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Ancheta sociala








ANCHETA SOCIALA

Realizata de asistentul social_______________________________________

Locul si data____________________________________________________

Persoane prezente_______________________________________________



Scopul_________________________________________________________

I. Date de identificare a beneficiarului

Nume si prenume:_______________________________________________

Locul si data nasterii:_____________________________________________

CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/ B.I._____________________

Domiciliul legal:_________________________________________________

Domiciliul in fapt:________________________________________________

Stare civila:____________________________________________________

Studii:__________________________Ocupatia:_______________________

Etnia:__________________________ Religia:________________________________

II. Date despre familie:

Date despre mama(sotia)

Nume si prenume:_______________________________________________

Locul si data nasterii:_____________________________________________

CNP: __/__/__/__/__/__/__/__/__/__/__/__/__/ B.I._____________________

Domiciliul legal:_________________________________________________

Domiciliul in fapt:________________________________________________

Stare civila:____________________________________________________

Studii:___________________________Ocupatia:______________________

Etnia:____________________________Religia:_______________________________

Date despre tata(sotul)

Nume si prenume:_______________________________________________

Locul si data nasterii:_____________________________________________

CNP: __/__/__/__/__/__/__/__/__/__/__/__/__/ B.I._____________________

Domiciliul legal:_________________________________________________

Domiciliul in fapt:________________________________________________

Stare civila:____________________________________________________

Studii:___________________________ Ocupatia:_____________________

Etnia:____________________________ Religia:_______________________

Date despre copiii din familie

Nr.

crt.

Nume si prenume

Data nasterii

Ocupatia

Locul unde se afla copilul:familie/institutie

Observatii

1

2

3

4

5

Date despre alte persoane care locuiesc la aceeasi adresa

Nr.crt.

Nume si prenume

Varsta

Stare civila




Ocupatie

1

2

3

III. Istoricul social al beneficiarului

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

IV. Starea de sanatate

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

V. Situatia materiala/financiara

Locuinta

Proprietate personala: da nu Numarul de camere:_______

□ Electricitate □ Apa curenta □ Incalzire □ Telefon

Starea de igiena: □ Satisfacatoare □ Nesatisfacatoare

Suprafata de teren cultivata (tipul culturii):______________________________

Animale:________________________________________________________

Alte proprietati:___________________________________________________

Venituri

Stabile:_________________________________________________________

Ocazionale:_____________________________________________________

VI. Relatiile in familie si comunitate

Relatii in familie:__________________________________________________

_______________________________________________________________

_______________________________________________________________

Relatiile in comunitate:_____________________________________________

_______________________________________________________________

_______________________________________________________________

VII. Observatii

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VIII. Concluzii si recomandari

_______________________________________________________________

_______________________________________________________________

______________________________________________________________________________________________________________________________

_______________________________________________________________

_______________________________________________________________

______________________________________________________________________________________________________________________________

_______________________________________________________________

_______________________________________________________________ _______________________________________________________________

_______________________________________________________________

Asistent Social


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