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OSCA ID Application For Senior Citizen

This intake sheet collects information from senior citizens for the purpose of profiling and providing assistance. It requests identifying details, family composition, economic situation, health, living situation, skills, community involvement, problems encountered, and services received. The goal is to understand the senior's needs to improve support programs.

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barangay twentynine
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461 views2 pages

OSCA ID Application For Senior Citizen

This intake sheet collects information from senior citizens for the purpose of profiling and providing assistance. It requests identifying details, family composition, economic situation, health, living situation, skills, community involvement, problems encountered, and services received. The goal is to understand the senior's needs to improve support programs.

Uploaded by

barangay twentynine
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines Code No.

______
Household No._______ Department of Social Welfare and Development Field Office VI

___________________
Province
___________________
Municipality/City
___________________
Baranagay
SENIOR CITIZENS GENERAL INTAKE SHEET
(Please answer appropriately and legibly)
I. Identifying Information
NAME:
(Last Name) (First Name) (Middle Name) (Suffix)
ADDRESS:
(House No. & Street Name) (Barangay/District) (Municipality/City)

(Province) (Region)
DATE OF BIRTH:
(Year) (Month) (Day)
PLACE OF BIRTH:____________________________
CIVIL STATUS: ______ Single ______Widow/Widower ______ Separated ______ Married

RELIGION: Roman Catholic ____ _____Iglesia Ni Cristo


Protestant ______ _____Islam Other, pls. Specify ______

___________ NHTS-PR (Listahan)


___________ Indigenous People _____________Pantawid Beneficiary
Type of Ethnic Group (pls. specify)
A.
B. C. Other_____________
EDUCATIONAL ATTAINMENT:
_____Elementary Level _____High School Level _____College Level
_____Elementary Graduate _____High School Graduate _____College Graduate
_____Not Attended Any School _____Vocational _____Post Graduate

ID NUMBER OSCA______________ GSIS ___________________ TIN__________


SSS ______________ PHILHEALTH__________ Others: (Please specify)_____________

MONTHLY INCOME: (In Philippine Peso)


______ 10,000 & Above ______ 7,000-7,999 _____ 4,000-4,999 ______ 1,000-1,999
______ 9,000-9,999 ______ 6,000-6,999 _____ 3,000-3,999 ______ 999 & Below
______ 8,000-8,999 ______ 5,000-5,999 _____ 2,000-2,999

SOURCE OF INCOME & ASSISTANCE: (Check all applicable)


______Own earnings, salaries/wages ______ Spouse`s salary ______ Rentals/Sharerooms ______ Savings
______Own pension, specify amount ₱. ______ Insurances ______No Pension ______Stocks/Dividends
______ Spouse`s pension ______ Specify amount ______Livestock/Orchards
______Dependent on children/relatives ____________others (please specify)

II. FAMILY COMPOSITION


FAMILY COMPOSITION
NAME ADDRESS RELATIONSHIP DATE OF BIRTH/AGE SEX CIVIL OCCUPATION MONTHLY
STATUS INCOME

LIVIG/RESIDING WITH: (Check all applicable)


______ Alone ______Common Law Spouse ______In Laws _____Spouse ______Grandchildren ______Care Institutions
____Househelps ________Children ______Relatives _______Friends ______Others, specify

AREAS OF SPECIALIZATION/SKILLS: (Check all applicable)


Medical _____________ Farming __________ Evangelization _____________ Engineering
__________ Teaching _____________ Fishing __________ Counseling _____________ Arts
__________ Legal Services _____________ Cooking __________ Dental _____________ Vocational
INVOLVEMENT IN COMMUNITY ACTIVITIES: (Check all applicable)
_______ Medical _______ Neighborhood Support Services _______ Resource Volunteer _______ Religous
_______ Community Beautification _______ Counseling/referral ______ Community/Organizational
_______Sponsorship _______ Dental _______ Legal Services ______ Friendly Visits _______ Others,specify

PROBLEMS/NEEDS COMMONLY ENCOUNTERED: (Check all applicable)


A. Economic/Financial
_________ Lack of income/resources
_________Loss of income/resources
_________Skills/Capability Training: (specify) ____________________
_________livelihood opportunities: (specify) ____________________
_________Others, _____________________________________
a.1. Have you experienced economic/financial abuse?
A. _______No B. _______Yes If yes, Please specify_____________

b. Social/Emotional/Psychological
_______ Feeling of neglect & rejection __________Inadequate leisure/recreational activities
_______ Feeling of helplessness & worthless __________Senior Citizen Friendly Environment
_______ Feeling of loneliness & isolation __________Others, specify ________________

b .1 Have you experienced emotional/psychological abuse?


A. ______No B. _________Yes if yes, please specify ______________
b .2 Have you experienced being neglected?
A______No B.__________Yes if yes, please specify_______________
b .3 Have you experienced being abandoned?
A.______No B.__________Yes if yes, please specify_______________

c. Health/Physical
Condition/Illnesses ______________________________
(please specify)
With maintenance: _______No _____Yes If yes, please specify (kind of medication _______________________
Amount: (please specify (weekly/monthly) _______________________

With Disability _______No _____Yes If yes, please specify (Type of Disability)


_____a. Physchological/Behavic _______e. Physical
_____b. Learning _______f. Hearing
_____c. Intellectual _______g. Speech Impairment
_____d. Visual
c.1 Have you experienced physical abuse?
a . _____ No b. ______ Yes if yes, please specify_____________

Concerns/Issues:
________ High cost medicines
________ Lack of medical professionals
________ Lack/No access to sanitation
________ Health problems/Ailments: specify ___________________
________ Lack/no health insurance/s inadequate health services
________ Lack of Hospitals/medical facilities
________ others, _______________________
d. Housing
________Overcrowding in the family home _______ Lost privacy
________ No permanent housing _______ Living in squater`s area
________ Longing for indipendent living/quiet atmosphere _______ high cost rent
________ Others, _________________________________
e. Program, Services and Assistance Availed from National Government Agencies, LGU and NGO
______No ______Yes if yes, what type of services/assistance Please specify Agency/LGU/NGO______
a . Medical b . Livelihood c . Educational d . Burial e . others
d. Are you satisfied with the programs, services and assistance provided to you?
______No _______Yes if no, please identify your other specific needs.
e . Community Service
Desire to participate Skills/resources to share, please specify__________ others, specify________
__________No ___________Yes

PRINTED NAME AND SIGNATURE/THUMBMARK OF SENIOR Printed Name And Signature of Interviewer
CITIZEN

Date of Interview : ______________________


NOTICE: The contents of this intake sheet at any attachments herein are intended safely for profiling purposes and may contain cinfidential and/or priveleged information and may be protected from
disclosure,subject to existing laws and regulations. If you are not the intended recipient, you are hereby notified that any ificit use, dissemination, copying, or storage of this information or its attachment is strictly
prohibitted under pain of penalty, subject to the provisions of sections 25 to 33 of republic act 10173 (Data Privacy Act of 2012) and chapters II and III of Republic Act 10175 (Cybercrime Prevention Act of 2012)

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