Post on 29-Sep-2015
description
PRIMRIA Serviciul. Nr.din.
PRIMAR
ANCHETA SOCIAL (pentru copilul cu dizabiliti)
1. Date de identificare a)Copilul
Numele i prenumele:______________________________________________________________________ Data i locul naterii:______________________________________________________________________ Domiciliul:______________________________________________________________________________
Religie:______________________________________________________Etnie:______________________
b)Printi: Mama:
Numele i prenumele:______________________________________________________________________ Domiciliul:______________________________________________________________________________
Profesia:_________________________Locul de munc:__________________________________________ Religie:_______________________________________________________Etnie:_____________________
Tata:
Numele i prenumele:______________________________________________________________________ Domiciliul:______________________________________________________________________________
Profesia:__________________________Locul de munc_________________________________________ Religie:_______________________________________________________Etnie:_____________________
c) Frai/surori
Nr.
crt
Numele i prenumele Vrsta coala/ Centru de recuperare frecventat()
Ocupaia
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
2. Date privind istoria personal a copilului: a) Familia extins ( rude pn la gradul IV) sau alte persoane care locuiesc cu familia
Nr.
crt
Numele i prenumele Vrsta Gradul de rudenie ( mama, tata, frate,sor, bunici, unchi, mtui, etc.)
1.
2.
3.
4.
5.
6.
b) Persoane apropiate (vecini, prieteni de familie, cadre didactice, altele):
Numele i prenumele:______________________________________________________________________ _______________________________________________________________________________________
Domiciliul:______________________________________________________________________________
3. Situaia socio-economic a familiei: a) Climatul familial, relaiile dintre membrii familiei:_____________________________________________ _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
b)Relaiile familiei cu comunitatea:___________________________________________________________ _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
c)Situaia economic a familiei - venituri:________________________________________________ _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
d) Climatul educaional al familiei, studii efectuate, ultima coal absolvit: __________________________ _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
e) Locuina: condiii igienico-sanitare, utiliti, faciliti speciale etc:________________________________ _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
f) Gradul de integrare i participare social:____________________________________________________ _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
4. Serviciile oferite de comunitate pentru copilul cu dizabiliti: ____________________________________ _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
5. Prestaii (tip, cuantum, perioada de acordare): ________________________________________________ _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Concluzii i propuneri: ____________________________________________________________________ _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
ASISTENT SOCIAL,
Numele i prenumele Semntura .....................