Ancheta Sociala Copil Dizabilitati

PRIMRIA Serviciul. Nr.din.

PRIMAR

ANCHETA SOCIAL (pentru copilul cu dizabiliti)

1. Date de identificare a)Copilul

Numele i prenumele:______________________________________________________________________ Data i locul naterii:______________________________________________________________________ Domiciliul:______________________________________________________________________________

Religie:______________________________________________________Etnie:______________________

b)Printi: Mama:

Numele i prenumele:______________________________________________________________________ Domiciliul:______________________________________________________________________________

Profesia:_________________________Locul de munc:__________________________________________ Religie:_______________________________________________________Etnie:_____________________

Tata:

Numele i prenumele:______________________________________________________________________ Domiciliul:______________________________________________________________________________

Profesia:__________________________Locul de munc_________________________________________ Religie:_______________________________________________________Etnie:_____________________

c) Frai/surori

Nr.

crt

Numele i prenumele Vrsta coala/ Centru de recuperare frecventat()

Ocupaia

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

2. Date privind istoria personal a copilului: a) Familia extins ( rude pn la gradul IV) sau alte persoane care locuiesc cu familia

Nr.

crt

Numele i prenumele Vrsta Gradul de rudenie ( mama, tata, frate,sor, bunici, unchi, mtui, etc.)

1.

2.

3.

4.

5.

6.

b) Persoane apropiate (vecini, prieteni de familie, cadre didactice, altele):

Numele i prenumele:______________________________________________________________________ _______________________________________________________________________________________

Domiciliul:______________________________________________________________________________

3. Situaia socio-economic a familiei: a) Climatul familial, relaiile dintre membrii familiei:_____________________________________________ _______________________________________________________________________________________

_______________________________________________________________________________________

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_______________________________________________________________________________________

b)Relaiile familiei cu comunitatea:___________________________________________________________ _______________________________________________________________________________________

_______________________________________________________________________________________

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c)Situaia economic a familiei - venituri:________________________________________________ _______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

d) Climatul educaional al familiei, studii efectuate, ultima coal absolvit: __________________________ _______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

e) Locuina: condiii igienico-sanitare, utiliti, faciliti speciale etc:________________________________ _______________________________________________________________________________________

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f) Gradul de integrare i participare social:____________________________________________________ _______________________________________________________________________________________

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4. Serviciile oferite de comunitate pentru copilul cu dizabiliti: ____________________________________ _______________________________________________________________________________________

_______________________________________________________________________________________

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5. Prestaii (tip, cuantum, perioada de acordare): ________________________________________________ _______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

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Concluzii i propuneri: ____________________________________________________________________ _______________________________________________________________________________________

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ASISTENT SOCIAL,

Numele i prenumele Semntura .....................