Ancheta Sociala Model
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Episcopia Dunarii de Jos Galati Proiect Phare 2006/018-147.04.02.03.02.01.201 Centrul multifunctional de servicii sociale Speranta ANCHETA SOCIALA Dosar nr.________ Realizata de asistentul social________________________________________________ Locul si data_____________________________________________________________ Persoane prezente_________________________________________________________ Date de identificare a beneficiarului___________________________________________ Nume si prenume:________________________________________________________ CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/ C.I._______________________________ Domiciliul legal:__________________________________________________________ Domiciliul in fapt:_________________________________________________________ Starea civila:___________________ Studii:______________________Ocupatia_____________________________ ________ Etnia:______________________ Religia______________________________________ Date despre familie: Date despre mama (sotia) Nume si prenume:________________________________________________________ CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/ C.I._______________________________
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Transcript of Ancheta Sociala Model
Episcopia Dunarii de Jos GalatiProiect Phare 2006/018-147.04.02.03.02.01.201Centrul multifunctional de servicii sociale Speranta
ANCHETA SOCIALA
Dosar nr.________Realizata de asistentul social________________________________________________Locul si data_____________________________________________________________Persoane prezente_________________________________________________________
Date de identificare a beneficiarului___________________________________________
Nume si prenume:________________________________________________________CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/C.I._______________________________Domiciliul legal:__________________________________________________________Domiciliul in fapt:_________________________________________________________Starea civila:___________________Studii:______________________Ocupatia_____________________________________Etnia:______________________ Religia______________________________________
Date despre familie:Date despre mama (sotia)Nume si prenume:________________________________________________________CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/C.I._______________________________Domiciliul legal:__________________________________________________________Domiciliul in fapt:_________________________________________________________Starea civila:___________________Studii:______________________Ocupatia_____________________________________Etnia:______________________ Religia______________________________________Date despre tata (sot)Nume si prenume:________________________________________________________CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/C.I._______________________________Domiciliul legal:__________________________________________________________Domiciliul in fapt:_________________________________________________________Starea civila:___________________Studii:______________________Ocupatia_____________________________________Etnia:______________________ Religia______________________________________Date despre copii1. Nume si prenume:_____________________________________________________CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/C.I._______________________________Domiciliul legal:__________________________________________________________Domiciliul in fapt:_________________________________________________________Starea civila:___________________Studii:______________________Ocupatia_____________________________________Etnia:______________________ Religia______________________________________
2. Nume si prenume:_____________________________________________________CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/C.I._______________________________Domiciliul legal:__________________________________________________________Domiciliul in fapt:_________________________________________________________Starea civila:___________________Studii:______________________Ocupatia_____________________________________Etnia:______________________ Religia______________________________________3. Nume si prenume:_____________________________________________________CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/C.I._______________________________Domiciliul legal:__________________________________________________________Domiciliul in fapt:_________________________________________________________Starea civila:___________________Studii:______________________Ocupatia_____________________________________Etnia:______________________ Religia______________________________________4. Nume si prenume:_____________________________________________________CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/C.I._______________________________Domiciliul legal:__________________________________________________________Domiciliul in fapt:_________________________________________________________Starea civila:___________________Studii:______________________Ocupatia_____________________________________Etnia:______________________ Religia______________________________________5. Nume si prenume:_____________________________________________________CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/C.I._______________________________Domiciliul legal:__________________________________________________________Domiciliul in fapt:_________________________________________________________Starea civila:___________________Studii:______________________Ocupatia_____________________________________Etnia:______________________ Religia______________________________________
Total venituri nete/familie_________________________________________________Venit pe membru de familie________________________________________________
Spatiul de locuit
1. Tipul locuintei______________________________________________________2. Regimul juridic al locuintei___________________________________________3. Grad de confort:Numar de camere___din care locuibile____Baie_______________________________Bucatarie___________________________Suprafata locative____________________Dotare cu aparatura electrocasnica si mobilier de stricta necessitate __________________________________________________________________________________________________________________________________________Racordare la - reteaua electrica
- reteaua de gaze naturale- reteaua de termoficare- reteaua de apa potabila
Conditii de igiena _________________________________________________________Gradul de degradare al locuintei _____________________________________________
______________________________________________________________________________________________________________________________________________Alte precizari privind starea de degradare a locuintei ___________________________________________________________________________________________________Incalzirea locuintei _______________________________________________________Familia detine in proprietate/folosintaTerenuri ________________________________________________________________Cladiri _________________________________________________________________Spatii locative ___________________________________________________________Alte bunuri _____________________________________________________________
Datorii la plata: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date despre sustinatorii legali: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Evaluarea nevoilor: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Observatii: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Semnatura beneficiarului:
Asistent social:______________________
Semnatura: _________________________
