Anexa nr.1 Aprobat prin ordinul MPSFC nr. 71 din 3 octombrie 2008Centrul pentru Copii i Tineri cu Disabiliti Mixte Severe DANCO

Ancheta social Evaluare iniial din _______________________ 20___ Comisia de examinare a condiiilor locative i sociale: (Numele, Prenumele, funcia membrilor comisiei) ______________________________________________________________________________________ ______________________________________________________________________________________ ___________________________________________________________ a cercetat condiiile de trai ale familiei ____________________________________________ domiciliat pe adresa __________________________________________________________ _____________________________________________________________________________ Tel.: _________________________________________________________________________ Am constatat urmtoarele: COMPONENA FAMILIEI Numele, prenumele

Data, luna, anul naterii

Statutul social al persoanei

IDNP

Legitimai a

Gradul de rudenie

CONDIIILE DE TRAI Statutul legal al spaiului locativ (de subliniat): locuin de stat, chirie. Tipul de locuin cmin, cas la sol, apartament la bloc. Altele specificai. Numrul de odi _______________________ Suprafaa locativ _______________________________ Suprafaa total _______________________________________________________________________ Alt imobil _____________________________________________________________________________ Pmnt agricol ______________________ Pmnt pe lng cas ________________________________ Bunuri: televizor _____ frigider _______ main de splat ______ (ani) ______________________________________________________________________________________ ______________________________________________________________________________________ Alte bunuri (autovehicol, maini agricole) _____ (ani) ______________________________________________________________________________________

Condiii. Conectri la reeaua de gaze naturale ____, energie termic ____, energie electric ____, ap ___ Altele ______________________________________________________________________________________ Starea igienic sanitar: __________________________________________________________________ Venitul lunar al familiei. Indicai sursa i suma: _______________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Patologii familiale (abuz de alcool, de droguri, violen domestic, abuz fa de copii, neglijarea obligaiilor printeti) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Probleme cu care se confrunt familia. Din relatrile membrilor de familie ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Ajutoare de care a beneficiat familia: Data Tipul de ajutor Organizaia care a acordat ajutorul Motivul solicitrii Suma, Mrimea

Concluzii ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Recomandri ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Semnturile membrilor comisiei: _____________________________ ____________________________ _____________________________ ____________________________ _____________________________ ____________________________