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ANCHETA SOCIAL

I. Date de identificare a beneficiarului


Nume

prenume:_________________________________________________________
_____
Locul

data

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

fapt:_____________________________________________________________
__
Stare
civil:____________________________________________________________
_______

Studii:__________________________Ocupaia:__________________________
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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
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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

nclzire

Starea de igien:

Satisfctoare

Nesatisfctoare

Suprafaa

de

teren

cultivat

Telefon

(tipul

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

familie:__________________________________________________________
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________________________________________________________________
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Relaiile

comunitate:_______________________________________________________
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VII. Observaii
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VIII. Concluzii i recomandri
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Director General Adjunct

Sef serviciu

Asistent Social