1. Reference Code:
REGION PROVINCE
CITY/MUNICIPALITY BARANGAY
First Name Middle Name Extension (Jr,Sr)
Province City/Municipality
3. Date 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
Number
14. GSIS/SSS 15. TIN
16. Philhealth 17. SC Association / Org ID No. 18. Other Gov't. ID
19. Capability to
Travel
20. Service/ Business/
Employment (specify)
21. Current Pension
(specify)
Extension (Jr,Sr)
Extension (Jr,Sr)
25. Child(ren)
Occupation Income Age
Working/not
working
25.A Other Dependents
3 Common Law Spouse 1 No privacy
6 Care Institution 3 Informal Settler
9 Friend(s) 5 High cost of rent
3 High School Level 1 Medical 2 Teaching
6 College Graduate 4 Dental 5 Counseling
9 Not Attended School 7 Fishing 8 Cooking
10 Engineering 11 Carpenter
13 Barber 14 Mason
16 Evangelization 17 Tailor
19 Millwright
Republic of the Philippines
Office of the President of the Philippines
NATIONAL COMMISSION OF SENIOR CITIZENS
SENIOR CITIZEN DATA FORM
Middle Name
First Name
Last Name
23. Father's Name
First Name
26. Living/Residing with (check all applicable) 27. Housing
2. Address
4 No permanent house
Middle Name
Full name
24. Mother's Maiden
Name
Last Name
III. DEPENDENCY PROFILE
Last Name First Name Middle Name
Last Name
Barangay
I. IDENTIFYING INFORMATION
Region
1. Name of Senior
Citizen
House No./Zone/Purok/Sitio
4. Place of Birth
Street
1 Yes 2 No
II. FAMILY COMPOSITION
22. Name of Spouse
2 Overcrowded in home
1 Alone 2 Grand Child(ren)
4 High School Graduate 5 College Level
7 Child(ren) 8 Relative(s)
10 Others, pls specify 7 Others, specify
4 Spouse 5 In-law(s)
6 Longing for independent living quiet atmosphere
IV. EDUCATION / HR PROFILE
28. Educational Attainment
1 Elementary Level
18 Chef/Cook
20 Others, specify
7 Post Graduate 8 Vocational
15 Sapatero
29. Areas of Specialization / Technical Skills (Check all applicable)
Page 1 of 2
NCSC-SCDF v. 4.0b THIS FORM IS NOT FOR SALE
30. Share Skill (Community Service)
1
2
3
3 Legal Services
6 Farming
9 Arts
12 Plumber
2 Elementary Graduate
-
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
2. 11 Sponsorship
3 House & Lot Automobile Personal Computer
5 Fishpond / resort Heavy Equipment Laptops
Motorcycle Mobile Phones
40,000 to 50,000
10,000 to 20,000
Below 1,000
Coronary Heart Disease
36.B Dental Concern
38. Do you have a scheduled medical/physical check-up?
Yearly
_______________________________
Name and Signature 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: __________________________________
Yes No
37. List of Medicines for Maintenance
38.A If Yes, when is it done? Every 6 months Others
31. Involvement in Community Activities (Check all applicable)
34. Monthly Income (in Philippine Peso)
2 Resource Volunteer 3 Community Beautification
4 Community / Organization Leader 6 Friendly Visits
5 Dental
1 Medical
7 Neighborhood Support Services 8 Legal Services 9 Religious
10 Counseling / Referral
2 Lot / Farmland
32. Source of Income and Assistance (Check all applicable)
V. ECONOMIC PROFILE
1 Own earnings, salary / wages 2 Own Pension
Chronic Obstructive Pulmonary Disease
Others, pls specify
Feeling helplessness / worthlessness
Lack leisure / recreational activities
Lack SC friendly environment
3 Stocks / Dividends
4 Dependent on children / relatives 5 Spouse's salary 6 Insurance
9 Savings
10 Livestock / orchard / farm
7 Spouse's Pension 8 Rentals / sharecrops
11 Fishing 12 Other, specify
Arthritis / Gout
Hypertension
Diabetes Chronic Kidney Disease
Alzheimer's / Dementia
Health problems / ailments
Others
36.E Social / Emotional
Feeling neglect / rejection
Feeling neglect / rejection
V. HEALTH PROFILE
Aural impairment
Physical Disability (specify):
36.A Medical Concern 36.D Aural
Blood Type: O A B
Feeling loneliness / isolate
Drones
4 Commercial Building
6 Others, specify Specify
35.A Problems / Needs Commonly Encountered (Check all applicable)
1 House
THIS FORM IS NOT FOR SALE Page 2 of 2
Right Thumb Print of Senior Citizen
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.
Lack of medical attention
Others
Others, specify
Others
36.C Optical
Eye impairment Lack of medicines
36.F Area / Difficulty
High Cost of medicines
Needs Dental Care
5 Others, specify
Needs eye care
Others
12 Others, specify
35.A Economic
1 Lack of income / resources
2 Loss of income / resources
3 Skills / capability training (specify)
4 Livelihood opportunities (specify)
60,000 and above
30,000 to 40,000
5,000 to 10,000
50,000 to 60,000
20,000 to 30,000
1,000 to 5,000
33.A Assets: Real and Immovable Properties (Check all applicable) 33.B Assets: Personal and Movable Properties
Boats
