left
005___Underdeveloped right leg 005___Partial visual impairment, right
006___Underdeveloped both legs 006___Partial visual impairment, both
007___Missing left leg
008___Missing right leg Hearing Impairment
009___Missing both legs 001___Total hearing impairment, right
010___Missing left foot 002___Total hearing impairment, left
011___Missing right foot 003___Total hearing impairment, both
012___Missing both feet 004___Partial hearing impairment, left
013___Weak, paralyzed left arm 005___Partial hearing impairment, right
014___Weak, paralyzed right arm 006___Partial hearing impairment, both
015___Weak, paralyzed both arms
016___Underveloped left arm Speech, Language, Communication
017___Underdeveloped right arm 001___Total speech impairment
018___Underdeveloped both arms 002___Partial speech impairment (Unclear speech)
019___Missing left arm 003___Partial speech impairment (Irrelevant words)
020___Missing right arm
021___Missing both arms Mental Impairment
022___Missing left hand 001___Mentally Ill
023___Missing right hand 002___Mentally retarded
024___Missing both hands 003___Autistic
025___Polio
Deformities
Motor Disability 001___Hunchback
001___Cerebral palsy 002___Cleft palate
002___Stroke
003___Severe Debilitating Arthritis Other Impairment (Please specify)
004___Epilepsy _________________________

Etiology Rehabilitation
001___Inborn 001___Commnity-based
002___Acquired by 002___Institution-based
___Illness 003___None
___Armed conflict
___Environmental
___Accident
Duration (years) of condition _________________

MEDICAL CERTIFICATE
FINAL DIAGNOSIS AND IMPRESSION:

Health Physician’s Signature over Printed Name:

_________________________________
PRC License No.____________________
PTR No. __________________________

Note: Any information in this form is voluntarily obtained from the filer and that any changes/alterations in the date encoded by this office are with the consent
of the filer. And it is understood that once this form is encoded in the data file of DOH-PPWDRS said information will be subject to public exposure for purposes
not contrary to law. And that I have no objection if my personal data will be published in whatever form of the electronic media for as long as it will promote my
well-being. And I hold this agency free from any legal obligations or damages that may arise as a consequence of the electronic publications brought by a third
party who in any way not connected to this agency.