institutie de ocrotire care (numele)________________________ 11111k104l ____________________ 11111k104l _____________

 Are instituita o masura de protectie īn persoana: ____________________ 11111k104l ____________________ 11111k104l __

 NU are instituita o masura de protectie

Altele:________________ ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l _____

8. Starea de sanatate: ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l _______

Īnscris la medicul de familie (care) ____________________ 11111k104l ____________________ 11111k104l ___________________

10. Conduita sociala

____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l _______

11. Evaluarea modului īn care copilul beneficiaza de drepturile* prevazute de Legea 272/2004

□ Dreptul la identitate-art.8.......... ..... ...... .......... ..... ...... .......... ..... ...... ............................

□ Dreptul de a pastra legaturi cu familia (nucleara/extinsa) si cu alte persoane fata de care minorul a dezvoltat legaturi de atasament -art.14:.......... ..... ...... .......... ..... ...... .......... ..... ...... .........

□ Dreptul la protejarea imaginii publice si a vietii intime -art.22.......... ..... ...... .......... ..... ...... ....

□ Dreptul la libertatea de exprimare, de gāndire, de religie -art.25, 23.......... ..... ...... .........................

□ Dreptul la libera asociere-art.26.......... ..... ...... .......... ..... ...... .......... ..... ...... ..................

□ Dreptul de a fi protejat īmpotriva oricaror forme de violenta, abuz, rele tratamente sau neglijenta si īmpotriva nerespectarii personalitatii si individualitatii sale-art.28, 85.......... ..... ...... .......... ..... ...... ..........

□ Dreptul de a creste alaturi de parintii sai-art.30.......... ..... ...... .......... ..... ...... .........................

□ Dreptul la educatie (art.47)____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____

□ Dreptul la sanatate, asistenta medicala si recuperare-art.43.......... ..... ...... .......... ..... ...... ....

□ Dreptul la īngrijire speciala pentru copiii cu handicap-art.46.......... ..... ...... .......... ..... ...... .....

□ Dreptul la protectie īmpotriva exploatarii, abuzului-art.87/99.......... ..... ...... .......... ..... ...... .....

□ Dreptul la odihna si vacanta-art.49.......... ..... ...... .......... ..... ...... .......... ..... ...... .............

□ Dreptul la protectie īmpotriva folosirii de stupefiante si substante psihotrope-art.88.......... ..... ......

□ Dreptul copilului de peste 14 ani de a ataca īn instante masurile de protectie speciala, instituite conf. Legii nr.272/2004, beneficiind de asistenta juridica gratuita-art.57.......... ..... ...... ............................

* unde se identifica probleme legate de exercitarea acestor drepturi bifati si detaliati la sectiunea Probleme Identificate!

12. Probleme identificate:

____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l _______________

13. Informatii suplimentare relevante:

____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l _

B. DATE DESPRE FAMILIA COPILULUI

1. Date despre parinti

2. Date despre frati/surori (nume si prenume, vārsta, locuiesc cu copilul sau nu, ocupatie etc.)

____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l _______

3. Relatiile din cadrul familiei:

a. maritale____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ___________________

b. parentale____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l __________________

c. altele____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l _

4. Bugetul familiei:

Veniturile familiei se constituie din: alocatia de stat (.......................), alocatia complementara/de sustinere (........................), alocatia pt. nou nascuti (.......................), indemnizatie de hrana pt. persoane cu HIV (.......................), ajutor pt. īncalzire (........................), ajutor social (......................), ajutor de somaj (........................), pensie (........................), salarii (............................),

altele (burse, bani din strainatate, ajutor de la ONG-uri, gospodarie, terenuri etc.) ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ______________

5. Date despre locuinta familiei:

apartament/ imobil, proprietatea parintilor lui a altei persoane, de stat

compus din ___________ camere ne/decomandate.

Conditiile locative sunt____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l _________

Restante la intretinere____________________ 11111k104l alte datorii ____________________ 11111k104l ____________________ 11111k104l

Aici locuiesc____________________ 11111k104l _____persoane ____________________ 11111k104l ____________________ 11111k104l ____

6. Alte Informatii relevante (probleme de sanatate, antecedente penale sau probleme legale prezente, conflicte īn comunitate, motivul plecarii īn strainatate etc.)

____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l _______

7. Probleme identificate:

____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l ____________________ 11111k104l _______________

6. Bugetul familiei persoanei de īngrijire:

Veniturile familiei se constituie din: alocatia de stat (.......................), alocatia complementara/de sustinere (........................), alocatia pt. nou nascuti (.......................), indemnizatie de hrana pt. persoane cu HIV (.......................), ajutor pt. īncalzire (........................), ajutor social (......................), ajutor de somaj (........................), pensie (........................), salarii (............................),

9. Probleme identificate:

Nota: Prezentul document reprezinta componenta din perspectiva sociala a procesului de evaluare detaliata a cazului.

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