Republic of the Philippines

Office of the President of the Philippines

NATIONAL COMMISSION OF SENIOR CITIZENS
SENIOR CITIZEN DATA FORM
Reference Code: -
REGION VIII PROVINCE Biliran
CITY/MUNICIPALITY Biliran BARANGAY San Isidro
I. IDENTIFYING INFORMATION
1. Name of Senior Cerera Alberto Macorol
Citizen Last Name First Name Middle Name Extension (Jr,Sr)
2. Address VIII Biliran Biliran San Isidro
Region Province City/Municipality Barangay
Sitio Omas Sitio Omas
House No./Zone/Purok/Sitio Street
3. Date of Birth 4. Place of Birth 6. Marital Status
0 4 0 7 4 8
m m d d y y San Isidro Single
7. Contact Number 8. Email Address rizmullon25@gmail.com 9. Messenger
+639061724661 Toyang Young
10. Religion 11. Ethnic Origin 12. Language Spoken /
Roman Catholic Waraywaray Written
Tagalog/Waraywaray

13. OSCA ID 14. GSIS/SSS 15. TIN

Number 1391 None None
16. Philhealth 17. SC Association / Org ID No. 18. Other Gov't. ID
None 1391 Senior Cetizen
19. Capability to 20. Service/ Business/ 21. Current Pension
1 Yes 2 No None None
Travel Employment (specify) (specify)

II. FAMILY COMPOSITION

22. Name of Spouse None None None

Last Name First Name Middle Name Extension (Jr,Sr)
23. Father's Name Cerera Gregorio Brecio Sr.
Last Name First Name Middle Name Extension (Jr,Sr)
24. Mother's Maiden Macorol Feliza Udtohan
Name Last Name First Name Middle Name
25. Child(ren) Full name Working/not
Occupation Income Age
working
None None None None None

25.A Other Dependents None None None None None

III. DEPENDENCY PROFILE

26. Living/Residing with (check all applicable) 27. Housing
1 Alone 2 Grand Child(ren) 3 Common Law Spouse 1 No privacy 2 Overcrowded in home
4 Spouse 5 In-law(s) 6 Care Institution 3 Informal Settler 4 No permanent house
7 Child(ren) 8 Relative(s) 9 Friend(s) 5 High cost of rent 6 Longing for independent living quiet atmosphere
10 Others, pls specify 7 Others, specify

IV. EDUCATION / HR PROFILE

28. Educational Attainment 29. Areas of Specialization / Technical Skills (Check all applicable)
1 Elementary Level 2 Elementary Graduate 3 High School Level 1 Medical 2 Teaching 3 Legal Services
4 High School Graduate 5 College Level 6 College Graduate 4 Dental 5 Counseling 6 Farming
7 Post Graduate 8 Vocational 9 Not Attended School 7 Fishing 8 Cooking 9 Arts
30. Share Skill (Community Service) 10 Engineering 11 Carpenter 12 Plumber
1 None 13 Barber 14 Mason 15 Sapatero
2 None 16 Evangelization 17 Tailor 18 Chef/Cook
3 None 19 Millwright 20 Others, specify
Reference code Prefix : A=Region I (Ilocos); B=Region II (Cagayan Valley); C=Region III (Central Luzon); D=Region IVA (CALABARZON); E=Region IVB (MIMAROPA);F=Region V (Bicol);
G=Region IV (Western Visayas); H=Region VII (Central Visayas); I=Region VIII (Eastern Visayas); J=Region IX (Zamboanga Peninsula);
K=Region X (Northern Mindanao); L=Region XI (Davao); M=Region XII (SOCCSKSARGEN); N=Region XIII (CARAGA); O=NCR; P=CAR; Q=BARMM
NCSC-SCDF v. 4.0b THIS FORM IS NOT FOR SALE
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31. Involvement in Community Activities (Check all applicable)
1 Medical 2 Resource Volunteer 3 Community Beautification
4 Community / Organization Leader 5 Dental 6 Friendly Visits
7 Neighborhood Support Services 8 Legal Services 9 Religious
10 Counseling / Referral 11 Sponsorship 12 Others, specify

V. ECONOMIC PROFILE
32. Source of Income and Assistance (Check all applicable)
1 Own earnings, salary / wages 2 Own Pension 3 Stocks / Dividends
4 Dependent on children / relatives 5 Spouse's salary 6 Insurance
7 Spouse's Pension 8 Rentals / sharecrops 9 Savings
10 Livestock / orchard / farm 11 Fishing 12 Other, specify
33.A Assets: Real and Immovable Properties (Check all applicable) 33.B Assets: Personal and Movable Properties
1 House 2 Lot / Farmland 3 House & Lot Automobile Personal Computer Boats
4 Commercial Building 5 Fishpond / resort Heavy Equipment Laptops Drones
6 Others, specify Motorcycle Mobile Phones Specify
34. Monthly Income (in Philippine Peso) 35.A Problems / Needs Commonly Encountered (Check all applicable)
60,000 and above 50,000 to 60,000 40,000 to 50,000 35.A Economic
30,000 to 40,000 20,000 to 30,000 10,000 to 20,000 1 Lack of income / resources
5,000 to 10,000 1,000 to 5,000 Below 1,000 2 Loss of income / resources
3 Skills / capability training (specify)
4 Livelihood opportunities (specify)
5 Others, specify
V. HEALTH PROFILE
36.A Medical Concern 36.D Aural
Blood Type: O A B Aural impairment
Physical Disability (specify): Others
Health problems / ailments 36.E Social / Emotional
Hypertension Arthritis / Gout Coronary Heart Disease Feeling neglect / rejection
Diabetes Chronic Kidney Disease Feeling neglect / rejection
Alzheimer's / Dementia Feeling helplessness / worthlessness
Chronic Obstructive Pulmonary Disease Feeling loneliness / isolate
Others, pls specify Lack leisure / recreational activities
36.B Dental Concern Lack SC friendly environment
Needs Dental Care Others, specify
Others 36.F Area / Difficulty
36.C Optical High Cost of medicines
Eye impairment Lack of medicines
Needs eye care Lack of medical attention
Others Others
37. List of Medicines for Maintenance

38. Do you have a scheduled medical/physical check-up? Yes No

38.A If Yes, when is it done? Yearly Every 6 months Others

This certifies that I have willingly given my personal consent and willfully participated in the provision of data and relevant information
regarding my person, being part of the establishment of database of Senior Citizens.

Alberto M. Cerera
_______________________________
Name and Signature of Senior Citizen
Right Thumb Print of Senior Citizen

Riza Mullon
__________________________________ Niece
________________________
Name and Signature of Assisting Person 1 Relationship to Senior Citizen

Riza Mullon
__________________________________ Niece
________________________
Name and Signature of Assisting Person 2 Relationship to Senior Citizen

_________________________________ ________________________
Name of Signature of Interviewer/Verifier Organization/Office

Date of Interview: __________________________________

Place of Interview: __________________________________

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