COMISIA PENTRU PROTECTIA DREPTURILOR COPILULUI SIBIU

CONSILIUL JUDEŢEAN SIBIU

COMISIA PENTRU PROTECŢIA DREPTURILOR COPILULUI SIBIU

Serviciul de Evaluare Complexa

Mama copilului

Tatal copilului

Nume prenume __________ ______ ____ __________ ______ ____ _____ _______ ______ _________

C.N.P. __________ ______ ____ ___ B.I./C.I : Seria ___________ Nr. _____ _______ ______ ______________

Data si locul nasterii :__________ ______ ____ __________ ______ ____ ___________________

Domiciliul legal :__________ ______ ____ __________ ______ ____ _____ _______ ______ _______

Resedinta : __________ ______ ____ __________ ______ ____ _____ _______ ______ ____________

Locuieste fara forme legale in __________ ______ ____ __________ ______ ____ ____________

Nationalitatea _______________Cetatenia _________________ Religia __________ ______ ____ _________

Studii _____ _______ ______ _____________ Ocupatia __________ ______ ____ _____ _______ ______ ___________

Loc de munca __________ ______ ____ __________ ______ ____ _____ _______ ______ __________

Venit _____ _______ ______ ______ Alte surse de venit __________ ______ ____ _____ _______ ______ ___________

Starea civila actuala __________ ______ ____ __________ ______ ____ ____________________

Casatorii anterioare(data,locul.,motivul incetarii ) __________ ______ ____ _____ _______ ______ _____________

Cati copii locuiesc cu tata __________ ______ ____ __________ ______ ____ ________________

Antecedente penale

Boli cronice si psihice :__________ ______ ____ __________ ______ ____ __________________

Vicii ( droguri, alcool, prostitutie, altele) __________ ______ ____ __________ ______ ____ ____

Locuinta tatalui :

Alte observatii referitoare la tata __________ ______ ____ __________ ______ ____ ___________

Alte persoane care locuiesc împreuna cu copilul si familia

57. Nume, prenume __________ ______ ____ __________ ______ ____ _____ _______ ______ _________

58. Data nasterii __________ ______ ____ __________ ______ ____ _____ _______ ______ ____________

59. Domiciliul __________ ______ ____ __________ ______ ____ _____ _______ ______ _____________

60. Ocupatia __________ ______ ____ __________ ______ ____ _____ _______ ______ _______________

61. Gradul de rudenie __________ ______ ____ __________ ______ ____ _____ _______ ______ ________

62. Recomandarile asistentului social __________ ______ ____ __________ ______ ____ __________

Data completarii anchetei sociale_____ _______ ______ ______________

Semnatura asistentului social__________ ______ ____

Supervizor ...........