HHo0s

interview questionnaireTestimony of injured from GazaAll information on this form is kept confidential under medical confidentialityInterview Setting:Date of visit:Name of Interviewer:Name of Translator (if applicable):Hospital/Place of interview:Agreement for: publishing story photography publishing photoPhoto by:photo name/number:Signature affirming this agreement: Signed Waiver of Confidentialiy?YES (attach form), NOBackground on PatientName of patient:Name of person that is interviewed (if the patient was unable to speak):IDGender (F/M)AgeMarried (Y/N)Contact telephone numberResidence: (location and whether that is a refugee camp, urban, or ruralsetting)Occupation:Any other sources of income besides work:Level of education:Number of family members (defined as those living in the samehousehold and eating under one roof):Was the interviewee head of a household prior to his injury?Injury type and circumstancesInjuries (type and whether the injury will cause a permanent disability)Any symptoms of psychosocial stress/ PTSD?221