Performance Task in Disciplines and Ideas in the Applied Social Sciences (DIASS)

SOCIAL CASE STUDY REPORT

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Date of Interview
I. Name : IDENTIFYING INFORMATION

Age :
Sex :
Civil Status :
Religion :
Date of Birth :
Place of Birth :
Present Address :
Contact No. :
Educational Attainment :
Occupation :
Monthly Income :
CLIENTELE CATEGORY: () Needy Adult () Needy Youth () CICL () C/PWD
() Survivor () Needy Senior Citizen
FAMILY COMPOSITION:
Name of Age / Relationship Educational Health Skills Occupation Income
HH Birthday Attainment Problems
Members

Other Income: () Laborer () Driver () Housekeeper () Carpenter

() Vendor () Waste Picker () Street Sweeper () None
() Others:
Overall Monthly Family Income: P
II. PROBLEM PRESENTED:
() Educational Assistance () Temporary Shelter () Food Assistance () Financial Aid
() Capital Assistance () Hospital Bills () Medical Assistance () Others:
III. SOURCES OF INFORMATION
 IV. BACKGROUND INFORMATION
A. CLIENT INFORMATION
B. HISTORY OF THE PROBLEM
C. FAMILY BACKGROUND
D. COMMUNITY INFORMATION
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V. INITIAL ASSESSMENT

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VI. RECOMMENDATION

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Prepared by:

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Social Work Intern

Noted by:
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CSWD/MSWD OFFICER