lOMoARcPSD|3789568
SCDF V4b2 - Senior Citizen Data Form
Accounting (Taguig City University)
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lOMoARcPSD|3789568
Republic of the Philippines
Office of the President of the Philippines
NATIONAL COMMISSION OF SENIOR CITIZENS
SENIOR CITIZEN DATA FORM
Reference Code: -
REGION PROVINCE
CITY/MUNICIPALITY BARANGAY
I. IDENTIFYING INFORMATION
1. Name of Senior
Citizen Last Name First Name Middle Name Extension (Jr,Sr)
2. Address
Region Province City/Municipality Barangay
House No./Zone/Purok/Sitio Street
3. Date of Birth 4. Place of Birth 6. Marital Status
m m d d y y
7. Contact Number 8. Email Address 9. Messenger
10. Religion 11. Ethnic Origin 12. Language Spoken /
Written
13. OSCA ID 14. GSIS/SSS 15. TIN
Number
16. Philhealth 17. SC Association / Org ID No. 18. Other Gov't. ID
19. Capability to 20. Service/ Business/ 21. Current Pension
1 Yes 2 No
Travel Employment (specify) (specify)
II. FAMILY COMPOSITION
22. Name of Spouse
Last Name First Name Middle Name Extension (Jr,Sr)
23. Father's Name
Last Name First Name Middle Name Extension (Jr,Sr)
24. Mother's Maiden
Name Last Name First Name Middle Name
25. Child(ren) Full name Working/not
Occupation Income Age
working
25.A Other Dependents
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 13 Barber 14 Mason 15 Sapatero
2 16 Evangelization 17 Tailor 18 Chef/Cook
3 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.
_______________________________
Name and Signature of Senior Citizen
Right Thumb Print of Senior Citizen
__________________________________ ________________________
Name and Signature of Assisting Person 1 Relationship to Senior Citizen
__________________________________ ________________________
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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