lOMoARcPSD|29998591

Final-GIS-CE - Appreciation notes .

Bachelor of Technology Livelihood Education (Isabela State University)

Studocu is not sponsored or endorsed by any college or university

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 lOMoARcPSD|29998591

PROTECTIVE SERVICES DIVISION

CRISIS INTERVENTION SECTION/FIELD OFFICE II
DSWD-PMB-GF-011 | REV 01 / 30 SEPT 2022

GENERAL INTAKE SHEET

MAARING MAGPATULONG SUMAGOT SA DSWD PERSONNEL

QN: PCN: Time Start: Date:

New Returning On-Site Walk-in Referral Off-Site

IMPORMASYON NG BENEPISYARYO (Beneficiary’s Identifying Information)

Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)
TUMAUINI ISABELA II
House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)

Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Civil Status (Katayuang Sibil) Trabaho (Occupation) Buwanang Kita (Monthly Salary)

IMPORMASYON NG KINATAWAN (Representative’s Identifying Information)

Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)

Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Civil Status (Katayuang Sibil) Trabaho (Occupation) Buwanang Kita (Monthly Salary)

Relasyon sa Benepisyaryo (Relationship to the Beneficiary) Time End:

Huwag susulatan ang DSWD lamang ang pwede gumamit (Do not write below this part for DSWD's use only)
Beneficiary Category Social worker's Assessment
Target Sector: Specify Sub-Category
Solo Parents
The family finds difficulty to provide and sustain the schools needs. The
FHONA
SC Indigenous People income of the family is insufficient to sustain the educational needs due to the
WEDC Recovering Person who used drugs effects of the pandemic and high cost of living. To date, client is problematic
YNSP 4PS DSWD Beneficiary
on where to get finances for the school needs, projects and allowances. Client
PWD Street Dwellers
Psychosocial/Mental/Learning Disability belongs to the indigent group in the community. Hence, client is eligible for
PLHIV
CNSP
Stateless Person/Asylum Seekers/Refugees financial assistance.
Others:

KOMPOSISYON NG PAMILYA (Family Composition)

Buong Pangalan Relasyon sa Benepisyaryo Edad Trabaho Buwanang kita
(Complete Name) (Relationship to the Beneficiary) (Age) (Occupation) (Monthly Salary

Material Assistance: Psychosocial Support: Referral:

Financial Assistance:
Medical Food Assistance Family Food Packs _________
Other Food Items Psychological First Aid
Funeral _________
Transportation Hygiene & Sleeping Kits
Cash Assistance for Social Work Counseling
Educational Assistive Device & Technologies

Provided Amount Fund Source

1
TUITION FEE/ALLOWANCE/SCHOOL NEEDS
2

"I declare under oath that I personally accomplished the GIS Form and all the
information provided herewith is TRUE, CORRECT, VALID, and COMPLETE pursuant
to existing laws, rules, and regulations of the Republic of the Philippines. I authorized
the Agency Head/Authorized Representatives to verify and validate the contents stated Interviewed by: Reviewed & Approved by:
herein. I also AGREE that any MISINTERPRETATION and information/acts to
DEFRAUD the government, including attached documents, shall cause the filing of
appropriate case/s against me."

Buong Pangalan at Pirma Social Worker Approving Authority

(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

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DSWD Field Office 02, #3 Dalan na Pagayaya, Regional Government Center, Carig, Tuguegarao City, Philippines 3500
Email: fo2@dswd.gov.ph Tel.Nos.: (078) 304-0656; (078) 304-1004

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 lOMoARcPSD|29998591

PROTECTIVE SERVICES DIVISION

CRISIS INTERVENTION SECTION/FIELD OFFICE II
DSWD-PMB-GF-013 | REV 01 / 30 SEPT 2022

CERTIFICATE OF ELIGIBILITY
(Educational Assistance)

QN: PCN: Date:

New Returning On-Site Walk-in Referral Off-Site

Male Femal
This is to certify that, ,
Kumpletong Pangalan (First name, Middle name, Last name) Kasarian (Sex) Edad (Age)

and presently residing at TUMAUINI, ISABELA

Kumpletong Tirahan (Complete Address)

has been found eligible for assistance after the assessment and validation conducted, for his/herself or through the representation of his/her

Relasyon ng Kinatawan sa Benepisyaryo (Relationship of the Representative to Beneficiary) Buong Pangalan ng Benepisyaryo (Name of Beneficiary)

Records of the case such as the following are confidentially filed at the Crisis Intervention Division (CID)

General Intake Sheet Medical Certificate/Abstract Discharge Summary Death Summary

Valid I.D. Presented Prescriptions Laboratory Referral Letter
Statement of Account Charge Slip Social Case Study Report
4PS DSWD I.D. Treatment Protocol Funeral Contract Others
Justification Quotation Death Certificate

The Client is hereby recommended to receive EDUCATIONAL assistance for TUITION FEE/SCHOOL NEEDS

in the amount of Php. CHARGEBLE AGAINST: PSP

(Year)

Conforme: Prepared by: Approved by:

Beneficiary/Representative Social Worker Approving Authority

(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

Acknowledgement Receipt

Date:

Financial Assistance Php

(Amount in words)
Medical Assistance Transportation Assistance Food Assistance
Funeral Assistance Educational Assistance Cash Assistance for Support Services

Tinanggap ni: Binayaran ni: Sinaksihan ni:

Beneficiary/Representative RDO / SDO SWO / ADMIN

(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

*E.O 163 series 2022

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DSWD Field Office 02, #3 Dalan na Pagayaya, Regional Government Center, Carig, Tuguegarao City, Philippines 3500
Email: fo2@dswd.gov.ph Tel.Nos.: (078) 304-0656; (078) 304-1004

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