002_ancheta_sociala1
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Transcript of 002_ancheta_sociala1
ROMANIACONSILIUL JUDEŢEAN MARAMUREŞ
DIRECŢIA GENERALĂ DE ASISTENTA SOCIALA SI PROTECŢIE A COPILULUI MARAMURES
RO BAIA MARE. Str.Banatului , Nr. 1Tel. 0040- (0)262-228299
Tel/fax: 0040-0262-228322; Email: [email protected] Management de Caz
Cod operator date cu caracter personal nr. 9355
Nr____________/_____________
ANCHETA SOCIALĂ
I. Date de identificare a beneficiarului
Nume şi
prenume:_________________________________________________________
_____
Locul şi data
naşterii:__________________________________________________________
__
CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/
B.I.____________________________________
Domiciliul
legal:____________________________________________________________
____
Domiciliul în
fapt:_____________________________________________________________
__
Stare
civilă:____________________________________________________________
_______
Studii:__________________________Ocupaţia:__________________________
____________
Etnia:__________________________
Religia:___________________________________________
II. Date despre familie:
Date despre mama(soţia)
Nume şi
prenume:_________________________________________________________
_____
Locul şi data
naşterii:__________________________________________________________
__
CNP: __/__/__/__/__/__/__/__/__/__/__/__/__/
B.I.____________________________________
Domiciliul
legal:____________________________________________________________
____
Domiciliul în
fapt:_____________________________________________________________
__
Stare
civilă:____________________________________________________________
_______
Studii:___________________________Ocupaţia:_________________________
____________
Etnia:____________________________Religia:_____________________________
______________
Date despre tata(soţul)
Nume şi
prenume:_________________________________________________________
_____
Locul şi data
naşterii:__________________________________________________________
__
CNP: __/__/__/__/__/__/__/__/__/__/__/__/__/
B.I.____________________________________
Domiciliul
legal:____________________________________________________________
____
Domiciliul în
fapt:_____________________________________________________________
__
Stare
civilă:____________________________________________________________
_______
Studii:___________________________
Ocupaţia:____________________________________
Etnia:____________________________ Religia:______________________________________
Date despre copiii din familieNr.crt.
Nume si prenume Data nasterii
Ocupatia Locul unde se afla copilul:familie/instituţie
Observaţii
1
2
3
4
5
Date despre alte persoane care locuiesc la aceeaşi adresăNr.
crt.
Nume şi prenume Vârsta Stare civilă Ocupaţie
1
2
3
III. Istoricul social al beneficiarului________________________________________________________________
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IV. Starea de sănătate
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V. Situaţia materială/financiară
Locuinţa
Proprietate personală: da nu Numarul de camere:_______
□ Electricitate □ Apă curentă □ Încălzire □ Telefon
Starea de igienă: □ Satisfăcătoare □ Nesatisfăcătoare
Suprafaţa de teren cultivată (tipul
culturii):____________________________________________
Animale:_________________________________________________________
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Alte
proprietăţi:________________________________________________________
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Venituri
Stabile:__________________________________________________________
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Ocazionale:_______________________________________________________
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VI. Relaţiile în familie şi comunitate
Relaţii în
familie:___________________________________________________________
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Relaţiile în
comunitate:_______________________________________________________
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VII. Observaţii
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VIII. Concluzii şi recomandări________________________________________________________________
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________________________________________________________________
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Director General Adjunct Sef serviciu
Asistent Social