Social Pension Beneficiary Update For

PDPB-SPBUF v.4 March 6, 2019

SENIOR CITIZEN ID NO. Encoded Time Started:

Grantee âGO TO 1 Not Grantee à CONTINUE Name of Respondent:
I. IDENTIFICATION
1. Name of Pensioner/
Senior Citizen
Last Name First Name

2. Mother's Maiden Name

Last Name First Name

3. Names of Authorized
Representatives 1.

2.

3.
Last Name First Name

4. Place of Birth
Region Province

5. Address
Region Province

House No./Zone/Purok/Sitio

6. Date of Birth 7. Name of Guardian/Care Giver

8. Relationship of (7) to the Senior

m m d d y y Citizen

10. Sex 11. Contact Number

1 Male 2 Female

II. SOCIOECONOMIC INFORMATION

A. Income Sources and Financial Support
13. Do you receive any form of pension?
1 Yes âGO TO 13
2 No â GO TO 14
3 Don't know â GO TO 14

14.What pension/s did you receive in the past 6 months? You may read the options.
1 DSWD Social Pension
2 GSIS
3 SSS

4 AFPSLAI

5 Others________________________
15. . What are your sources of income and financial support in the past 6 months (other than your
pension/s)? You may read the options. For each source, indicate if it is regular then record the
estimated amount of income and divide by the household size, if applicable.
ion Beneficiary Update Form
Reference Code:
Time Ended:

Middle Name Name Extension (Jr,Sr)

Middle Name Name Extension (Jr,Sr)

Middle Name Name Extension (Jr,Sr)

City/Municipality Barangay

City/Municipality Barangay

urok/Sitio Street

9. Marital Status
1 Single 2 Married

3 Widowed 4 Separated
5 Live-in 6 Others

12. Household Size

B. Health and Social Condition

16. Who are you living with?
1 Living alone
2 Living with spouse only

3 Living with a child (including adopted children), child-in-law or grandchild

4 Living with another relative (other than a spouse or child/grandchild)

5 Living with unrelated people only, apart from the older person’s spouse

17. Frailty Questions

17.1 Are you older than 85 years?
0 No 1 Yes
16.2 In general, do you have any health problems that require you to 0 No 1 Yes
limit your activities?

17.3 Do you need someone to help you on a regular basis?

0 No 1 Yes
17.4 In general, do you have any health problems that require you to
stay at home? 0 No 1 Yes
 A. Source B. Is it regular? C. Income
1 Wages/Salaries 0 No 1 Yes PhP____________/___=

2 Profits from Entrepreneurial Activities 0 No 1 Yes PhP____________/___=

3 Household Family Members/ Relatives 0 No 1 Yes PhP____________/___=

4 Domestic Family Members/ Relatives 0 No 1 Yes PhP____________/___=

5 International Family Members/Relatives 0 No 1 Yes PhP____________/___=

6 Friends/Neighbors 0 No 1 Yes PhP____________/___=

7 Transfers from the Government 0 No 1 Yes PhP____________/___=
8 Others_________________ 0 No 1 Yes PhP____________/___=
III. UTILIZATION OF SOCIAL PENSION
21. Where do you spend your Social Pension? Do not read the options.
1 Food
2 Medicines and Vitamins
3 Health check-up and other hospital/medical services
4 Clothing
5 Utilities (e.g. electric and water bills)
6 Debt payment
7 Livelihood/Entrepreneurial Activities
8 Others_______________________________
17.4 In general, do you have any health problems that require you to
stay at home?

17.5 If you need help, can you count on someone close to you? 0 No 1 Yes

17.6 Do you regularly use a stick/walker/wheelchair to move about? 0 No 1 Yes

18. Do you have any disability?

1 Yes - Disability:_________________________________ 2 None

19. Do you have any critical illness or disease?

1 Yes - Illness:___________________________________ 2 None

20. On the average, how many meals did you have in a day during the past week?
1 At most one 2 Two 3 At least three
NOTES

1 Always ask for the senior citizen's ID as reference for accomplishing section I.
2 Questions with option list/circle symbols "○" will allow only one answer.
3 Questions with checkboxes "o" will allow multiple responses.
4 Accomplish the Beneficiary Validation Log (Annex 1)after each interview.
5 Accomplish the Non-validated Beneficiary Log (Annex 2) for beneficiaries that were not validated.
IV. DECLARATION
On behalf of all the members of my household, I confirm that the information I have provided in
this form is true and represents accurate information of our household.

I understand that the data collected from this validation will be processed, managed and
maintained in a secure database by the Department of Social Welfare and Development (DSWD).
Such data will be used to determine poverty status, serve as basis for research, and in the
development and implementation of social protection programs and services to promote the
interest of the poor.

I authorize DSWD to manage the information, including personal data obtained from the
household validation activity and allow the processing and controlled disclosure or transfer of
data to its development partners and other stakeholders in accordance with the DSWD policies
on data sharing and the provisions of Republic Act No. 10173 or the Data Privacy Act (DPA) of
2012.

Name of Respondent

REMARKS
V. CERTIFICATION
As Validator hired by DSWD for the purpose of this activity, I confirm that for this household the data
gathering process was accomplished in accordance with the policies and procedures prescribed by the
National Household Targeting System for Poverty Reduction (NHTS-PR) or Listahanan.

I attest that the information provided in this form was personally obtained and reviewed by me.

I further declare that all household information collected and validated was managed with strict
confidentiality and protected from unlawful and unauthorized processing.

I am are aware that any violation committed on the foregoing will be penalized in accordance with
pertinent provision of RA 10173 or the Data Privacy Act of 2012.
Department of Social Welfare and Development
Annex 1 Validation and Monitoring of Social Pension Beneficiaries

BENEFICIARY VALIDATION LOG

Barangay________________________
Municipality/City of _____________________________
Province of __________________________
Date of Validation ___________________

Senior Citizen ID Number Name of Social Pension Beneficiary

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
____

Remarks
Department of Social Welfare and Development
Annex 2 Validation and Monitoring of Social Pension Beneficiaries

NON-VALIDATED BENEFICIARY LOG

Barangay________________________
Municipality/City of _____________________________
Province of __________________________
Date of Validation ___________________

Status
Name of Social Pension Beneficiary Transferred No Qualified
Unlocated
Residence Respondent

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
NEFICIARY LOG
______________
____________________
________________
_______________

Status
Vacant Housing Conflict/ Others (please
Refused
Unit Disaster Area specify)