Edit Member

Personal Information

Member No.

Full Name

Gender

Date of Birth

Age

County

Region

District

Branch

Employment & Professional

Workplace / Facility

Facility Type

Employment Status

Professional Cadre

Join Date

Expiry Date

Disability Information

Disability Primary Type

Disability Type Details

Physical

YES NO

Visual

YES NO

Hearing

YES NO

Speech

YES NO

Psychosocial

YES NO

Multiple

YES NO

Other (Details)

Assistive Devices

Assistive Devices (Notes)

Wheelchair

YES NO

Walking Aid

YES NO

Hearing Aid

YES NO

Visual Aid

YES NO

Communication Device

YES NO

Other Device (Notes)

Employment Challenges

Challenges (Notes)

Promotion

YES NO

Accommodation

YES NO

Communication

YES NO

Stigma

YES NO

Lack of Assistive Tech

YES NO

Other Challenge (Notes)

None

YES NO

Communication & Emergency

Phone

Email

Preferred Communication Methods

SMS

YES NO

Email Comm

YES NO

Phone Comm

YES NO

Other Comm (Notes)

Emergency Contact Name

Relationship

Emergency Phone

Alternative Phone

Emergency Email

Additional Emergency Contacts

Leadership & Workplace

Participates in TANNA Leadership

YES NO

TANNA Leadership Position

Reports Workplace Barriers

YES NO

Workplace Barrier Description

Additional Information

Details

Additional Notes

TANZANIA NATIONAL NURSES

ASSOCIATION

Check Off / Non-Check Off

Status & Statistics

Personal Information

Employment & Professional

Disability Information

Assistive Devices

Employment Challenges

Communication & Emergency

Leadership & Workplace

Additional Information