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:_____________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
b)Relaiile familiei cu
comunitatea:___________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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:________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
f) Gradul de integrare i participare
social:____________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
4. Serviciile oferite de comunitate pentru copilul cu
dizabiliti: ____________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
5. Prestaii (tip, cuantum, perioada de acordare):
________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Concluzii i propuneri:
____________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
ASISTENT SOCIAL,
Numele i prenumele Semntura .....................
