Screening Checklist for DSW Social Protection Programmes

SPS, DAS, TAS, C&P (Group 1 and 2), FAS, FARPMS.

This checklist is used for preliminary screening for potential eligibility for programs, especially for Applicants who lack knowledge of specific programs and are requesting general assistance.

Section A. Applicant Information

Please note: Each screening form should be completed for one person or household only (for example, yourself, your household, someone you care for, or someone you are a third party for). If you wish to provide information for more than one person or household, submit a separate form for each

1. Personal Details

BRN/CCN

Ethnicity

Given Name

Surname

Date of Birth

Gender

1. Contact details

Division

Province

District

Village/Town/City

Street

Apartment, Building, or Lot Number

DSW Office

Postal Address (if different from residential)

Only if different from residential address

Email address

Phone Number

Whose phone number is this?

Captcha Code

Screening Checklist for DSW Social Protection Programmes