Nr____________/_____________

ANCHETA SOCIAL

I. Date de identificare a beneficiarului

Nume

prenume:_________________________________________________________
_____
Locul

data

naterii:__________________________________________________________
__
CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/
B.I.____________________________________
Domiciliul
legal:____________________________________________________________
____
Domiciliul

fapt:_____________________________________________________________
__
Stare
civil:____________________________________________________________
_______

Studii:__________________________Ocupaia:__________________________
____________
Etnia:__________________________
Religia:___________________________________________
II. Date despre familie:
Date despre mama(soia)
Nume

prenume:_________________________________________________________
_____
Locul

data

naterii:__________________________________________________________
__
CNP:

__/__/__/__/__/__/__/__/__/__/__/__/__/

B.I.____________________________________
Domiciliul
legal:____________________________________________________________
____
Domiciliul

fapt:_____________________________________________________________
__
Stare
civil:____________________________________________________________
_______
Studii:___________________________Ocupaia:_________________________
____________
Etnia:____________________________Religia:_____________________________
______________
Date despre tata(soul)

Nume

prenume:_________________________________________________________
_____
Locul

data

naterii:__________________________________________________________
__
CNP:

__/__/__/__/__/__/__/__/__/__/__/__/__/

B.I.____________________________________
Domiciliul
legal:____________________________________________________________
____
Domiciliul

fapt:_____________________________________________________________
__
Stare
civil:____________________________________________________________
_______
Studii:___________________________
Ocupaia:____________________________________
Etnia:____________________________
Religia:______________________________________
Date despre copiii din familie
Nr. Nume si prenume
Data
crt.
nasterii

Ocupatia

Locul unde Observaii

se
afla
copilul:fami
lie/instituie

1
2
3
4
5
Date despre alte persoane care locuiesc la aceeai adres

Nr.

Nume i prenume

Vrsta

Stare civil

Ocupaie

crt.
1
2
3
III. Istoricul social al beneficiarului
________________________________________________________________
_____________
________________________________________________________________
_____________
________________________________________________________________
_____________
________________________________________________________________
_____________
________________________________________________________________
_____________
________________________________________________________________
_____________
________________________________________________________________
_____________
________________________________________________________________
_____________
________________________________________________________________
_____________
IV. Starea de sntate
________________________________________________________________
_____________
________________________________________________________________
_____________
________________________________________________________________
_____________

________________________________________________________________
_____________
________________________________________________________________
_____________
________________________________________________________________
_____________
V. Situaia material/financiar
Locuina
Proprietate personal:

da

nu

Numarul de camere:_______

Electricitate

Ap curent

nclzire

Starea de igien:

Satisfctoare

Nesatisfctoare

Suprafaa

de

teren

cultivat

Telefon

(tipul

culturii):____________________________________________
Animale:_________________________________________________________
_____________
Alte
proprieti:________________________________________________________
_________
Venituri
Stabile:__________________________________________________________
_____________
Ocazionale:_______________________________________________________
____________
VI. Relaiile n familie i comunitate
Relaii

familie:__________________________________________________________
______

________________________________________________________________
_____________
________________________________________________________________
_____________
Relaiile

comunitate:_______________________________________________________
____
________________________________________________________________
_____________
________________________________________________________________
_____________

VII. Observaii
________________________________________________________________
____________
________________________________________________________________________
_____________
VIII. Concluzii i recomandri
________________________________________________________________
_____________
________________________________________________________________
_____________
________________________________________________________________
_____________
________________________________________________________________
_____________

Director General Adjunct

Sef serviciu

Asistent Social