General Santos CIity Time Start:

General Intake Time End:

Contact #:
I. IDENTIFICATION
Household ID
Family Name: First Name: Middle Name:
Age: Civil Status: Religion: Tribe: Sex:
Educational Attainment:
Occupation: Job Status: Permanent ( ) Casual ( ) Contractual ( )
Place of Origin Years stay in Gensan:
Estimated Monthly Income:
Address: 12 General Santos City
Region Province Municipality/City Barangay
Homeless
Purok/ Sitio/Zone/District Street Address Building No. House No.
No. of Household (HH) No. of Families: H1 H2 H3
in the Housing Unit: Status of occupancy: Owner ( ) Renter ( ) Household Sharer ( )
Status of Lot Occupancy: Owner ( ) Renter ( ) Household Sharer ( ) CR: Owner ( ) Sharer ( )
Housing Characteristics: Concrete ( ) Semi concrete ( ) Bungalow ( ) Salvage ( )
Senior Citizen: With Pension ( ) Without Pension ( ) Vehicles: Tricycle ( ) Car ( ) Motorcycle ( ) Scooter ( ) Van ( )
Without ID ( ) Solo Parent: With ID ( ) Without ID ( ) 4ps : With ID ( ) Without ID ( ) People with Disability: With ID ( )
Insurance: PAG-IBIG ( )Frame( )Life plan( )Phil health( SSS ( )Type of PWD: Physical ( ) Menta ( )Deaf ( )
Lighting Facility: Light Bulb ( ) Fluorescent light (LED ( ) Estado sa Tubig: Spring ( ) Metro ( ) Gapalit ( )
II. HOUSEHOLD ROSTER
Name A S Date Of Birth Relationship Educational Civil Occupatio Monthly
g e MM DD YY To the HH Attainment Status n Income
e x

Total Family Income: Per Capita Income: Classification:

TOP 3 PROBLEMS IN COMMUNITY
1. 2.
III. DECLARATION
On behalf of all the members of my household, I confirm that the
information I have provided in this form are true and represent
accurate information of our household.
I understand that the data collected from this General Intake Sheet
(GIS) will be processed, managed, and maintained in a secured
database by the City Government of General Santos. Such data will
be used to profile and 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 the City Government of General Santos to manage the
information, including personal data, obtained from this GIS and
allow the processing and controlled disclosure or transfer of data to
its development partners and other stakeholders in accordance with
the provisions of Republic Act No. 10173 or the Data Privacy Act
(DPA) of 2012.
3.
IV. CERTIFICATION
As Social Work Intern by the City Government of General Santos for
the purpose of this assessment, I confirm that for this household,
the data gathering process was accomplished in accordance with
the policies and procedures prescribed.
I attest that the information provided in this form was personally
obtained and reviewed.
I further declare that all household information collected and
validated was managed with strict confidentiality and protected from
unlawful and unauthorized processing.
We are aware that any violation committed on the foregoing will be
penalized in accordance with pertinent provisions of RA 10173 or the
Data Privacy Act of 2012.

Signature Over Printed Name of Social Worker/Staff/Intern

Date Accomplish:
Name of Respondent

Signature Over Printed Name of CSWDO SW Intern

Date Received:

Signature of the Thumb mark of

Respondent Respondent