ANCHETA SOCIALĂ

Realizată de asistentul social_______________________________________

Locul şi data____________________________________________________
Persoane prezente_______________________________________________
Scopul_________________________________________________________

I. Date de identificare a minorului

Nume şi prenume:_______________________________________________
Locul şi data naşterii:_____________________________________________
CNP:__/__/__/__/__/__/__/__/__/__/__/__/__/ B.I._____________________
Domiciliul legal:_________________________________________________
Etnia:__________________________ Religia: ________________________________

II. Date despre familie:

Date despre mama

Nume şi prenume:_______________________________________________
Locul şi data naşterii:_____________________________________________
CNP: __/__/__/__/__/__/__/__/__/__/__/__/__/ B.I._____________________
Domiciliul legal:_________________________________________________
Domiciliul în fapt:________________________________________________
Stare civilă:____________________________________________________
Studii:___________________________Ocupaţia:______________________
Etnia:____________________________Religia:_______________________________
Date despre tata
Nume şi prenume:_______________________________________________
Locul şi data naşterii:_____________________________________________
CNP: __/__/__/__/__/__/__/__/__/__/__/__/__/ B.I._____________________
Domiciliul legal:_________________________________________________
 Domiciliul în fapt:________________________________________________
Stare civilă:____________________________________________________
Studii:___________________________ Ocupaţia:_____________________
Etnia:____________________________ Religia:_______________________

Date despre copiii din familie

Nr. Nume si prenume Data Ocupatia Locul unde Observaţii
crt. nasterii se afla
copilul:familie
/instituţie
1

Date despre alte persoane care locuiesc la aceeaşi adresă

Nr. Nume şi prenume Vârsta Stare civilă Ocupaţie
crt.
1
2
3

III. Istoricul copilului

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IV. Starea de sănătate
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V. Situaţia materială/financiară

Locuinţa
Proprietate personală:  da  nu Numarul de camere:_______
□ Electricitate □ Apă curentă □ Încălzire □ Telefon
Starea de igienă: □ Satisfăcătoare □ Nesatisfăcătoare

Suprafaţa de teren cultivată (tipul culturii):______________________________

Animale:________________________________________________________
Alte proprietăţi:___________________________________________________

Venituri
Stabile:_________________________________________________________
Ocazionale:_____________________________________________________

VI. Relaţiile în familie şi comunitate

Relaţii în familie:__________________________________________________
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Relaţiile în comunitate:_____________________________________________
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VII. Observaţii
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VIII. Concluzii şi recomandări
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Asistent Social