ANCHETA SOCIALA

Asistent social.
Locul i data
Scopul.
Numrul de nregistrare a cererii: .......................................................
I.

Date de identificare beneficiar

Nume i prenume:...Tel...
Data i locul naterii:..Vrsta..
CNP: __/__/__/__/__/__/__/__/__/__/__/__/__/ C.IStare civil..
Domiciliul legal:
Domiciliul n fapt:...
Studii:
primare

generale

liceale

post liceale

profesionale

superioare

Ocupaia actual / instituia

Etnia: Religia: .
II.
a)

Date despre familia beneficiarului:

So (soie)
Nume i prenume:...Tel...
Data i locul naterii:Vrsta
CNP: __/__/__/__/__/__/__/__/__/__/__/__/__/ C.I
Domiciliul legal:.
Domiciliul n fapt:..
Studii:
primare

generale

liceale

post liceale

profesionale

superioare

Ocupaia actual / instituia

Etnia:.. Religia:..

Alte date despre soi

.
b)

Copii
Nr. Nume si prenume

Varsta

Ocupatia

Institutia

III. Alte persoane care locuiesc mpreun cu beneficiarul:

1. ................................................................................................................................................................
....
2. ................................................................................................................................................................
....
3. ................................................................................................................................................................
....

IV. Situaia material / financiar:

a) Locuinta:
casa

apartament

alte situatii

personala

cu chirie

locuinta sociala

alte situatii

Nr. camere: Nr. persoane (adulti).../copii

Telefon

Electricitate

frigider

aragaz

Ap curent
televizor

nclzire

baie

buctrie

alte..

Alte.precizri

b) Venituri / cheltuieli
Nr.
1.
2.
3.
4.
5.

Venituri lunare
Suma

Cheltuieli lunare
Suma
Pentru ce ?

Sursa

V. Condiii igienico-sanitare:

VII.. Starea de sntate

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VII. Relaiile n familie i comunitate:
Relaii n familie

...
Relaiile n comunitate:

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...

Relatiile cu rudele si vecinii

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...
Relatiile cu institutiile......................

**Biserica

VIII. Observaii si concluzii:

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IX. Nevoi identificate:
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Persoane prezente la ntocmirea anchetei sociale:

Asistent social

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