ANCHETA SOCIAL

Realizat de asistentul social_____________________________________

Locul i data__________________________________________________
Persoane prezente_____________________________________________
Scopul_____________________________________________________
I. Date de identificare a beneficiarului
Nume i prenume:_____________________________________________
Locul i data naterii:___________________________________________
CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/ C.I._____________________
Domiciliul legal:______________________________________________
Domiciliul n fapt:_____________________________________________
Stare civil:__________________________________________________
Studii:______________________Ocupaia: _____________________
Etnia:__________________________ Religia:________________________________
II. Date despre familie:
Date despre mama(soia)
Nume i prenume:_____________________________________________
Locul i data naterii:___________________________________________
CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/ C.I._____________________
Domiciliul legal:______________________________________________
Domiciliul n fapt:_____________________________________________
Stare civil:__________________________________________________
Studii:_________________________Ocupaia:______________________
Etnia:____________________________Religia:_____________________
Date despre tata(soul)
Nume i prenume:____________________________________________
Locul i data naterii:___________________________________________
CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/ B.I._____________________
Domiciliul legal:______________________________________________
Domiciliul n fapt:_____________________________________________
Stare civil:__________________________________________________
Studii:_________________________ Ocupaia:_____________________
Etnia:___________________________Religia:______________________
Date despre copiii din familie
Nr.crt Nume
si Data nasterii
prenume
1
2
3
4

Ocupatia

Locul unde se afla Observaii

copilul:familie/instituie

5
Date despre alte persoane care locuiesc la aceeai adres
Nr.cr Nume i prenume
Vrsta
Stare civil
t
1
2
3

Ocupaie

III. Istoricul social al beneficiarului

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IV. Starea de sntate
_______________________________________________________________________
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V. Situaia material/financiar
Locuina
Proprietate personal:
da
nu
Numarul de camere:_______
Electricitate
Ap curent
Telefon
Starea de igien:
Satisfctoare
Nesatisfctoare

nclzire

Suprafaa de teren cultivat (tipul culturii):________________________

Animale:_____________________________________________________
Alte proprieti:_______________________________________________
Venituri
Stabile:_____________________________________________________
Ocazionale:__________________________________________________
VI. Relaiile n familie i comunitate
Relaii n familie:________________________________________________________
_________________________________________________________________
Relaiile n comunitate____________________________________________________
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VII. Observaii
________________________________________________________________________
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________________________________________________________________________
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Concluzii i recomandri
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Asistent Social