The Puducherry Juvenile Justice (Care and Protection of Children) Rules, 2011 notified vide G. O. M.s. No. 27/2011-Wel. (SW-V), dated 6th September, 2011 shall stand repealed immediately on the publication of these rules provided that anything done or omitted to be done or order issued before such repeal shall in so far as it is not inconsistent with provisions of these rules, be construed to have been done or issued under the relevant provisions of these rules.
165PART–II] LA GAZETTE DE L'ETAT FORM 1 [Rules 8 (1), 8 (5)] SOCIAL BACKGROUND REPORT FIR/DD No. :
U/Sections :
Police Station :
Date & Time :
Name of I.O. :
Name of CWPO :
1. Name :
2. Father/Mother/Guardian's name :
3. Age/Date of Birth :
4. Address :
5. Religion-
(i) Hindu (OC/BC/SC/ST) :
(ii) Muslim/Christian/Others (pl. :
specify).
6. Whether the child is differently abled :
(i) Hearing Impairment :
(ii) Speech Impairment :
(iii) Physically disabled :
(iv) Mentally disabled :
(v) Others (please specify) :
166 LA GAZETTE DE L'ETAT [PART–II
7. Family Details:
Sl. Name and Age Sex Education Occupation Income Health History Addictions No. Relationship status of (if any) Mental Illness (if any)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
8. Reasons for leaving home :
9. Whether there is a history of involvement : Yes/No of family members in offences, if any.
10. Habits of the child:
A B
(i) Smoking (i) Watching TV/movies
(ii) Alcohol consumption (ii) Playing indoor/ outdoor games
(iii) Drug use (specify) (iii) Reading books
(iv) Gambling (iv) Drawing/painting/acting/singing
(v) Begging (v) Any other
(vi) Any other
11. Employment Details, if any :
12. Details of income utilization :
(i) Sent to family to meet family need : Yes/No
(ii) Used by self for : Yes/No
(a) For dress materials Yes/No
(b) For gambling Yes/No
(c) For alcohol Yes/No
(d) For drug Yes/No
(e) For smoking Yes/No
(f) Savings Yes/No
13. The details of education of the child-
(i) Illiterate :
(ii) Studied up to V Standard :
(iii) Studied above V Standard but below VIII Standard. :
167PART–II] LA GAZETTE DE L'ETAT
(iv) Studied above VIII Standard but :
below X Standard.
(v) Studied above X Standard :
14. The reason for leaving School-
(i) Failure in the class last studied :
(ii) Lack of interest in the School activities :
(iii) Indifferent attitude of the teachers :
(iv) Peer group influence :
(v) To earn and support the family :
(vi) Sudden demise of parents :
(vii) Bullying in School :
(viii) Rigid School atmosphere :
(ix) Absenteeism followed by running :
away from School.
(x) No age appropriate School nearby :
(xi) Abuse in School :
(xii) Humiliation in School :
(xiii) Corporal punishment :
(xiv) Medium of instruction :
(xv) Others (please specify) :
15. The details of the School in which studied last-
(i) Corporation/Municipal/Panchayat :
(ii) Government/SC Welfare School/ :
BC Welfare School.
(iii) Private management :
(iv) School under NCLP :
168 LA GAZETTE DE L'ETAT [PART–II
16. Vocational training, if any :
17. Majority of the friends are-
(i) Educated :
(ii) Illiterate :
(iii) The same age group :
(iv) Older in age :
(v) Younger in age :
(vi) Same sex :
(vii) Opposite sex :
(viii) Addicts :
(ix) With criminal background :
18. Whether the child has been subjected to any form of abuse: Yes/No
19. Whether the child is a victim of any : Yes/No offence.
20. Whether the child is used by any gangs : Yes/No or adults or group of adults or has been used for drug peddling:
21. Reason for alleged offence such as :
parental neglect or over protection, peer group influence etc.
22. Circumstances in which the child was :
apprehended.
23. Details of articles recovered from :
the child.
Sl.No. Type of Abuse Remarks 1 Verbal abuse – parents/siblings/ employers/others , (pl. specify) 2 Physical abuse(pl. specify) 3 Sexual abuse parents/siblings/ Employers/others (pl. specify) 4 Others (pl. specify) (please specify) (please specify) (please specify) (please specify) 169PART–II] LA GAZETTE DE L'ETAT
24. Alleged role of the child in the offence :
25. S u g g e s t i o n s o f C h i l d We l f a r e :
Police Officer.
Date : Signed by Place: Child Welfare Police Officer.
FORM–2 [Rule 8 (7)] UNDERTAKING BY THE PARENT OR GUARDIAN OR FIT PERSON GIVEN INTERIM CUSTODY PENDING INQUIRY Whereas I, ………......…… (Name), resident of House No.……., Street……….... . .……... .. . . . .. . . ,Village/Town………………………., District………..Union Territory……………..do hereby declare that I am willing to take charge of (name of the child)……………………..
aged……………. under the orders of the Board ……………………. subject to the following terms and conditions:
1. That I have annexed true, correct and authentic identification and address proof of myself.
2. That I undertake to produce him/her before the Board as and when required.
3. That I shall do my best for the welfare and education of the child as long as he/she remains in my charge and shall make proper provision for his/her maintenance.
4. That in the event of his/her illness, he/she shall have proper medical attention in the nearest hospital and a report of it followed by a fitness certificate shall be submitted before the Board.
5. That I shall do my best to ensure that the child will not be subjected to any form of abuse/ neglect or exploitation.
170 LA GAZETTE DE L'ETAT [PART–II
6. That if his/her conduct requires further supervision or care and protection, I shall at once inform the Board.
7. That if the child goes out of my charge or control, I shall immediately inform the Board.
Dated this the ……………………..day of ………………..20 Signature of person executing the Undertaking/Bond.
(Signed before me) Juvenile Justice Board.
FORM–3 [Rule 10 (1)(iii)] SUPERVISION ORDER When the child is placed under the care of a fit person/fit institution/ Probation Officer pending inquiry FIR/DD No. ………… of………… 20……….PS…………...
Whereas ..…………………. (name of the child) is alleged to have committed an offence and is placed under the care of (Name)..…………………......(address) …………………………………… on executing a bond by the said …………………………………. and the Board is satisfied that it is expedient to deal with the said child by making an order placing him/her under supervision.
It is hereby ordered that the said child be placed under the supervision of …………………………for a period of……………subject to the following conditions:
1. That the child shall reside at………………… for a period of…………..and shall be produced before the Board as and when directed.
2. That the child shall not be allowed to quit the district jurisdiction of …………..without the permission of the Board.
3. That the child shall not be allowed to associate with such person who shall negatively influence the child.
171PART–II] LA GAZETTE DE L'ETAT
4. That the person under whose care the child is placed shall arrange for the proper care, education and welfare of the child.
5. That the preventive measures will be taken by the person under whose care the child is placed to see that the child does not commit any offence punishable by any law in India.
6. That the child shall be prevented from taking narcotic drugs or psychotropic substances or any other intoxicants. The person under whose supervision the child is placed shall report any such act of the child to the Board.
Dated this the…………….day of……………………………. 20…………… (Signature) Principal Magistrate/Member Juvenile Justice Board.
Note: Additional conditions, if any, may be inserted by the Juvenile Justice Board.
FORM–4 [Rule 10 (1)(iv)] ORDER OF PLACING A CHILD IN CHILD CARE INSTITUTION PENDING INQUIRY To The Officer in-charge Whereas, on the…………day of…………..20……., ………….(Name of the child), son/daughter of……………………aged….……..,residing at ………………………………… alleged to be involved in FIR/DD No. ………………… PS……………………is ordered by the Juvenile Justice Board to be kept in the Child Care Institution (Observation Home/ Place of Safety) namely………… for a period of ……………………..
172 LA GAZETTE DE L'ETAT [PART–II This is to authorize and require you to receive the said child into your charge, and to keep him in the Child Care Institution (Observation Home/ Place of Safety)……………………………….. and to produce the child as and when directed by the Board, for the aforesaid order to be carried into execution according to law.
Next date of hearing……………………….
Given under my hand and the seal of Juvenile Justice Board On this the ………………….. day of ……………….. 20…………… (Signature) Principal Magistrate/Member, Juvenile Justice Board.
FORM–5 [Rule 10 (2)] ORDER FOR SOCIAL INVESTIGATION REPORT FIR No…………………………...…… U/Sections………………………...…..
Police Station………………………… To Probation Officer/Person in-charge of Voluntary or Non-Governmental Organization.
Whereas, ……...............…………(Name of the Child), son/daughter of……………. age……….residing at………………………………., has been produced before the Board.
You are hereby directed to enquire into the social antecedents, family background and circumstances of the alleged offence by the said child and submit your social investigation report on or before ……………….or within such time as allowed to you by the Board.
173PART–II] LA GAZETTE DE L'ETAT You are also hereby directed to consult an expert in child psychology, psychiatric treatment or counselling or any other expert for their expert opinion if necessary and submit such report along with your Social Investigation Report.
Dated this the ………….day of …………………20……………….
(Signature) Principal Magistrate/Member-Juvenile Justice Board.
FORM–6 [Rules 10 (9), 11 (2), 68 (1), 68 (3) (i)] SOCIAL INVESTIGATION REPORT FOR CHILDREN IN CONFLICT WITH LAW Sl. No………….
Submitted to the Juvenile Justice Board................................................
(address).
Probation Officer/ Voluntary/Non- Governmental Organization…………………… (Name of the person) FIR No……………………….……… Under sections………………….…… Police Station………………………..
Nature of offence alleged: Petty/Serious/Heinous
1. Name :
2. Age/Date/Year of Birth :
3. Sex :
4. Caste :
5. Religion :
6. Father's Name :
7. Mother's Name :
8. Guardian's Name :
174 LA GAZETTE DE L'ETAT [PART–II
9. Permanent Address :
10. Landmark of the address :
11. Address of last residence :
12. Contact No. of father/mother/ :
family member.
13. Whether the child is differently : Yes/No abled
(i) Hearing Impairment :
(ii) Speech Impairment :
(iii) Physically disabled :
(iv) Mentally disabled :
(v) Others (please specify) :
14. Family Details :
Sl. Name and Age Sex Education Occupation Income Health History Addictions No. Relationship status of (if any) Mental Illness (if any)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
15. If, the child or person is married, name, age and details of spouse and children:
....................................................................................................................
..................................................................................................
16. Relationship among the family members:
(i) Father and mother Cordial/ Non cordial/ Not known
(ii) Father and child Cordial/ Non cordial/ Not known
(iii) Mother and child Cordial/ Non cordial/ Not known
(iv) Father and siblings Cordial/ Non cordial/ Not known
(v) Mother and siblings Cordial/ Non cordial/ Not known
(vi) Child and siblings Cordial/ Non cordial/ Not known
(vii) Child and grandparents (paternal/maternal) Cordial/ Non cordial/ Not known 175PART–II] LA GAZETTE DE L'ETAT Sl.
No.
Relationship Nature of Crime Legal status of the case Arrest if any made Period of confinement Punishment awarded 1 Father 2 Step father 3 Mother 4 Step mother 5 Brother 6 Sister 7 Others (uncle/ aunty/ grandparents)
18. Attitude towards religion of child and family...............................
...............................................
19. Present living conditions........................................................
........................................................
20. Other factors of importance if any…………………………………
21. (i) Habits of the child (Tick as applicable):
(a) A Smoking (g) B Watching TV/movies
(b) Alcohol consumption (h) Playing indoor/ outdoor games
(c) Drug use (specify) (i) Reading books
(d) Gambling (j) Religious activities
(e) Begging (k) Drawing/painting/acting/singing
(f) Any other (l) Any other
(ii) Extra-curricular interests..........................................................
(iii) Outstanding characteristics and personality traits..................
22. C h i l d ' s o p i n i o n / r e a c t i o n t o wa r d s d i s c i p l i n e i n t h e home................................................................
23. Employment Details of the child, if any.....................................
24. Details of income utilization and manner of income utilization................................................................
17. History of involvement of family members in offences, if any:
176 LA GAZETTE DE L'ETAT [PART–II
25. Work record (reasons for leaving vocational interests, attitude towards job or employers)....................................
26. The details of education of the child:
(i) Illiterate
(ii) Studied up to V Standard
(iii) Studied above V Standard but below VIII Standard
(iv) Studied above VIII Standard but below X Standard
(v) Studied above X Standard
27. Attitude of class mates towards the child………......………
28. Attitude of teachers and classmates towards the child ..………
29. The reason for leaving School (tick Yes/No as applicable):
(i) Failure in the class last studied
(ii) Lack of interest in the School activities
(iii) Indifferent attitude of the teachers
(iv) Peer group influence
(v) To earn and support the family
(vi) Sudden demise of parents
(vii) Bullying in School
(viii) Rigid School atmosphere
(ix) Absenteeism followed by running away from School
(x) There is no age appropriate School nearby
(xi) Abuse in School
(xii) Humiliation in School
(xiii) Corporal punishment
(xiv) Medium of instruction
(xv) Others (please specify) 177PART–II] LA GAZETTE DE L'ETAT
30. The details of the School in which studied last:
(i) Corporation/Municipal/Panchayat
(ii) Government/SC Welfare School/BC Welfare School
(iii) Private management
(iv) School under NCLP
31. Vocational training, if any............................................................
32. Majority of the friends are
(i) Educated
(ii) Illiterate
(iii) The same age group
(iv) Older in age
(v) Younger in age
(vi) Same sex
(vii) Opposite sex
(viii) Addicts
(ix) With criminal background
33. Attitude of the child towards friends........................................
34. Attitude of friends towards the child........................................
35. Observations of neighbours towards the child ......................
........................................
36. Observations about neighborhood (to assess the influence of neighbourhood on the child)..................................................................
37. Whether the child has been subjected to any form of abuse, if applicable: Yes/No Sl.No Type of abuse Remarks 1 Verbal abuse – parents/siblings/employers/ others , (pl. specify) 2 Physical abuse(pl. specify) 3 Sexual abuse parents/siblings/ Employers/others (pl. specify) 4 Others (pl. specify) (please specify) (please specify) (please specify) (please specify) 178 LA GAZETTE DE L'ETAT [PART–II
38. Whether the child is a victim of any offence: Yes/No
39. Whether the child is used by any gangs or adults or group of adults or has been used for drug peddling: Yes/No
40. Does the child has tendency to run away from home, give details if any: Yes/No
41. Circumstances of apprehension of the child .......................
.....................................................................
42. Alleged role of the child in the offence.......................
............................................................................................
43. Reason for alleged offence:
(i) Parental neglect
(ii) Parental overprotection
(iii) Parents criminal behaviour
(iv) Parents influence (negative)
(v) Peer group influence
(vi) Bad habits (to buy drugs/alcohol)
(vii) Others (please specify)
44. Whether the child has been apprehended earlier for any offence, if yes give details including stay in a child care institution Yes/No ...........................................................................................................
...........................................................................................................
45. Previous institutional/case history and individual care plan, if any:
46. Physical appearance of the child:
47. Health condition of the child (including medical examination report, if applicable)
48. Mental condition of the child:
49. Any other remark 179PART–II] LA GAZETTE DE L'ETAT RESULT OF INQUIRY
1. Emotional factors.......................................................................
2. Physical condition......................................................................
3. Intelligence...................................................................................
4. Social and economic factors........................................................
5. Suggestive causes of the problems.............................................
6. Analysis of the case, including reasons/contributing factors for the offence.
7. Opinion of experts consulted......................................................
8. Recommendation regarding rehabilitation by Probation Officer/ Child Welfare Officer ............………………………………………………….
Place: Signature of the Probation Officer/Child Welfare Date : Officer/Social Worker Stamp and Seal where available.
FORM–7 [Rules 11 (3), 13 (7) (vi), 13 (8) (ii), 21(4), 21(17), 66 (6)(x), 73 I (3)] INDIVIDUAL CARE PLAN Child in Conflict with Law/Child in Need of Care and Protection (tick whichever is applicable) Name of Case Worker/Child Welfare Officer/Probation Officer…………………………………………………………… Date of preparing the ICP ………………………………………………… Case/Profile No……………of 20………………… FIR No :
U/Sections (Type of offence), applicable :
in case of Children in Conflict with Law.
Police Station :
180 LA GAZETTE DE L'ETAT [PART–II Address of the Board or the Committee :
Admission No. (if, child is in an institution) :
Date of Admission (if child is in an institution) :
Stay of the child (Fill as applicable) :
(i) Short term (up to six months) :
(ii) Medium Term (six months to one year) :
(iii) Long term (more than 1 year) :
A. PERSONAL DETAILS (to be provided by child/parent/both on admission of the child in the institution):
1. Name of the Child :
2. Age/Date of birth :
3. Sex: Male/Female :
4. Father's name :
5. Mother's name :
6. Nationality :
7. Religion :
8. Caste :
9. Language spoken :
10. Level of Education :
11. Details of Savings Account of the :
child, if any.
12. Details of child's earnings and belongings, :
if any.
13. Details of awards/rewards received by :
the child, if any.
181PART–II] LA GAZETTE DE L'ETAT
14. Based on the results of Case History Social Investigation report and interaction with the child, give details on following areas of concern and interventions required, if any:
Sl. Category Areas of Proposed No. concern Interventions
(1) (2) (3) (4) 1 Child's expectation from care and protection.
2 Health and nutrition needs 3 Emotional and psychological support needs.
4 Educational and Training needs 5 Leisure, creativity and play 6 Attachments and Inter-personal Relationships.
7 Religious beliefs 8 Self care and life skill training for Protection from all kinds of abuse, neglect and maltreatment.
9 Independent living skills 10 Any other such as significant experiences which may have impacted the development of the child like trafficking, domestic violence, parental neglect, bullying in school, etc. (Please specify).
B. PROGRESS REPORT OF THE CHILD (to be prepared every fortnight for first three months and thereafter to be prepared once a month):
[Note: Use different sheet for progress report]
1. Name of the Probation Officer/Case :
Worker/Child Welfare Officer.
2. Period of the report :
182 LA GAZETTE DE L'ETAT [PART–II
3. Admission No. :
4. Board or Committee :
5. Profile No. :
6. Name of the Child :
7. Stay of the child (Fill as applicable)
(iv) Short term (up to six months) :
(v) Medium Term (six months to one year) :
(vi) Long term (more than 1 year) :
8. Place of interview …………………….. Dates…………………….
9. General conduct and progress of the child during the period of the report.
10. Progress made with regard to proposed interventions as mentioned in point 14 of Part A of this Form:
Sl. Category Proposed Progress of No. Interventions the child
(1) (2) (3) (4) 1 Child's expectation from care and protection.
2 Health and nutrition needs 3 Emotional and psychological support needed.
4 Educational and training needs 5 Leisure, creativity and play 6 Attachments and Inter-personal relationships.
7 Religious beliefs 8 Self care and life skill training for protection from all kinds of abuse, neglect and maltreatment.
9 Independent living skills 10 Any other such as significant experiences which may have impacted the development of the child like trafficking, domestic violence, parental neglect, bullying in school, etc., (Please specify).
183PART–II] LA GAZETTE DE L'ETAT
11. Any proceedings before the Committee or Board or Children's Court.
(i) Variation of conditions of bond
(ii) Change of residence of the child
(iii) Other matters, if any
12. Period of supervision completed on……………………………… Result of supervision with remarks (if any)………………………………….
Name and Addresses of the parent or guardian or fit person under whose care the child is to live after the supervision is over………………… ……………………………………… Date of report........…………………Signature of the Probation Officer ………………… C. PRE-RELEASE REPORT (to be prepared 15 days prior to release)
1. Details of place of transfer and authority concerned responsible in the place of transfer/release.
2. Details of placement of the child in different institutions/family
3. Training undergone and skills acquired.
4. Last progress report of the child (to be attached, refer Part B)
5. Rehabilitation and restoration plan of the child (to be prepared with reference to progress reports of the child):
Sl. Category Rehabilitation and No. restoration plan of the child
(1) (2) (3) 1 Child's expectation from care and protection 2 Health and nutrition 3 Emotional and psychological 4 Educational and training 5 Leisure, creativity and play 6 Attachments and inter-personal relationships 7 Religious belief 8 Self care and life skill training for protection from all kinds of abuse, neglect and maltreatment.
9 Independent living skills 10 Any other 184 LA GAZETTE DE L'ETAT [PART–II
6. Date of release/transfer/repatriation………………………………
7. Requisition for escort if required……………………………......…
8. Identification Proof of escort such as Driving License, Aadhaar Card, etc.,………………......…
9. Recommended rehabilitation plan including possible placements/ sponsorships………………......…
10. Details of Probation Officer/Non-Governmental Organization for post-release follow-up ………………............…………………......……………
11. Memorandum of understanding with Non-Governmental Organisation identified for post-release follow-up (Attach a copy)………………......…………………......…
12. D e t a i l s o f s p o n s o r sh i p a g e n cy / i n d i v i d ua l sp o n s o r , if any………………......…
13. Memorandum of understanding between the sponsoring agency and individual sponsor (Attach a copy)………………......…………………......…
14. Medical examination report before release………………......…
15. Any other information………………......…………………......… D. POST-RELEASE/RESTORATION REPORT OF THE CHILD
1. Status of Bank Account : Closed/Transferred
2. Earnings and belongings of the child: handed : Yes/No over to the child or his parents/guardians-
3. First interaction report of the Probation :
Officer/Child Welfare Officer/Case Worker/ Social Worker/Non-Governmental Organisation identified for follow-up with the child post-release.
4. P r o g r e s s ma d e wi t h r e f e r e n c e t o :
Rehabilitation and Restoration Plan.
5. Family's behavior/attitude towards the child :
185PART–II] LA GAZETTE DE L'ETAT
6. Social milieu of the child, particularly :
attitude of neighbours/community.
7. How is the child using the skills acquired :
8. Whether the child has been admitted to a : Yes/No School or vocation? Give date and name of the School/Institute/any other agency.
9. Report of second and third follow-up :
interaction with the child after two months and six months respectively.
10. Efforts towards social mainstreaming and :
child's opinion/views about it.
11. Identity Cards and Compensation :
[Instruction: Please verify with the physical documents] Date : Signature of the Probation Officer/Child Welfare Officer, Place: Stamp and Seal where available FORM 8 [Rule 11(6)] UNDERTAKING/BOND TO BE EXECUTED BY A PARENT/ GUARDIAN/ /FIT PERSON IN WHOSE CARE A CHILD IN CONFLICT WITH LAW IS PLACED Whereas I, ……………………. being the parent, guardian, relative or fit person under whose care………………………..(name of the child) has been ordered to be placed by the Juvenile Justice Board………………………… having been directed by the said Board to execute an undertaking/bond with surety in the sum of `………../ IDENTITY CARDS Present status (Please tick whichever is applicable) Yes No Action taken Birth Certificate School certificate Caste certificate BPL Card Disability Certificate Immunization card Ration Card Adhaar Card Received compensation from Government Card 186 LA GAZETTE DE L'ETAT [PART–II (Rupees………………………………..……………) or without surety, I hereby bind myself to be responsible for the good behavior and well-being of the said ………………….and to observe the following conditions for a period of ………………… years with effect from …………………………...
1. That I shall not change my place of residence without giving previous intimation in writing to the Juvenile Justice Board through the Probation Officer;
2. That I shall not remove the said child from the limits of the jurisdiction of the Juvenile Justice Board without previously obtaining the written permission of the Board;
3. That I shall send the said child daily to school/to such vocation as is approved by the Board unless prevented from so doing by circumstances beyond control;
4. That I shall sincerely give effect to the Individual Care Plan with the help of the Probation Officer;
5. That I shall report immediately to the Board whenever so required by it and also produce the child before the Board as and when directed to do so;
6. That I shall produce the said child in my care before the Board, if he/she does not follow the orders of Board or his/her behavior is beyond my control;
7. That I shall report to the Board if the child goes out of my control or charge;
8. That I shall render all necessary assistance to the Probation Officer to enable him to carry out the duties of supervision;
In the event of my making default herein, I undertake to appear before the Board and bind myself to pay to Government the sum of `.……………../ (Rupees…………………………….).
Dated this ………………..day of ……………………………..20.
Signature of person executing the Undertaking/Bond.
(Signed before me) Principal Magistrate/ Member, Juvenile Justice Board.
187PART–II] LA GAZETTE DE L'ETAT Additional conditions, if any, by the Juvenile Justice Board may be entered numbering them properly; (Where a bond with sureties is to executed add) I/We …………………………..of ………………………(place of residence with full particulars) hereby declare myself/ourselves as surety/sureties for the aforesaid ……………........….. (name of the person executing the undertaking/bond) to adhere to the terms and conditions of this undertaking/bond. In case of ………………….(name of the person executing the bond) making fault therein, I/We hereby bind myself/ourselves jointly or severally to forfeit to government the sum of `………………/ (Rupees…………………………….) Dated this the……….. day of ….......………….20…………..in the presence of ………………………… Signature of Surety(ties) (Signed before me) Principal Magistrate/Member, Juvenile Justice Board.
FORM–9 [Rules 11(7)] PERSONAL BOND BY CHILD Whereas I, ……………………inhabitant of……………………..(give full particulars such as house number, road, village/town, tehsil, district, State, Union Territory) have been ordered to be sent back/restored by the Juvenile Justice Board …………………..under section ………..
of the Juvenile Justice (Care and Protection of Children) Act, 2015 on my entering into a personal bond to observe the conditions mentioned herein below. Now, therefore, I do solemnly promise to abide by these conditions during the period…………………………...
I hereby bind myself as follows:
1. That during the period………….. I shall not ordinarily leave the village/town/district to which I am sent and shall not ordinarily return to…………………….or go anywhere else beyond the said district without the prior permission of the Board;
2. That during the said period I shall attend School/vocational training in the Village/Town or in the said district to which I am sent;
188 LA GAZETTE DE L'ETAT [PART–II
3. That in case of my attending school/vocational training at any other place in the said district I shall keep the Board informed of my ordinary place of residence.
I hereby acknowledge that I am aware of the above conditions which have been read over/explained to me and that I accept the same.
(Signature or thumb impression of the child).
Certified that the conditions specified in the above order have been read over/explained to (Name of child) ……………………..and that he has accepted them as the conditions upon non-compliance of which he/she may be placed in safe custody.
Certified accordingly that the said child has been released/ relieved on (date) ………………….
Date : Signature Place: Principal Magistrate/Members, Juvenile Justice Board FORM–10 [Rules 11 (9), 68 (3) (xiii)] PERIODIC REPORT BY PROBATION OFFICER WHEN A CHILD IS RELEASED ON PROBATION FIR No……………. Police Station …………..U/Sections…………… In the matter of……………….. Vs…………………………………… Whereas (name of the child) ………………….., age…………, has on……. (date) been found to be a child in conflict with law, and has been placed under the care of …............…………… (parent/guardian/ fit person/fit facility) and under the supervision of …………………(name of Probation Officer).
189PART–II] LA GAZETTE DE L'ETAT Reg. No.:- Age (approximately):- Sex:- Male/Female/ Name:- Fathers Name:- Religion:- Education:- Vocational Training, if any Language(s) known:- Next Court date:- Employment, if any Date of admission (in case of fit person/fit facility) Case details and summary ................................................................................................................
................................................................................................................
................................................................................................................
1. Preliminary details:
(i) Visit Date: ………………./…………………../……………………
(ii) Name of Parent/Guardian…………………….......……………...…
(iii) Names of Other Adults Living in the Home and with whom the Probation Officer interacted:
2. Observations:
(i) Child's behaviors .…….......…………….....……………………
(ii) Physical and mental health status/needs of child and family…….......…………….....……………………………
(iii) Inter-personal relationship of the child with the family …….......…………….....……………………….........……
(iv) Inter-personal relationship with friends….........…....
...…………...............…
(v) Safety and supervision in the family ............……………………
(vi) Difficulties faced by the child......................……………………
(vii) Difficulties faced by the family ….....…..........……………………
(viii) Changes in the household ..….....................……...……………
(ix) Vocational training, if any being undertaken by the child……………………….
190 LA GAZETTE DE L'ETAT [PART–II
(x) Engagement of child in any anti-social activities or harmful activities (Examples could be exhibiting bullying behaviour, violent outbursts, destructions, self-harm, lying, defiance, impulsiveness, lack of empathy, sexually deviant actions etc.,) …………………………………………… ……………………
(xi) Time elapsed since last engagement in any anti-social behavior or harmful activities………………….
3. Visit to school/vocational training centre
(i) Name of the school/centre ...………………………………………
(ii) Name of the Teacher/Principal met………………………………
(iii) Any unusual behavior observed ………………………………...
(iv) Feedback received on the progress of the child………..……
(v) Attitude of the peers towards the child……………….....……
(vi) Attitude of the child towards the peers…....…………………
4. Visit to place of employment:
(i) Nature of work…....……………………....……………………....…
(ii) Working hours…....……………………....……………………....…
(iii) Attitude of the child towards work…....……………………....……
(iv) Violation of any labour laws, Low wages or wages being withheld, if observed and action taken against employer …....…………………
5. Did you spend time speaking privately with the child : Yes/No If no, give reasons:…....……………………....………....…………………… …....……………………....………....……………………..…....……………………
6. Progress made as per Rehabilitation and Restoration Plan under the Individual Care Plan (refer point 14 of form 7)…....……………………....… …....……………………....………....……………………..…....…………………… 191PART–II] LA GAZETTE DE L'ETAT
7. Recommendations for modifications in Rehabilitation and Restoration Plan under the Individual Care Plan, if any:
Prepared by: …....……………………....………....…………………… (Probation Officer …../.…./.… (date) Plan: Date of next visit: …………………… Action point if, any: ……………………………… Date : Signature Place: (Probation Officer) FORM 11 [Rule 12(1)] CASE MONITORING SHEET (Separate Sheet may be used in case there are more than one child) Juvenile Justice Board, District……………… Case No. .............................of.............................Case Name:
Police Station................................ Date...........................
U/S................................................. FIR/ GD/ DD No. ...........................
Name of Probation Officer...........
.......................................................
Name of Lawyer ........................... Name of IO.................................
(If, not represented provide Legal Name of Child Welfare Police Aid Lawyer) Officer......................................
NATURE OF OFFENCE PETTY (maximum punishment up to three years) SERIOUS (maximum punishment between three to seven years) HEINOUS (minimum punishment for seven years or more) 192 LA GAZETTE DE L'ETAT [PART–II PARTICULARS OF CHILD Name Parents/Guardian Present address Permanent with address
(1) (2) (3) (4) DATE AND TIME CHILD APPREHENDED DATE AND TIME OF FIRST PRODUCTION DATE OF MEDICAL EXAMINATION UNDER SECTION 54 Cr.P.C.
AGE DETERMINATION Age on the Date of offence Date of age determination Time taken for age determination Determination by Evidence Relied:
BOARD COURT Documents Medical CUSTODY OF THE CHILD In Observation Home/ Date of grant of bail Sent under supervision Place of Safety (Name of Institution) From....................
To.........................
193PART–II] LA GAZETTE DE L'ETAT PROGRESS OF INQUIRY (Time schedule for disposal of the case to be fixed on the first day of hearing) Place: signed by Date : Juvenile Justice Board FORM 12 [Rule 12(2)] QUARTERLY REPORT BY JUVENILE JUSTICE BOARD District Quarterly Report for the period: From…………… to…………… Details of JJB Steps to be taken Scheduled Date Actual Date Day 1: Social Background Report by Police (in Form No. 1) Dated……..
Day 1: Consideration of Bail Dated……..
Day 2: Age determination Dated……… Day 2: SIR (Form No.6) by Probation Officer Dated……….
Day 2: Section 173 CrPC Final Report by Police on completion of Investigation Dated……….
Day 3: Submission of Report on Provisions of further investigation, if any Dated………… Day 3: Section 251 CrPC Notice Dated………….
Day 4-6: Prosecution Evidence (From……… to…….)
Depending on the number of witnesses continuous dates may be fixed) Dated……..
Dated……… Dated……….
Day 7: Statement of child under Section 281 CrPC Dated………… Day 8: Defence Evidence Dated………..
Day 8: Individual Care Plan (In case of child in institutional care Individual Care Plan should be prepared within one month of admittance Dated………….
Day 9: Final Arguments Dated………… Day 10: Dispositional (Final) Order Dated………..
Day 11: Post Dispositional Review Dated………… Sl.No. Details Date of Appointment Training attended 1 Principal Magistrate 2 Member 1 3 Member 2 4 Member 3 Cr. PC Investigation Cr. PC Notice Cr. PC 194 LA GAZETTE DE L'ETAT [PART–II VISIT TO HOMES BY PRINCIPAL MAGISTRATE Date of visit:
Name and Address of Home :
Remark:
VISIT TO JAILS BY PRINCIPAL MAGISTRATE Date of Visit:
Whether any children found:
Action taken:
PENDENCY OF CASES FINAL ORDER Total number of final orders passed CASES INSTITUTED DURING THE QUARTER:
PETTY SERIOUS HEINOUS ΤΟΤΑL Number cases Number of Children Children granted bail Children sent to Observation Home Number of cases where preliminary reports were submitted in stipulated time Nature of case Old cases New cases Disposal Current pendency Less than 4 months 4 months to 6 months 6 months to 1 year More than 1 year Petty Serious Heinous Total Discharged Transfer to other JJB Abated on Death Repatriated to Foreign Country Transferred to Children’s Court Declared Compounded & file consigned Terminated under rule ……. (postproduction process) Acquitted/ Finding of commission in offence Nature of Dispositional Orders where child has committed Offence (mention the No. of orders) 195PART–II] LA GAZETTE DE L'ETAT COMPLAINT/SUGGESTION, IF ANY, RECEIVED AND ACTION TAKEN .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
REMARK/SUGGESTION BY BOARD
(a) Principal Magistrate
(b) Member : 1
(c) Member : 2 Principal Magistrate Member-1 Member-2 FORM–13 [Rules 13(8)(iv)] PERIODIC REVIEW OF A CHILD IN PLACE OF SAFETY FIR No……………………………….. PS…………..U/Sections In the matter of ……………………… vs. …………………………..
Whereas, (name of the child) …………………..,age……….., has on ………………(date) been found to be a child in conflict with law, and has been placed in.................................................. (Name of place of safety)- Date of admission to place of safety- Period of Review: From……………… to……………..
Name of the Child ….........……………………………………………… Father's Name….........…………………………………..........…………… Date of Admission….........………………………………….............…… Next date of hearing….........………………………………….............……
1. Case details and summary ….........………………………………….............……….........………………… ….........…………………………………..........................……….........… 196 LA GAZETTE DE L'ETAT [PART–II
2. Individual Care Plan (Attach a copy) ….........………………………………….............……….........………………… ….........………………………..…………..........................……….........…
3. Fortnightly progress made as per Individual Care Plan ….........………………………..…………..........................……….........… ….........………………………..…………..........................……….........…
4. Development of new interests ….........………………………..…………..........................……….........… ….........………………………..…………..........................……….........…
5. Psycho-social progress made by the child: (to be prepared with the help of a psycho-social expert)..……………………….............
I. Mental Status Evaluation:
(a) Appearance (Observed) - Possible descriptors: posture, clothes, grooming.
(b) Behavior (Observed) - Possible descriptors: Mannerisms, gestures, psychomotor activity, expression, eye contact, ability to follow commands/requests, compulsions II. Attitude (Observed) - Possible descriptors: Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, defensive.
III. Level of Consciousness (Observed) - Possible descriptors:
Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating.
IV. Orientation (Inquired) - Possible questions: "What is your full name?" "Where are we at (floor, building, city, county, and state)?"
"What is the full date today (date, month, year, day of the week, and season of the year)?" "How would you describe the situation we are in?"
197PART–II] LA GAZETTE DE L'ETAT V. Speech and Language (Observed) A. Quantity - Possible descriptors:
Talkative, spontaneous, quiet B. Rate - Possible descriptors: Fast, slow, normal, pressured. C. Volume (Tone).
VI. Mood (Inquired): A sustained state of inner feeling - Possible questions: "How are you feeling?" "Have you been discouraged/depressed/ low?" "Have you been energized/elated/high/out of control lately?" "Have you been angry/irritable?"
VII. Affect (Observed): An observed expression of inner feeling.
VIII. Thought Processes or Thought Form (Inquired/Observed):
logic, relevance, organization, flow and coherence of thought in response to general questioning during the interview. - Possible descriptors: goaldirected, circumstantial, loose associations, incoherent, evasive, perseveration.
IX. Thought Content (Inquired/Observed) X. Suicidality and Homicidality - Assessment XI. Insight (Inquired/Observed)- XII. Attention (Inquired/Observed)- XIII. Feelings of guilt/remorse: present/absent
6. Status of Current Educational/Vocational Rehabilitation Programme:
Motivation for the programme.............................................................
Level of cooperativeness.............................................................
Regularity......................................................................................
Quality of work/performance.............................................................
7. Impact of institutionalization on the person .................................
8. Approach to evaluation/periodic follow ups.................................
Willingness/ability to participate in treatment and rehabilitation in programs/facilities, consistent with public safety.
198 LA GAZETTE DE L'ETAT [PART–II Recommendations (including whether the person may be released or released on conditions or requires further institutionalization with justification) Date :
Place :
Name :
Designation :
Signature :
Recommendations/Findings: ……………… Signature/Seal.……………… Prepared by: ……………………………………..… (Probation Officer ….../.…./.… (date) FORM–14 [Rules 7 (1) (ii), 13 (8) (iv) (C) (cd), 19 (vi), 21 (20), 69(3) (viii), 73 E (2), 73 I (4), 73 J (1), 73 J (3)] REHABILITATION CARD FIR No./Case No.
U/Sections:
PS:
Nature of Offence: heinous, serious or petty (in case of child in conflict with law) Name of Probation Officer/Child Welfare Officer/Rehabilitationcum-Placement Officer:….....………………………………… Name of the child :
Age :
Sex :
Father's name :
Mother's name :
199PART–II] LA GAZETTE DE L'ETAT Indicators Child’s expectation from care and protection First Month Plan :
Outcome :
Second Month Plan :
Outcome :
Third Month Plan :
Outcome :
Fourth Month Plan :
Outcome :
Health and Nutrition First Month Plan :
Outcome :
Second Month Plan :
Outcome :
Third Month Plan :
Outcome :
Fourth Month Plan :
Outcome :
Admission No. :
Date of Admission :
Date of Provisional Release/ :
Release Services availed under Individual Care Plan - 200 LA GAZETTE DE L'ETAT [PART–II Emotional and psychological support needed First Month Plan :
Outcome :
Second Month Plan :
Outcome :
Third Month Plan :
Outcome :
Fourth Month Plan :
Outcome :
Education and Training First Month Plan :
Outcome :
Second Month Plan :
Outcome :
Third Month Plan :
Outcome :
Fourth Month Plan :
Outcome :
Leisure, creativity and play First Month Plan Outcome Second Month Plan Outcome Third Month Plan Outcome Fourth Month Plan Outcome Attachments and Inter-personal Relationships First Month Plan Outcome :
Second Month Plan Outcome :
Third Month Plan Outcome :
Fourth Month Plan Outcome :
201PART–II] LA GAZETTE DE L'ETAT Other services provided to the child, including compensation, other benefits etc.
Report of the detailed psychiatric assessment done by certified psychiatrist to be attached along with Rehabilitation Card:
Date of report and reason for conducting the said assessment (Provisional Release/Release/Any other).
2. Child's acceptance and understanding of his actions and its consequences.
Self Care and Life Skill Training for Protection from all kinds of abuse, neglect and maltreatment First Month Plan Outcome :
Second Month Plan Outcome :
Third Month Plan Outcome :
Fourth Month Plan Outcome :
Independent living skills First Month Plan Outcome :
Second Month Plan Outcome :
Third Month Plan Outcome :
Fourth Month Plan Outcome :
Any other such as significant experiences which may have impacted the development of the child like trafficking, domestic violence, parental neglect, bullying in school etc.
First Month Plan Outcome :
Second Month Plan Outcome :
Third Month Plan Outcome :
Fourth Month Plan Outcome :
etc.
202 LA GAZETTE DE L'ETAT [PART–II
3. Child's willingness to reform
4. Child's behavior and conduct
5. Offence committed by the child , if any reported by family or neighborhood, in case of a child in conflict with law who is not placed in a Child Care Institution.
Date : Signed by Place: JJB/CWC FORM–15 [Rule 19 (1) (i)] CASE SUMMARY MAINTAINED BY THE CHILD WELFARE COMMITTEE Case No…………………......………...
In Re……………………...........……...
Case Record…………………………...
1. Name of the child…………………………...…………………………...
2. Father's/Mother's/Guardian's name (if, available)………………………
3. Date of production of the child…………………….............……...
4. Name of person producing the child………………….……………
5. A list of all follow up dates (of the child, before the Committee)…………………………...
6. Orders passed by the CWC (tick as applicable):
(i) Declaration that child is in need of care and protection.
(ii) Finding on age of child
(iii) Medical Examination
(iv) Interim custody
(v) Undertaking (by parent, guardian or fit person, if applicable) 203PART–II] LA GAZETTE DE L'ETAT
(vi) Order appointing Case Worker & NGO etc.
(vii) Order for compensation/recovery of wages (if, applicable)
(viii) Transfer order
(ix) Final Order (concluding inquiry)
(x) Any other Order.
7. Medical Records including but not limited to age verification………………….
8. Social Investigation Report under Form 22………......………….
9. Individual Care Plan under Form 7…………………....................
10. Rehabilitation Card in Form 14…………….........................…….
11. Case History Form 43………………….………………….……………
12. All details, documents and records with regards to Sponsorship/Foster Care/Adoption Services (if, applicable).
Date : (Signatures) Child Welfare Committee.
Place:
FORM 16 [Rules 19 (1) (v), 22(2)] QUARTERLY REPORT BY CHILD WELFARE COMMITTEE District:
Quarterly Report for the period: From…………… to…………… Details of CWC.
Sl.No. Details Date of Appointment Training attended
1. Chairperson
2. Member 1
3. Member 2
4. Member 3
5. Member 4 204 LA GAZETTE DE L'ETAT [PART–II Details of Cases with CWC VISIT TO HOMES BY CHAIRPERSON/ MEMBERS Date of visit:
Name and Address of Home visited:
Remarks/Suggestions of the Committee……………..
Signature of Chairperson.
Seal FORM–17 [Rules 20 (2), 21 (25)] R E P O R T T O B E S U B M I T T E D A T THE TIME OF PRODUCTION OF CHILD BEFORE THE COMMITTEE Case No: ……………………….
Produced before the Child Welfare Committee: ……………………….
Date of production: ……………………….
Time of production: ……………………….
Place of production: ……………………….
1. Details of person who is producing the child:
(i) Name of the person ……………………….
(ii) Age ……………………….
Sl.
No.
Number of cases at the beginning of Quarter Number of cases received during the quarter Number of cases disposed of during the quarter Number of cases pending at the end of quarter Reasons for pendency FINAL ORDER Total number of final orders passed during the quarter Released to parent/guardian/ fit person/fit institution Transfer to other CWC Ordered to stay in CCI Repatriated to Foreign Country Declared legally free for adoption Ordered for foster care / sponsorship/ Aftercare Recommend to JJB for filing FIR Initiate process of compensati on to child, if eligible 205PART–II] LA GAZETTE DE L'ETAT
(iii) Sex ……………………….
(iv) Address ……………………….
(v) Contact Number ……………………….
(vi) Occupation/Designation ……………………….
(vii) Name of the organization/CCI/SAA
2. The child who is being produced:
(i) Name (if, any) ……………………….
(ii) Age (stated age/ age based on appearance)……………………….
(iii) Sex ……………………….
(iv) Identity mark/s ……………………….
(v) Language used by the child ……………………….
3. Details of parents/guardians (if, available):
(i) Name ……………………….
(ii) Age ………………………....
(iii) Address………………………
(iv) Contact Number……………
(v) Occupation…………………
4. Place where the child was found……………………….
5. The details of the person (if, any) with whom the child was found:
(i) Name……………………….
(ii) Age……………………...….
(iii) Address…………………….
(iv) Contact Number…………..
(v) Occupation………………...
6. Circumstances under which the child was found ……………………….
206 LA GAZETTE DE L'ETAT [PART–II
7. Allegation by the child of any offence/ abuse committed on the child in any manner……………………….
8. Physical condition of the child ……………………………………
9. Belongings of the child at the time of production ……………………………………
10. Date and time at which the child came to the CCI/ SAA……………………………………
11. Immediate efforts made to trace family of the child ……………………………………
12. Medical treatment, if provided to the child ……………………………………
13. Whether police has been informed ……………………...…… Signature/Thumb impression of the child Signature/Thumb impression of the person who produced the child Police-Local Police/Special Juvenile Police Unit/designated child welfare Police Officer/Railway Police/Probation Officers/any public servant/ Social Welfare Organization/Social Worker/Person in-charge CCI/ SAA/ any citizen/child himself/herself (fill as applicable).
FORM–18 [Rules 20 (5), 20 (9), 21 (26)] ORDER OF PLACEMENT OF A CHILD IN AN INSTITUTION (Children's Home/Fit Facility/SAA) Case No……………………………… To, The Officer-in-Charge, Whereas, on the ………………day of ………………20 ……………… (name of the child) ………………, son/daughter of……………… aged ………………………………residing at ……………… being in care and 207PART–II] LA GAZETTE DE L'ETAT protection under the Juvenile Justice (Care and Protection) Act, 2015 is ordered by the Child Welfare Committee ………………, to be kept in the Children's Home/SAA/Fit Facility………………for a period of ……………… This is to authorize and require you to receive the said child in your charge, and to keep him/her in the Children's Home/Fit Facility/ SAA……………… for the aforesaid order to be carried into execution according to law. The concerned official shall upload the details in case of an orphan or abandoned child in the Track Child/relevant Web Portal.
Given under my hand and the seal of Child Welfare Committee.
Dated this the……………… day of ……………… (Signature) Chairperson/ Member Child Welfare Committee.
Encl:
Copy of the orders, particulars of home and previous record, case history and individual care plan, as applicable:
FORM–19 [Rule 20(8)] ORDER FOR PLACEMENT OF CHILD UNDER THE CARE OF A PARENT, GUARDIAN OR FIT PERSON PENDING INQUIRY Case No. …….of ……………….20……………………… In Re………………… Whereas, (name of the child) …………………… has on …………….(date) been found to be in need of care and protection, and is placed under the care and supervision of (name)……………………..
(address)…………………..on executing a bond by the said …………………..
and the Committee is satisfied that it is expedient to deal with the said child by making an order placing him/her under supervision.
208 LA GAZETTE DE L'ETAT [PART–II Reason for the child being produced before the CWC…………………………………… ………………………………………………………………………………………………… It is hereby ordered that the said child be placed under the supervision of (name)……………………….. (address) ………………………… for a period of ………………………………………..
This shall be subject to the following conditions that:
1. the child along with the copies of the order and the bond, if any, executed by the said…………………………. shall be produced before the Committee as and when required by the person executing the bond
2. the child shall reside at ……………………….. for a period of ………………….
3. the child shall not be allowed to quit the district jurisdiction of …………………without the permission of the Committee.
4. the child shall go to school/ vocational training centre regularly. The child shall attend ……………….(name of school)/vocational training centre (if, already identified) at ………………….(address of school/vocational training centre).
5. the person under whose care the child is placed shall arrange for the proper care, education and welfare of the child.
6. the child shall not be allowed to associate with undesirable characters and shall be prevented from coming in conflict with law.
7. the child shall be prevented from taking narcotic drugs or psychotropic substances or any other intoxicants.
8. the directions given by the Committee from time to time, for the due observance of the conditions mentioned above, shall be carried out.
Dated this the…………………. day of ………………… 20……… (Signature) Chairperson/Member Child Welfare Committee.
Additional conditions, if any may be inserted by the Child Welfare Committee.
209PART–II] LA GAZETTE DE L'ETAT FORM–20 [Rule 20 (8), 21 (7)] UNDERTAKING BY THE PARENT OR GUARDIAN OR 'FIT PERSON' I …………………….resident of House No. ………………Street ………………………………………………Village/Town…………………District ……………………………… State ………………………………………………… do hereby declare that I am willing to take charge of (name of the child) ……………… Aged……. under the orders of the Child Welfare Committee…………………. subject to the following terms and conditions:
1. If his conduct is unsatisfactory I shall at once inform the Committee.
2. I shall do my best for the welfare and education of the said child as long as he remains in my charge and shall make proper provision for his maintenance.
3. In the event of his/her illness, he shall have proper medical attention in the nearest hospital.
4. I agree to adhere to the conditions that may be imposed by the Committee from time to time and also to keep the Committee informed about the compliance with the conditions.
5. I undertake to produce him/her before the Committee as and when required.
6. I shall inform the Committee immediately if, the child goes out of my charge or control. Dated this the ………………day of ………………..
Signature Signed before Child Welfare Committee FORM–21 [Rule 21 (3)] ORDER FOR SOCIAL INVESTIGATION REPORT OF CHILD IN NEED OF CARE AND PROTECTION To Child Welfare Officer/Social Worker/Case Worker/Person in-charge of Home/Representative of Non-Governmental Organization.
210 LA GAZETTE DE L'ETAT [PART–II Whereas, a report under section 31 (2) of the Juvenile Justice (Care and Protection of Children) Act, 2015 has been received from ….....………… in respect of (name of the child)……………, aged (approximate)……………, son/daughter of …………......…residing at……..................………, who has been produced before the Committee under section 31 of the Juvenile Justice (Care and Protection of Children) Act, 2015.
You are hereby directed to conduct Social Investigation as per Form 22 for the above child. You are directed to enquire into socio economic and family background of the said child.
You are directed to submit the Social Investigation Report on or before ……. (date).
Dated this the ………......……day of ………....……20…………… (Signature) Chairperson/Member Child Welfare Committee.
FORM–22 [Rule 21 (8)] SOCIAL INVSTIGATION REPORT FOR CHILD IN NEED OF CARE AND PROTECTION Sl. No……………………….
Produced before the Child Welfare Committee…………………..
Case No……………………………………… Social Investigation Report Prepared by: Child Welfare Officer/Social Worker/Case Worker/Person in-charge of Home/Representative of Non- Governmental Organization.
Details of child in need of care and protection:
1. Name :
2. Age/Date/Year of Birth :
3. Sex :
211PART–II] LA GAZETTE DE L'ETAT
4. Caste :
5. Religion :
6. Father's name :
7. Mother's name :
8. Guardian's name :
9. Permanent address :
10. Landmark of the address :
11. Address of last residence :
12. Contact no. of father/mother/ :
family member.
13. Whether the child is differently : Yes/No abled.
(i) Hearing impairment
(ii) Speech impairment
(iii) Physically disabled
(iv) Mentally disabled
(v) Others (please specify)
14. Family Details:
15. Relationship among the family members:
Sl.
No.
(1) Name and Relationship
(2) Age
(3) Sex
(4) Education
(5) Occupation
(6) Income
(7) Health status
(8) History of Mental Illness
(9) Addictions
(10)
(i) Father and mother Cordial/ Non cordial/ Not known
(ii) Father and child Cordial/ Non cordial/ Not known
(iii) Mother and child Cordial/ Non cordial/ Not known
(iv) Father and siblings Cordial/ Non cordial/ Not known
(v) Mother and siblings Cordial/ Non cordial/ Not known
(vi) Child and siblings Cordial/ Non cordial/ Not known
(vii) Child and relative Cordial/ Non cordial/ Not known 212 LA GAZETTE DE L'ETAT [PART–II
16. If, child is married, name, age and details of spouse and children…………………..
…………………..…………………..…………………..…………………..………
17. History of involvement of family members in offences, if any:
18. Attitude towards religion ..…………………………………………
19. Present living conditions..………………………………..…………
20. Other factors of importance if, any..………………………..........
21. Habits of the child
22. Extra-curricular interests …………………………………….……
23. Outstanding characteristics and personality traits …………………………….
24. The details of education of the child (tick as applicable):
(i) Illiterate
(ii) Studied up to V Standard
(iii) Studied above V Standard but below VIII Standard
(iv) Studied above VIII Standard but below X Standard
(v) Studied above X Standard Sl.
No.
Relationship Nature of Crime Legal status of the case Arrest if any Made Period of Confinement Punishment awarded 1 Father 2 Step father 3 Mother 4 Step mother 5 Brother 6 Sister 7 Others (uncle/ aunty/ grandparents)
(i) A Smoking
(i) B Watching TV/movies
(ii) Alcohol consumption (ii) Playing indoor/outdoor games
(iii) Drug use (specify) (iii) Reading books
(iv) Gambling (iv) Religious activities
(v) Begging (v) Drawing/painting/acting/singing
(vi) Any other (vi) Any other 213PART–II] LA GAZETTE DE L'ETAT
25. The details of the school in which studied last(tick as applicable):
(a) Corporation/Municipal/Panchayat
(b) Government/SC Welfare School/BC Welfare School
(c) Private management
(d) School under NCLP
26. Attitude of class mates towards the child ………………………… ……………………
27. Attitude of teachers and classmates towards the child…………………………
28. The reason for leaving School (tick as applicable)
(a) Failure in the class last studied
(b) Lack of interest in the School activities
(c) Indifferent attitude of the teachers
(d) Peer group influence
(e) To earn and support the family
(f) Sudden demise of parents
(g) Bullying in School
(h) Rigid School atmosphere
(i) Absenteeism followed by running away from School
(j) There is no appropriate level of school nearby
(k) Abuse in School
(l) Humiliation in School
(m) Corporal punishment
(n) Medium of instruction
(o) Others (please specify)
29. Vocational training, if any……………………..……………………
30. Employment Details, if any……………………….…….........……
31. Details of income utilization ……………………......……………
32. Work record (reasons for leaving vocational interests, attitude towards job or employers)……………… 214 LA GAZETTE DE L'ETAT [PART–II
33. Majority of the friends are (tick as applicable)
(a) Educated
(b) Illiterate
(c) The same age group
(d) Older in age
(e) Younger in age
(f) Same sex
(g) Opposite sex
(h) Addicts
(i) With criminal background
34. Attitude of the child towards friends ..……………………………
35. Attitude of friends towards the child..……………………………
36. Observation about neighbourhood (to assess the influence of neighbourhood on the child)..……………………………
37. Mental condition of the child: (Present and past)
38. Physical condition of the child: (Present and past)..……………………………
39. Health status of the child
(i) Respiratory disorders - present/not known/absent
(ii) Hearing impairment - present/not known/absent
(iii) Eye diseases- present/not known/absent
(iv) Dental disease- present/not known/absent
(v) Cardiac diseases- present/not known/absent
(vi) Skin disease-present/not known/absent
(vii) Sexually transmitted diseases - present/not known/absent
(viii) Neurological disorders- present/not known/absent
(ix) Mental handicap- present/not known/absent
(x) Physical handicap- present/not known/absent 215PART–II] LA GAZETTE DE L'ETAT
(xi) Urinary tract infections - present/not known/absent
(xii) Others (please specify)-
40. Whether the child has any addiction: Yes/No
41. With whom the child was staying prior to production before the Committee:
(i) Parent(s) - Mother/Father/Both
(ii) Siblings/Blood relative
(iii) Guardian(s) - Relationship
(iv) Friends
(v) On the street
(vi) Night shelter
(vii) Orphanages/Hostels/Similar Homes
(viii) Other (please specify)
42. History/tendency of the child to run away from home, if any……………………..
43. Parents attitude towards discipline in the home and child's reaction……………………..
44. Reasons for leaving the family (tick as applicable):
(i) Abuse by parent(s)/guardian(s)/stepparents(s)
(ii) In search of employment
(iii) Peer group influence
(iv) Incapacitation of parents
(v) Criminal behaviour of parents
(vi) Separation of Parents
(vii) Demise of parents
(viii) Poverty
(ix) Others (please specify)
45. Whether the child is a victim of any offence : Yes/No 216 LA GAZETTE DE L'ETAT [PART–II
46. Types of abuse met by the child (tick as applicable):
(i) Verbal abuse - parents/siblings/ employers/others (pl.
specify)
(ii) Physical abuse
(iii) Sexual abuse parents/siblings/employers/others (pl.
specify)
(iv) Others - parents/siblings/employers/others (pl. Specify)
47. Types of ill-treatment met by the child(tick as applicable).
(i) Denial of food - parents/siblings employers/other (pl. specify).
(ii) Beaten mercilessly - parents/Siblings/employers/other (pl. specify).
(iii) Caus ing in j u ry-p a ren t s / s ib l ings /emp lo ye r s /o the r (pl. specify).
(iv) Detention - parents/siblings/employers/other (pl. specify)
(v) Other(please specify) - parents/siblings/employers/others (pl. specify).
48. Exploitation faced by the child:
(i) Extracted work without payment
(ii) Little (low) wages with longer duration of work
(iii) Others (pl. specify)
49. Whether the child has been bought or sold or procured or trafficked for any purpose: Yes/No
50. Whether the child has been used for begging: Yes/No
51. Whether the child is used by any gangs or adults or group of adults or has been used for drug peddling: Yes/No
52. Previous institutional/case history and individual care plan, if any: ………………..
53. Details of perpetrator: (such as Name, Age, Contact number, Address details, Physical Characteristics, Relationship with the family, middle men involved, is there any other child from the same village who is abused/harassed/taken/sent by the perpetrator, how the child came in contact with the perpetrator)………………………..
………………………..………………………..…………...……………..………… 217PART–II] LA GAZETTE DE L'ETAT
54. Attitude of the child towards the perpetrator ………………………..
55. Whether the police have been informed……………...………….
56. Action taken, if any against the perpetrator ………………………..
57. Any other remark……………………….......................................
OBSERVATIONS OF INQUIRY
1. Emotional factors…………….......................................
2. Physical condition…………….......................................
3. Intelligence…………….......................................
4. Social and economic factors…………….......................................
5. Suggestive causes of the problems……………......................................
6. Analysis of the case, including reasons/contributing factors for the offence…………….......................................
7. Reasons for child's need for care and protection …………….......................................
8. Opinion of experts consulted….…………....……………………..
9. Psycho-social expert's assessment….…………....……………………
10. Religious factors………………………………………….
11. Risk analysis for the child to be restored to the family ….…………....……………………..
12. Previous institutional/case history and individual care plan, if any:….…………....……………………..
13. Recommendation of Child Welfare Officer/Case Worker/ Social Worker regarding psychological support, rehabilitation and reintegration of the child and suggested plan….…………....……………………..
Date : Signature Place: (Of the Person assigned) 218 LA GAZETTE DE L'ETAT [PART–II FORM–23 [Rule 21 (22)] APPLICATION FOR SURRENDER OF CHILD Date ….........…….
To Child Welfare Committee, District…………...…….
I/We………………(name of the applicant/s) …………….(relation with the child) of ………………(name of the child), aged about……….years, intend to surrender…………………..name of child) before this Child Welfare Committee as ………………………………………….................(reason/s for surrender).
I/we am/are fully conscious and making this application before this Child Welfare Committee. I have not been forced or unduly influenced by any one to take this decision of surrendering…………………….
(name of child). I shall have no objection if the child is given in adoption.
I am fully aware of the consequences of surrendering the child.
Full signature of the applicant(s)/ Thumb impression (if the CWC deems appropriate) Name and address.
…………………………….
Date…………… (Signature of the Chairperson/Member Time…………… Before whom such application is submitted) Place………….. Committee Member/s present:…………… 219PART–II] LA GAZETTE DE L'ETAT FORM–24 [Rule 21(22)] DEED OF SURRENDER Declaration by Person surrendering the child or children Case No …………..
In Re………………….
I/We, the undersigned …...................……………Family name/First name(s)…....……….....……............residing at, surrender the child (named)……….Aged………having date of birth…………………for the reason:…………....…………
(ii) I/we are surrendering my/our child or children on our own and without any coercion, compulsion, threat, payment, consideration, compensation of any kind;
(iii) I/we have been counselled and informed about the implication that I/we can withdraw our consent until 60th day of this surrender deed after which my/our consent will be irrevocable and I/we shall have no claim over the child or children.
(iv) I/we have been made aware of the implications of surrender and are conscious of the fact that after the 60th day from date of the surrender deed, the legal parent-child relationship between my/our child or children and me/us will be terminated.
(v) I/we understand that my/our child may be adopted by person(s) residing in India or abroad and give my/our consent for this purpose.
(vi) I/we understand that the adoption of my/our child will create a permanent parent-child relationship with the adoptive parent(s) and then cannot claim back the child.
(vii) I/we wish/do not wish (please tick whichever is applicable) my/our identity and address to be disclosed to my/our child when he/ she returns for root search.
220 LA GAZETTE DE L'ETAT [PART–II
(viii) I/we declare that I/We have read the above statements carefully and have fully understood the same.
Done at ................ on ................
[Signature or Thumb Impression of surrendering person(s)].
2. Declaration by Witnesses We the undersigned have witnessed the above surrender.
(a) Signature, Name and Address of the first witness ...........................................................................
...........................................................................
(b) Signature, Name and Address of the second witness ...........................................................................
...........................................................................
3. Certification of child welfare committee We hereby certify that the person and the witness(es) named or identified above appeared before me this date and signed this document in our presence.
Done at ................ on................
Signature and Seal of Members/Chairperson Child Welfare Committee.
FORM–25 [Rule 21 (29)] CERTIFICATE DECLARING THE CHILD LEGALLY FREE FOR ADOPTION
1. In exercise of the powers vested in the Child Welfare Committee………………….under section 38 of the Juvenile Justice (Care and Protection of Children) Act, 2015, child……………date of birth……………placed in the care of the Specialized Adoption Agency/ Child Care Institution (name and address) vide order no …………….
dated……………………. of this Committee, is hereby declared legally free for adoption on the basis of the following:
221PART–II] LA GAZETTE DE L'ETAT Inquiry report of the Probation Officer/Child Welfare Officer/ Social Worker/Case Worker/any other (as the case may be);
Deed of surrender executed by the biological parent(s) or the legal guardian of the child before this Committee on (date);
Declaration submitted by District Child Protection Unit and the Child Care Institution or Specialized Adoption Agency concerned to the effect that they have made restoration efforts as required under Section 40(1) of the Act, the Rules and Adoption Regulations, but, nobody has approached them for claiming the child as biological parents or legal guardian as on date of the said declaration.
2. This is to certify that:
The biological parent(s)/legal guardian, wherever available, has/ have been counselled and duly informed of the effects of their consent including the placement of the child or children in adoption which would result in the termination of the legal relationship between the child and his or her family of origin;
The biological parents/legal guardian have given their consent freely, in the required legal form, and the consents have not been induced by payment or compensation of any kind and the consent of the mother (where applicable), has been given only after the birth of the child.
The Specialized Adoption Agency/Child Care Institution to which the aforesaid child is entrusted shall post the photograph and other essential details of the child in the CARINGS and shall place such child in adoption as per the procedure laid down in the Act and Adoption Regulations.
Signature Chairperson and Members of the Committee.
(Seal of the Child Welfare Committee) Date :
Place:
To The Child Care Institution/Specialized Adoption Agency/District Child Protection Unit Concerned - for information and necessary action.
(Signature: and Seal) Date:……………… 222 LA GAZETTE DE L'ETAT [PART–II FORM–26 [Rule 22 (1)] CASE MONITORING SHEET FOR COMMITTEE CASE MONITORING SHEET (Separate Sheet may be used in case there are more than one child) Child Welfare Committee, District……………… Case No. .............................of.............................
Case Name:
Police Station ................................................
U/S...................................................................
Date......................................................... FIR/ GD/ DD No. .......................................
Name of Probation Officer............................... Name of IO ............................................
PARTICULARS OF CHILD Name Parents/ Guardian with Contact No.
Present address Permanent address DΑΤΕ ΑΝD ΤΙΜΕ CHILD PRODUCED BEFORE THE COMMITTEE DATE AND TIME OF FIRST PRODUCTION DATE OF MEDICAL EXAMINATION UNDER SECTION 54 Cr.P.C. (if any) ΑGΕ DΕΤΕRΜΙΝΑΤΙΟΝ Age on the Date of offence Date of age Determination Time taken for age determination Determination by Committee Evidence Relied: Documents Medical determination 223PART–II] LA GAZETTE DE L'ETAT PROGRESS OF ENQUIRY (Time schedule for disposal of the case to be fixed on the first day of hearing) Date : Signed by Place: Child Welfare Committee.
FORM–27 [Rule 23 (2) and 26 (2)] APPLICATION FOR REGISTRATION OF CHILD CARE INSTITUTION UNDER THE JUVENILE JUSTICE (CARE AND PROTECTION OF CHILDREN) ACT, 2015
1. Detail of Applicant/Institution which proposes to run the Child Care Institution:
(i) Type of Institution :
(ii) Name of the Institution/ :
Organization.
PLACEMENT ΟF ΤΗΕ CHILD In Children’s Home Sent under supervision (Name of Institution) From....................То.........................
Steps to be taken Scheduled Date Actual Date Age determination Dated……… Social Investigation Report (Form No.22) Dated……… Submission of Report on Provisions of further investigation, if any Dated……… Statement of Child Dated……… Individual Care Plan (In case of child in institutional care Individual Care Plan should be prepared within one month of admittance Dated……… Dispositional (Final) Order Dated……… Post Dispositional Review Dated……… 224 LA GAZETTE DE L'ETAT [PART–II
(iii) Registration number and date :
of Registration of the Institution/ Institution/Organization under the relevant Act (Annex-Relevant documents of registration and bye-laws, memorandum of association).
(iv) Period of validity to run the :
Institution/Organization.
(v) Complete address of the Applicant/ :
Institution/organization.
(vi) STD code/Telephone No. :
(vii) STD code/ Fax No. :
(viii) E-mail address :
(ix) Whether the organization is of :
all India character, if yes, give address of its branches, in other states.
(x) W h e t h e r t h e I n s t i t u t i o n / : Yes/No Organization had been denied registration earlier.
(xi) Ref. No. of application which :
resulted in denial of registration as CCI.
(a) Date of denial :
(b) Which department has denied :
the registration.
(xii) Reason for denial of registration :
as CCI.
2 . Details of the proposed Child :
Care Institution.
(i) Name of the proposed Child :
Care Institution.
225PART–II] LA GAZETTE DE L'ETAT
(ii) Typ e /Kind o f Chi ld Ca re :
Institution.
(iii) Complete address/location of :
proposed child Care Institution or organization.
(iv) STD code/Telephone No :
(v) STD code/Fax No :
(vi) E-mail address :
3. Connectivity (Name and Distancefrom the proposed Child Care Institution).
(i) Main Road :
(ii) Bus -stand :
(iii) Railway Station :
(iv) Any landmark :
4. Infrastructure
(i) No. of Rooms (mention with :
measurement).
(ii) No. of toilets (mention with :
measurement).
(iii) No. of Kitchen (mention with :
measurement). :
(iv) No. of sick room :
(v) Annex - Copy of blue print of the :
building (authentic sketch plan of building).
(vi) A r r a n g e me n t t o d e a l w i t h :
unforeseen disaster also mention the kind of arrangement made.
(i) Fire :
(ii) Earthquake :
226 LA GAZETTE DE L'ETAT [PART–II
(iii) Any other arrangement :
(iv) Arrangement of Drinking water :
(v) Arrangement to maintain sanitation :
and hygiene. :
(vi) Pest Control :
(vii) Waste disposal :
(viii) Storage area :
(ix) Any other arrangement :
(x) R e n t a g r e e m e n t / b u i l d i n g :
maintenance estimate (whichever is applicable) (Annex - copy of Rent agreement).
5. Capacity of the Institution/Organization—
(i) No. of children (0-6 years) :
present in the home, (if any).
(ii) No. of children (6-10 years) :
present in the home, (if any).
(iii) No. of children (11-15 years) :
present in the home, (if any).
(iv) No. of children (16-18 years) :
present in the home, (if any).
(v) No. of persons (18-21 years) :
present in the home, (if any) 6 . Whether the Child Welfare : Yes/No Committee/Juvenile Justice Board has been informed about the children being housed in the Institution.
7. Facilities Available :
(i) Education facility :
(ii) Health Checkup arrangement, :
frequency of checkup, type of checkups proposed to be done.
227PART–II] LA GAZETTE DE L'ETAT
(iii) Any other facility that shall impact :
on the overall development of the child.
8. Staffing :
(i) Detailed staff list :
(ii) Education and Experience of the staff :
(iii) Name of partner organizations :
(iv) Name of the chief functionary of :
the organization.
9. Background of the Applicant :
(Institution/Organization).
(i) Major activities of the organization :
in last two years.
a. (Annex copy of Annual Report) :
(ii) An updated list of members of the management committee/governing b o d y i n t h e e n c l o s e d f o r m a t (Annex - resolution of the annual meeting).
(iii) List of assets/infrastructure of the :
organization.
(iv) If, the organization registered under :
the Foreign Contribution (Regulation) Act, 1976 (Annex - certificate of registration).
(v) Detai ls of fo reign cont r ibut ion :
received during the last two years (Annex - relevant documents).
(vi) List of other sources of grant-in-aid :
funding (if any) with the name of the scheme/project, purpose amount, etc., (separately).
(vii) Details of existing Bank Account :
of the agency indicating branch code Account No.
228 LA GAZETTE DE L'ETAT [PART–II
(viii) Whether the agency agree to open :
a separate bank account for the grant proposed.
(ix) Annex - Photocopy of Accounts of :
last three years.
(i) Auditors report :
(ii) Income and expenditure account :
(iii) Receipt and payment account :
(iv) Balance sheet of the organization :
I have read and understood The Juvenile Justice (Care and Protection of Children) Act, 2015 and the Juvenile Justice (Care and Protection of Children) Rules, 2016.
I declare that no person associated with the organization has been previously convicted or has been involved in any immoral act or in any act of child abuse or employment of child labour and that the organization has not been blacklisted by the Central or the State Government at any point of time.
………………………….(Name of the Organization / Institution) has complied with all the requirements to be granted registration as a Child Care Institution under the Juvenile Justice (Care and Protection of Children) Act, 2015 and The Juvenile Justice (Care and Protection of Children) Rules, 2016.
I undertake to abide by all the conditions laid down by the Central/ State Act, Rules, Guidelines and Notifications in this regard.
Signature of the authorized signatory:
Name:
Designation:
Address District Date:
Office stamp:
Signature of:
Witness No. 1:
Witness No. 2:
229PART–II] LA GAZETTE DE L'ETAT FORM–28 [Rule 23 (3) and 26(4)] CERTIFICATE OF REGISTRATION (UNDER SECTION 41 OF THE JJ ACT) After perusal of the documents submitted as per Form 27 is granted registration No………….as a Child Care Institution under section 41(1) of the Juvenile Justice (Care and Protection of Children) Act, 2015 with effect from………….for a period of………….years.
The Institution which has the capacity of……...…….Children shall remain bound to follow the Juvenile Justice (Care and Protection of Children) Act, 2015, the Juvenile Justice (Care and Protection of Children) Rules, 2016 and regulations framed by the Central/ State Government from time to time.
Dated this the …………. day of …………. 20 ………….
(Signature) Seal Name and Designation …………………………………… FORM–29 [Rule 26(9)] MONTHLY REPORT SUBMITTED BY OPEN SHELTER TO DCPU
1. Name of the Open Shelter :
2. Name of the In-charge :
3. Registration No. :
4. Address of the Home :
5. Period of the Report :
6. Details of children available on :
230 LA GAZETTE DE L'ETAT [PART–II
7. Total number of children admitted during :
the month.
8. Total number of children in the Open :
Shelter on the last day of the month.
9. Total number of children who availed the :
facilities of the Open Shelter during the month.
10. Out of these the number of children who :
availed the services only during the day in the month.
Date : Signature Place: In charge of the Open Shelter Home.
FORM–30 [Rule 27(9)] HOME STUDY REPORT FOR PROSPECTIVE FOSTER PARENTS DATE OF REGISTRATION :
AADHAR CARD NO of PFP :
NAME OF THE SOCIAL WORKER :
DATE OF HOME VISIT :
Part-I of the format shall be filled up by the prospective foster parents and Part-II of the template shall be filled up by the Social Worker to submit an assessment report along with his/her observation about suitability of the prospective adoptive/foster parents.
Sl.
No.
Name of the child Father’s name Address of the Child, if available Date of admission Reason for admission Duration of stay Facilities Availed Produced before CWC (Yes / No) Remarks, if any 231PART–II] LA GAZETTE DE L'ETAT
PART-I : SELF ASSESSMENT A. Information about the prospective foster parents and their family background.
B. Family background information:
(1) Give a short description of social status and background of the prospective foster parents along with the following information.
(2) Please complete the following table with the names of each of your respective children (adopted and biological), their sex, educational status (kindergarten, elementary, etc.,) and dates of birth.
Particulars of the foster parents Full Name Date of birth & age Place of birth Complete Address with e-mail ID (Present & Permanent Address) Identity Proof Religion Language(s) Date of Marriage Present Educational Qualification Employment/occupation Name & Address of the present Employer/Business concern Annual Income Health Status Details about Parents of the Applicants Father Mother Name in full Age Nationality/Citizenship Occupation Previous occupation Presently residing with 232 LA GAZETTE DE L'ETAT [PART–II
(3) If, there are other members residing, please furnish the following information in respect of them.
(4) Please describe how you believe the foster care would affect the family members (grand parents, children, relatives and others).
C. Professional/Employment Details (Professional career details for last 5 years):
D. Financial Position: (Give a short description of your income from all sources such as savings, investments, expenditures and liabilities and debts along with supporting documents) ……………………………… E. Description of Home and Neighbourhood: (Describe the accommodation details and neighbourhood relationship).
(1) How many rooms do you have in your home and describe the play area available for the child…………………………………..
(2) Please describe the neighbourhood in which you reside, including any aspect that you believe makes it child-friendly…………………………… Name of the Child Sex Date of Birth Educational Status Name Nature of Relationship Age Gender Occupation Foster Father Organisation Employer Details (Name & Address) Job Title From To Foster Mother Organisation Employer Details (Name & Address) Job Title From To 233PART–II] LA GAZETTE DE L'ETAT F Attitude and Motivation for foster care:
(1) Please circle the term which best describes the reason why you wish to take a child in foster care, you may circle more than one option, if applicable.
(a) Provide a companion to your other children;
(b) Provide a child with a happy home;
(c) Other, please specify…………………….
(2) Please circle the statement which describes how you think the foster care arrangement will improve the lives of your other children, you may circle more than one, if applicable:
(a) They will be less lonely;
(b) They will learn to be more accommodating:
(c) They will become more empathetic;
(d) Not applicable as I have no other children;
(e) Other, please specify…………………….…………………..… G. Attitude of grandparents/extended family members, other relatives and significant others towards the foster care: (Give a short description about the opinion of other important persons towards foster care who would have impact in the child rearing process)…………………………………………… H. Anticipated Plans of the prospective foster parents for the child and rearing in the Family:
(1) Please describe how you will manage caring for the child and other life commitments such as work.
(2) Who will be responsible for caring for the child when you are at work, or absent from the familial home (domestic help, grandparents, spouse).
(3) Please describe your disciplinary approach to parenting.
(4) In case the foster child demonstrates adjustment difficulties, please describe the steps that you plan to take to ease his/her transition into the family?
234 LA GAZETTE DE L'ETAT [PART–II
(5) Would you be prepared to utilize family counseling if, the child continues to have difficulties adjusting?
(a) Yes
(b) No
(6) Would you be willing to support financially higher professional studies of the foster child
(a) Yes
(b) No I. Preparation and Training: (Give details about the counselling sessions the prospective foster parent(s) have undergone on foster care, child care, handling of needs of children, etc. and their capacity, training and/or experiences in parenting children with their special need, if any).
J. Health Status (Emotional and Physical): (Give details of the state of emotional and physical health status of the applicant(s), if any.
If, a family member suffers from a particular disease, condition or syndrome, describe how the family copes with it and how this might affect any proposed foster care.)
(1) Do you or your spouse suffer from any medical condition? If so, would you please provide details?
(2) Are you or your spouse currently being treated by a psychologist or psychiatrist?
(3) Are you currently taking any prescribed medication?
(4) Are there currently any children in your house being treated for a medical condition?
(5) Does your family have health and hospitalization insurance coverage for all family members?
Date :
Place: Signature of the Prospective Foster Parents.
235PART–II] LA GAZETTE DE L'ETAT
PART-II: ASSESSMENT REPORT OF THE SOCIAL WORKER (To be used by the Social Worker to prepare the assessment report) (The information/facts filled in the template shall be kept confidential by the agencies/authorities.)
1. Factual Assessment
(i) Have you verified the contents of the facts mentioned in Part-I of the template?
Yes/No
(ii) Are you satisfied about the facts mentioned in the documents vis-à-vis observation during interviews and visits?
Yes/No
2. Psychosocial Assessment:
2.1 Interaction with the prospective foster parents
(i) Have you interacted with the prospective foster parents individually and jointly?
(ii) Are the prospective foster parents well prepared for fostering the child?
2.2 Home visit findings
(i) When did you visit the home of the prospective foster parents?
Who were the members present during your visit?
(ii) Whom did you interact during the home visit?
(iii) Have you met any neighbour/relative? Give a detailed description about the interaction?
(iv) Whether the home environment is conducive for the child?
(v) Are the prospective foster parents well prepared for foster care?
(vi) Did the prospective foster parents have any doubt about parenting issues or any other issues? Have you cleared their doubts?
236 LA GAZETTE DE L'ETAT [PART–II
2.3 Interaction with the family members
(i) Have you interacted with other family members of the prospective foster parents? What is their opinion about the proposed foster care?
Are they positive about the foster care arrangement?
(ii) Are there any other family member(s) whom you could not interact but, they might have a larger role in the proposed foster care?
If so, how did you interact? Would you plan to take their views?
(iii) Have you interacted with older child/ren present in the home of the prospective foster parents? If yes, please give details.
(iv) Have you noticed any adverse remarks from the family members?
If so, how far those remarks may have an impact on the foster care process?
2.4 Financial capacity
(i) What is your opinion about the financial status of the prospective foster parents? Are they financially sound to welcome another member into their family?
(ii) Have you observed any financial situation which is hidden in the template?
(iii) Would you recommend any financial assistance to them?
2.5 Physical and emotional capacity
(i) Are the prospective foster parents in a good physical and emotional state to take care of a child?
(ii) Have you observed any physical or psychological issues with the prospective foster parents or any other family members that is going to affect the life of the upcoming child? If so, give details.
(iii) Are the prospective foster parents emotionally equipped enough to take care of a child?
3. Recommendation for foster care
3.1 Do you recommend the prospective foster parents for foster care? Put your views and rationale for recommending the prospective foster parents for foster care.
237PART–II] LA GAZETTE DE L'ETAT
3.2 In case, you do not recommend the prospective foster parents for foster care, cite appropriate reasons for taking such decision.
Date :
Place:
Signature, name, designation and official seal.
FORM–31 [Rule 27(4)] CHILD STUDY REPORT CHILD STUDY REPORT S. No. Item Response
1. Date of Assessment
2. Source of Referral
3. Photograph of the Child to be refreshed periodically Profile of the Child
4. Name of the Child
5. Date of Birth
6. Place of Birth
7. Age
8. Nationality
9. Religion
10. Education
11. Mother Tongue
12. Present Address
13. Aadhaar Card Number
14. Contact Details a)Landline b) Mobile
15. Placement history if the child is from institution a) Date of Placement b) Name and Permanent details of the child c) Reason for leaving the family The child has not been placed in adoption
16. Reason for placement if the child is from Community Mother or both parents in prison Parents are suffering from long term illness Dysfunctional family(eg substance abuse, domestic violence etc.)
Parents in process of separation Parents in process of legal custody dispute Natural disaster Others CHILD STUDY REPORT 238 LA GAZETTE DE L'ETAT [PART–II I …………………………….. Social Worker hereby certify that the information given in this form about child ……………………………..is correct.
Signature:
Name:
Designation:
Place:
Date :
FORM–32 [Rule 27(15)] ORDER OF FOSTER CARE PLACEMENT WITH A FAMILY OR GROUP FOSTER CARE The child (name and address) …………………………approximate age………........…. D/o. or S/o. Mr…………......…………….. and Mrs ……………………….is in need of care and protection of a family. Mr………….……......……. and Mrs………………………resident of (complete address and contact numbers) ……………………………… are declared fit for foster-care placement of the child after considering the Individual Care Plan, Child Study Report and Home Study Report.
15. Placement history if, the child is from institution a) Date of Placement b) Name and Permanent details of the child c) Reason for leaving the family The child has not been placed in adoption
16. Reason for placement if, the child is from Community Mother or both parents in prison Parents are suffering from long term illness Dysfunctional family(e.g. substance abuse, domestic violence etc.)
Parents in process of separation Parents in process of legal custody dispute Natural disaster Others 239PART–II] LA GAZETTE DE L'ETAT OR Child Care Institution (Name and address) …………………………… is declared fit for foster-care placement of the child after considering the Individual Care Plan and Child Study Report.
The child (name)……………………………………is placed in foster care for a period of……………………………………under the supervision of the aforesaid Child Welfare Officer/Social Worker (name and contact)…………………………………… Date : Chairperson/Member Place: Child Welfare Committee FORM–33 [Rule 27(16)] UNDERTAKING BY THE FOSTER FAMILY/GROUP FOSTER CARE ORGANISATION I/We……………………………………resident(s) of House No.
……………………………………Street……………………………………Village/ Town……………………………………District……………………………………State ……………………………………/care giver associated with foster care home run by……………………………………organization at …………………… ……………………………………………(address), do hereby declare that I/ We am/are willing to take charge of (name of the child ……………………………………Aged …………..under the orders of the Child Welfare Committee ……………………subject to the following terms and conditions:
(i) If, the conduct of the child is unsatisfactory I/we shall at once inform the Committee.
240 LA GAZETTE DE L'ETAT [PART–II
(ii) I/We shall do my/our best for the welfare and education of the said child as long as he remains in my charge and shall make proper provision for his maintenance.
(iii) In the event of his illness, he shall have proper medical attention in the nearest hospital and a report of it followed by a fitness certificate shall be submitted before the Committee.
(iv) I/We shall inform the Committee about any change of address.
(v) I/We shall do my best to ensure that the child will not be subjected to any form of abuse.
(vi) I/We agree to adhere to the conditions laid by the Committee.
(vii) I/We undertake to produce him before the Committee as and when required.
(viii) I/We undertake to inform the Committee immediately if the child goes out of my charge or control.
Dated this the……………….day of ……………………………..
Signature and address of 2 witnesses Signature of Applicant(s) (Signed before me) Chairperson/Member, Child Welfare Committee.
FORM–34 [Rule 27(17)] RECORD OF A CHILD IN FOSTER CARE
(a) Case No……………..
(b) Name of the Child……………..……………..
(c) Age……………..
(d) Gender……………..……………..……………..
241PART–II] LA GAZETTE DE L'ETAT
(e) Name and address of the Child Care Institution, if any from where the child has been given for foster care……………..……………..
(f) Individual Care Plan
(g) Any other source of referral……………..……………..
(h) Details of the child placed in foster care including Photograph of the child, foster care giver/parent, biological parents, if available……………..……………..
(i) Details of the placement - individual or group including date and period of placement
(j) Home Study Report of the biological family, where applicable with photograph
(k) Home Study report of the foster family- individual or group care, with photograph
(l) Child Study Report
(m) Address of the Child Welfare Committee
(n) Particulars of the order of the Committee placing the child in foster care
(o) Record (number and significant details) of each visit with the child, foster family, Biological family, if available and child's school
(p) Record of all reviews of the placement including observations, extent and quality of compliance with Care Plan, child's developmental milestones, child's academic progress, and any changes in family environment
(q) In the case of extension or termination of the placement, record of date and reason for termination
(r) Date of the child being handed over to the foster family:
(s) Financial assistance provided, if any
(t) Name of the Case Worker appointed Date :
Place:
242 LA GAZETTE DE L'ETAT [PART–II FORM–35 [Rule 27(18)] MONTHLY INSPECTION OF FOSTER FAMILIES/ GROUP FOSTER CARE (Fill as applicable) Date of Visit:
(a) Name :
(b) Date of Birth and Age :
(c) Gender :
(d) Date of Placement :
1. Details of Foster Parents :
(a) Name of Foster Parents :
(b) Address :
(c) Contact details
(i) Landline
(ii) Mobile :
(d) Aadhaar Card Number :
(e) Photograph of Parents :
(Affix recent photo) (Affix recent photo) (Affix recent photo) 243PART–II] LA GAZETTE DE L'ETAT
3. Interaction with the Foster Child:
(a) Child’s experience being part of the family (with reference to whether the child is properly cared for – physical, emotional and health) describe
(i) Health Indicators a) Present Health Status b) Any record of Illness c) Any other treatment that the child is undergoing
(ii) Emotional Happy and well-adjusted In process of adjusting maladjusted
(b) How is the child performing in his studies?
(i) check in relation with the grades/marks the child achieved in previous examinations,
(ii) Foster parents have regular conversations with the child regarding his/her studies, extra curriculal activities
(iii) Do they attend PTA meetings?
Yes No Sometimes Yes No Sometimes
(c) i) The amount of time parents (foster) spend with the child either alone or together with their own children.
ii) How do they spend time together as a family and for what?
iii) Does the foster child share with the foster parent’s problems he /she is facing either at home, school in the neighbourhood or emotionally feeling not happy?
Having conversations Dining Playing Watching TV Going to school Doing homework together Others (specify) Yes No Sometimes
(d) Does the child get support from foster parents’ children?
( do they mutually help each other) Yes No Sometimes 244 LA GAZETTE DE L'ETAT [PART–II
5. Interaction with Foster Parents:
(e) Has there been any incident that made the foster child feel discriminated against?
Yes No Sometimes
(f) Has there been any incident/incidents that made you uncomfortable?
i) The way a foster parent/older sibling/any other member touched you.
ii)The conversations foster parents/older siblings/any other member had with you iii) Any materials- visuals, printed you were made to watch or read iv) Were you at any time sexually assaulted or abused?* *if the answers are “yes” immediate steps should be taken to remove the child and send to a place of safety and support the child with medical and psycho-social therapy.
** Actions to be taken against the foster carers or parents according to the procedures laid down.
*** Is similar treatment being meted out to their biological child also? Then the biological child should also be treated as a child in need of care and protection and appropriate action may be taken.
Yes No Yes No Yes No Yes No
(g) Whether the child keeps in contact with his/her family of origin (by telephone, letters, visits). Specify Yes No
(h) Have you been beaten by the foster parent at any time? Yes No
(i) Have you been spoken to in a manner that you felt humiliated?
Yes No
(j) Are you made to do household chores? Yes No
(k) Do the biological children of the foster parents made to do the same household chores?
Yes No
(a) Parent’s impressions about the behavior (emotional well-being) of the child in the family Happy and well-adjusted In process of adjusting Maladjusted No 245PART–II] LA GAZETTE DE L'ETAT
(b) Perception about his/her adjustment with the household and with other members in the family Happy and well-adjusted In process of adjusting Maladjusted
(c) How do you discipline the child? Reason with the child Scolding , Chastise Beat the child Other Methods (Specify)
(d) What are the behavior traits that are of concern and how do you as parents deal with them?
Lack of co-operation Lack of Adjustment Introvert Aggressive Not Communicative Any Other
(e) Do you spend time together with the foster child and biological children? Describe.
Yes No Sometimes
(f) Views on the progress of Child’s education and other talents i) Child is faring well in school ii) If the child is not faring well in school do you seek to find out the reasons a)from the child b) the school teacher iii) Do you attend PTA meetings?
Yes No Yes No Yes No Sometimes
(g) Do the foster parents consult the child while taking decisions on behalf of him/her?
Yes No Sometimes
(h) How does the child show his approval/disapproval to the foster parent’s decisions?? Accept the decision with happiness Accept the decisions but unhappy Refuse to accept the decision and shows aggressive behavior)
(i) Are the foster parents aware of the social networks of the child?
Yes No
(j) Views on child’s social relationship with the neighbors, school friends and teachers.
Good and regular interaction Periodic Interactions
(k) What is their plan for the child?(To be noted down)
(l) Does the foster child maintain the contact with his/her family of origin? (by telephone, letters, visits). Specify Yes No Sometimes
(m) Who maintains the bank account of the foster child as a parent?
246 LA GAZETTE DE L'ETAT [PART–II
(b) Perception about his/her adjustment with the household and with other members in the family Happy and well-adjusted In process of adjusting Maladjusted
(c) How do you discipline the child? Reason with the child Scolding , Chastise Beat the child Other Methods (Specify)
(d) What are the behavior traits that are of concern and how do you as parents deal with them?
Lack of co-operation Lack of Adjustment Introvert Aggressive Not Communicative Any Other
(e) Do you spend time together with the foster child and biological children? Describe.
Yes No Sometimes
(f) Views on the progress of Child’s education and other talents i) Child is faring well in school ii) If the child is not faring well in school do you seek to find out the reasons a)from the child b) the school teacher iii) Do you attend PTA meetings?
Yes No Yes No Yes No Sometimes
(g) Do the foster parents consult the child while taking decisions on behalf of him/her?
Yes No Sometimes
(h) How does the child show his approval/disapproval to the foster parent’s decisions?? Accept the decision with happiness Accept the decisions but unhappy Refuse to accept the decision and shows aggressive behavior)
(i) Are the foster parents aware of the social networks of the child?
Yes No
(j) Views on child’s social relationship with the neighbors, school friends and teachers.
Good and regular interaction Periodic Interactions
(k) What is their plan for the child?(To be noted down)
(l) Does the foster child maintain the contact with his/her family of origin? (by telephone, letters, visits). Specify Yes No Sometimes
(m) Who maintains the bank account of the foster child as a parent?
6. Interaction with biological children of the Foster Parents:
(a) The things they do together with the foster child Dining Playing Watching TV Going to school Doing homework together
(b) Do they have quarrels or fights between themselves and the foster child? If yes, how often, on what issues, and how do they resolve it. Please note down.
Yes No Sometimes
(c) How do you feel when your parents show love, affection and care to the foster child?
Happy Unhappy Angry Jealous
7. Interaction with the School Teachers:
(a) Information about the academic performance of the child in the school (verify with progress cards to see if the child has shown any progress) Good Fair Satisfactory Poor
(b) Teacher’s observation: if the child has adjusted to his/her foster parents Happy and well-adjusted In process of adjusting Maladjusted
(c) Do the foster parents attend parent-teacher meetings?
Yes No Sometimes
(d) Do they seem interested in the child’s studies?(by enquiring of his academic achievements, his relationship with teachers and classmates) Yes No Indifferent
(e) Observation on child’s behavior in the school ( his relationship with teachers, classmates) Happy and well-adjusted In process of adjusting Maladjusted
(f) Any concerns of the child in the school. If yes, give details if, the child has adjusted to 247PART–II] LA GAZETTE DE L'ETAT
(a) Information about the academic performance of the child in the school (verify with progress cards to see if the child has shown any progress) Good Fair Satisfactory Poor
(b) Teacher’s observation: if the child has adjusted to his/her foster parents Happy and well-adjusted In process of adjusting Maladjusted
(c) Do the foster parents attend parent-teacher meetings?
Yes No Sometimes
(d) Do they seem interested in the child’s studies?(by enquiring of his academic achievements, his relationship with teachers and classmates) Yes No Indifferent
(e) Observation on child’s behavior in the school ( his relationship with teachers, classmates) Happy and well-adjusted In process of adjusting Maladjusted
(f) Any concerns of the child in the school. If yes, give details
8. Interaction with Parents of Origin:
(a) Have the parents of origin maintained contact with their child (by telephone calls, letters, and visits?
How frequently?
Yes No Sometimes
(b) Was the child happy to meet them? Yes No Upset while meeting them
(c) Did the child raise any issues with regard to his or her foster carers/parents/family with them?
Yes No
(d) Do they have any interaction with the foster family regarding the wellbeing of the child?
Yes No Sometimes
(e) The family’s status to receive back the child Family is interested and in a position to receive back the child.
Family is interested but not in a position to receive back the child.
Family is not interested to receive back the child
(f) Received any support from the government or any other agency in helping them to receive back the child from the foster carers(If yes, give details) Yes No
9. Interaction with Neighbours:
(a) Knowledge about the neighbor fostering a child. Yes No
(b) Information about the attitude and behavior of the foster family towards the child. Positive and Happy Indifferent Attitude Negative Attitude Misbehavior towards foster children
(c) Observed any quarrel or issues between the family members and foster child or between neighborhood and the foster child ( if yes, give detail) Yes No Prepared by Signatures Dated this the……………….. day of………………… Government or any 248 LA GAZETTE DE L'ETAT [PART–II FORM–36 [Rule 28(5)] ORDER OF SPONSORSHIP PLACEMENT The child (name and address)…...................……..........………… age…………………. D/o. or S/o. Mr ……………………….……. and/or Mrs…...................……..........…………has been identified as a child needing sponsorship support for education/ health/ nutrition/ other developmental needs…………………………please specify). The District Child Protection Unit is hereby directed to release Rs………………………..per month/ Rs……………as one time sponsorship support to the said child for a period of ………………………(days/month) and carryout necessary follow up and for the said purpose shall open a bank account in the name of the child………………… to be operated by …………………………… Date : Children's Court/Principal Magistrate, Place: Juvenile Justice Board/Chairperson/Member, Child Welfare Committee.
FORM–37 [Rule 29(2)] ORDER OF AFTER CARE PLACEMENT The child (name) ……………….....…………….…. D/o. or S/o.
…………………………….…. has/will be completing 18 years of age on (date) ……………………….………. She/he is still in need of care and protection for the purpose of rehabilitation and reintegration and specifically for ………..….. (specify the purpose). She/he is placed in (name of organization) ………………..…. for providing aftercare.
The In-charge of the Organization is directed to admit the child and provide all possible opportunities for her/his rehabilitation and reintegration in its truest sense. The person shall be provided all these opportunities maximum till the age of 21 years only or till reintegration in the society, whichever is earlier. The In-charge will send half yearly report on the status of the child/youth to the Child Welfare Committee.
249PART–II] LA GAZETTE DE L'ETAT The District Child Protection Unit is hereby directed to release `…………per month towards after-care support to the said person for a period of ………… (days/month) and carryout necessary follow up and for the said purpose shall open a Bank Account in the name of the person………… Date : Children's Court/Principal Magistrate, Place: Juvenile Justice Board/Chairperson/Member, Child Welfare Committee.
Copy to:
District Child Protection Unit or concerned Department of the Government.
FORM–38 [Rule 31(2)] APPLICATION FOR FIT FACILITY INCLUDING GROUP FOSTER CARE
1. Detail of Institution/ Agency/ Organization which seeks recognition as fit facility
1.a Name of the Institution /Agency/ Organization
1.b Registration number and date of Registration of the Institution/ Organization under the relevant Act (Annex- Relevant documents of registration, bye-laws, memorandum of association)
1. c Complete address of the Applicant/ Institution/Organization
1.d STD code/ Telephone No.
1.e STD code Fax No.
1.f E-mail address
1.g Whether the Organization is of all India character, if yes, give address of its branches, in other states
1.h If the Institution had been denied recognition earlier? If, yes
(i) Reference No. of application leading to denial of recognition
(ii) Date of denial
(iii) Who had denied the recognition
(iv) Reason for denial of recognition
2. Details of the proposed fit facility:
2.a Complete address/ location of proposed Fit Facility
2.b STD code/ Telephone No.
2.c STD code Fax No.
2.d E-mail
3. Connectivity (Name and Distance from the proposed Fit Facility):
3.a Main Road
3.b Bus –Stand
3.c Railway Station
3.d Any landmark 250 LA GAZETTE DE L'ETAT [ P ART–II
4. Infrastructure:
4.a No. of Rooms (mention with measurement)
4.b No. of Toilets (mention with measurement)
4.c No. of Kitchens (mention with measurement)
4.d No. of Sick room
4.e Annex -Copy of blue print of the building (authentic sketch plan of building)
4.f Arrangement to deal with unforeseen disaster also mention the kind of arrangement made:
(i) Fire
(ii) Earth quake
(iii) Any other arrangement
4.g Arrangement of Drinking water Annex-Certified from public health engineering (PHE) Department.
4.h Arrangement to maintain sanitation and hygiene:
(i) Pest Control
(ii) Waste disposal
(iii) Storage area
(iv) Any other arrangement
4.i Rent agreement/ building maintenance estimate (whichever is applicable) (Annex- copy of Rent agreement)
5. Capacity of the Fit Facility
6. Facilities Available (would depend on the purpose for which recognition as fit facility is to be given)
6.c Any other facility that shall impact on the overall development of the child
7. Staffing
7.a Detailed staff list
7.b Name of partner organizations
8. Background of the Applicant
8.a Major activities of the organization in last two years
8.b An updated list of members of the management committee/ governing body in the enclosed format (Annex- resolution of the annual meeting)
8.c List of assets/ infrastructure of the organization
8.d If the organization is registered under the Foreign Contribution (Regulation) Act, 1976 (Annex – certificate of registration)
8.e Details of foreign contribution received last two years (Annex- relevant documents)
8.f List of other sources of grant- in – aid funding (if any )with the name of the scheme / project , purpose amount, etc. (separately)
8.g Details of existing bank account of the agency indicating branch code Account No.
251PART–II] LA GAZETTE DE L'ETAT I have read and understood The Juvenile Justice (Care and Protection of Children Act), 2015; and the Juvenile Justice (Care and Protection of Children) Rules, 2016.
………………………………..(Name of the Organization/Institution) has complied with all the requirements to be granted recognition as a Fit Facility under the Juvenile Justice (Care and Protection of Children) Act, 2015 and the Juvenile Justice (Care and Protection of Children) Rules, 2016.
I declare that no person associated with the organization has been previously convicted or has been involved in any immoral act or in any act of child abuse or employment of child labour or an offence involving moral turpitude and that the organization has not been blacklisted by the Central or the State Government at any point of time.
I undertake to abide by all the conditions laid down by the Central Act, Rules, Guidelines and Notifications in this regard.
I undertake to abide by the orders passed by the Juvenile Justice Board or the Child Welfare Committee from time to time.
Dated this the ………………….day of ………………….
Signature of the authorized signatory:
Name:
Designation:
Address:
District:
Date:
Office stamp:
Signature of:
Witness No.1: ……………………………… Witness No.2: ………………………………
8.h Whether the agency agrees to open a separate Bank Account for the grant proposed
8.i Annex - Photocopy of Accounts of last three years:
(i) Auditors report
(ii) Income and expenditure account
(iii) Receipt and payment account
(iv) Balance sheet of the organization.
252 LA GAZETTE DE L'ETAT [PART–II FORM–39 [Rule 31(4)] CERTIFICATE OF RECOGNITION OF FIT FACILITY INCLUDING GROUP FOSTER CARE After perusal of the documents and on the basis of an inspection of the Institution conducted on……. the ........................ (Name of the Institution) is recognized as a Fit Facility under section 51 of the Juvenile Justice (Care and Protection of Children) Act, 2015 with effect from…..
for a period of …..years.
The Facility shall remain bound to follow the Juvenile Justice (Care and Protection of Children) Act, 2015, the Juvenile Justice (Care and Protection of Children) Rules, 2016 and regulations framed by the appropriate Government from time to time.
The Facility shall remain bound to comply with the orders passed by the Juvenile Justice Board or the Child Welfare Committee from time to time.
Dated this the………………day of ……………………20 …………………… (Signature) (Seal) Dated this the …………………….day of………………20 …………………… (Signature) Chairperson, Child Welfare Committee/ Principal Magistrate, Juvenile Justice Board.
253PART–II] LA GAZETTE DE L'ETAT FORM–40 [Rule 65(3)(xii)] LIST OF CHILDREN SUBMITTED BY CCI TO BOARD OR COMMITTEE WEEKLY Details of the Child Care Institution:
Total Number of Children admitted during the week……………………… Total Number of Children released during the week……………………… Total Number of Children in the Institution as on………………………………… Date : Signature Place: Person-in-charge of the CCI.
FORM–41 [Rule 73(C)(1)] PROTECTIVE CUSTODY CARD
1. Name of the child :
2. Age of the child :
3. Mother's Name :
4. Father's Name :
5. Address of parent/guardians :
6. Date of receiving by Organization/:
Institution.
Sl.
No.
Name of Child FIR/DD/Case No. PS Date of Next Production 254 LA GAZETTE DE L'ETAT [PART–II
7. Name and contact details of the :
person producing child.
8. Date of Inquiry :
This is to authorize and direct you to receive the above named child in your Child Care Institution and keep her/him in your charge for protective custody under the J.J. Act, 2015.
And to produce the child on …........
Next Date of hearing…………......…..
Date : (Signature) Place: Principal Magistrate/Member, Juvenile Justice Board.
FORM–42 [Rules 73 (D) (4)] OVERNIGHT PROTECTIVE STAY Whereas, (name of the child) ..................................has this day been apprehended/found to be in need of overnight protective stay at the ………………………………………………. (Name of the Institution).
The said child has been produced by …………………… (Name of the child welfare Police Officer, from ………..........……… Police Station, ……………). The child has been br’ ought along with the required application seeking protective stay, medical report stating the general health condition of the child which has been duly perused by the person in-charge of the Institution.
The said child has been brought to the Institution at ……………….
(time) and shall be handed over on the following day to the concerned jurisdiction of the child welfare Police Officer on or before ………………(mention time).
255PART–II] LA GAZETTE DE L'ETAT The personal belongings of the child have been thoroughly searched and the following articles ……………………………………………. (if any) have been handed over to the concerned child welfare Police Officer.
In case the concerned child welfare Police Officer fails to report in due time to take custody of the child, such child shall be produced before the Juvenile Justice Board/Child Welfare Committee by the Officer in-charge of the institution at the earliest.
Copy to:
1. Child Welfare Police Officer
2. Board/Committee
3. The Person in-charge of the Institution Dated this …………………… day of ………………… 20……………… (Signature) (Signature) The Person-in-charge Child Welfare Police Officer.
of the Institution.
FORM–43 [Rule 73 (H) (3)] CASE HISTORY OF THE CHILD (For Child Care Institution) Case/Profile No………………….
Date and Time….………………… A. PERSONAL DATA
1. Name……………………………………………............……
2. Male/Female (tick the appropriate category) .................…… Affix a latest photograph here 256 LA GAZETTE DE L'ETAT [PART–II
3. Age at the time of admission……............................……….
4. Present age…………………………………
5. Category (tick as applicable):
(i) Separated from family
(ii) Abandoned/deserted
(iii) Victim of exploitation and violence (give detail)
(iv) Run-away
(v) Any other
6. Religion:
(i) Hindu (OC/BC/SC/ST)
(ii) Muslim/Christian/Other (pl. specify)
7. Native District and State:
8. Description of the Housing:
(i) Concrete building/Kuchha
(ii) Three bedroom/two bedroom/one bedroom/no separate bedroom
(iii) Owned/rental
9. By whom the child was brought before the Child Welfare Committee/Juvenile Justice Board (tick as applicable):
(i) Police-Local Police/Special Juvenile Police Unit / designated Child Welfare Police Officer/Railway Police/ Women Police.
(ii) Probation Officers
(iii) Social Welfare Organization
(iv) Social Worker
(v) Parent(s)/Guardian (s) (please specify the relationship)
(vi) Any public servant 257PART–II] LA GAZETTE DE L'ETAT
(vii) Any public spirited citizen
(viii) Child himself/herself
10. Reasons for leaving the family:
(i) Abuse by parent(s)/guardian(s)/step parents(s)
(ii) In search of employment
(iii) Peer group influence
(iv) Incapacitation of Parents
(v) Criminal behaviour of Parents
(vi) Separation of Parents
(vii) Demise of Parents
(viii) Poverty
(ix) Others (please specify)
11. Types of abuse met by the child:
(i) Verbal abuse - parents/siblings/employers/others (please specify).
(ii) Physical abuse
(iii) Sexual abuse parents/siblings/Employers/others (please specify).
(iv) Others-parents/siblings/employers/other (please specify)
12. Types of ill-treatment met by the child:
(i) Denial of food-parents/siblings employers/other (please specify).
(ii) Beaten mercilessly-parents/siblings/employers/other (please specify).
(iii) Causing injury - parents/siblings/employers/other (please specify).
(iv) Detention - parents/siblings/employers/other (please specify).
(v) Other (please specify) 258 LA GAZETTE DE L'ETAT [PART–II
13. Exploitation faced by the child:
(i) Extracted work without payment
(ii) Little (low) wages with longer duration of work
(iii) Others (pl. specify)
14. Health status of the child before admission:
(i) Respiratory disorders - present / not known / absent
(ii) Hearing impairment - present / not known / absent
(iii) Eye diseases - present / not known / absent
(iv) Dental disease - present / not known / absent
(v) Cardiac diseases - present / not known / absent
(vi) Skin disease - present / not known / absent
(vii) Sexually transmitted diseases - present / not known / absent
(viii) Neurological disorders - present / not known / absent
(ix) Mental handicap - present / not known / absent
(x) Physical handicap - present / not known / absent
(xi) Urinary tract infections - present / not known / absent
(xii) Others (pl. specify) - present / not known / absent
15. With whom the child was staying prior to admission:
(i) Parent(s) - Mother/Father/Both
(ii) Siblings/Blood relative
(iii) Guardian(s) - Relationship
(iv) Friends
(v) On the street
(vi) Night shelter
(vii) Orphanages/Hostels/Similar Homes
(viii) Others (please specify)
16. Visit of the parents to meet the child:
Prior to institutionalization - Frequently/Occasionally/ Rarely/Never.
After institutionalization - Frequently/Occasionally/ Rarely/Never.
259PART–II] LA GAZETTE DE L'ETAT
17. Visit of the Child to his parents:
Prior to institutionalization - Frequently/Occasionally/ Rare ly/Dur ing fe s t iva l t imes/Dur ing summer holidays/Whenever fallen sick/Never.
After institutionalization - Frequently/Occasionally/ Rare ly/Dur ing fe s t iva l t imes/Dur ing summer holidays/Whenever fallen sick/Never.
18. Correspondence with parents:
Prior to institutionalization - Frequently/Occasionally/ Rare ly/Dur ing fe s t iva l t imes/Dur ing summer holidays/Whenever fallen sick/Never.
After institutionalization - Frequently/Occasionally/ Rare ly/Dur ing fe s t iva l t imes/Dur ing summer holidays/Whenever fallen sick/Never.
19. Details of disability
20. Type Family: Family/joint family/broken family/single parent.
21. Relationship among the family members:
(i) Father and mother Cordial/ Non-cordial/ Not known
(ii) Father and child Cordial/ Non-cordial/ Not known
(iii) Mother and child Cordial/ Non-cordial/ Not known
(iv) Father and siblings Cordial/ Non-cordial/ Not known
(v) Mother and siblings Cordial/ Non-cordial/ Not known
(vi) Child and siblings Cordial/ Non-cordial/ Not known
(vii) Child and relative Cordial/ Non-cordial/ Not known 260 LA GAZETTE DE L'ETAT [PART–II
22. History of crime committed by family members, if any:
Sl.
No.
Relationship Nature of Crime Legal status of the case Arrest if any Made Period of confinement Punishment Awarded
1. Father
2. Step father
3. Mother
4. Step mother
5. Brother
(a)
(b)
(c)
(d)
6. Sister
(a)
(b)
(c)
(d)
7. Child
8. Others (uncle/ aunty/ grandparents)
23. Properties owned by the family:
(i) Landed properties (pl. specify the area)
(ii) House-hold articles - Cows/Cattle/Bull
(iii) Vehicles - two wheeler/three wheeler/four wheeler (lorry/bus/car/tractor/jeep)
(iv) Others (pl. specify)
24. Marriage details of family members:
(i) Parents Arranged/ Special Marriage
(ii) Brothers Arranged/ Special Marriage
(iii) Sisters Arranged/ Special Marriage
25. Social activities of family members:
(i) Participate in social and religious functions
(ii) Participate in cultural activities
(iii) Does not participate in social and religious functions
(iv) Not known 261PART–II] LA GAZETTE DE L'ETAT
26. Parental care towards child before admission:
(i) Over protection
(ii) Affectionate
(iii) Attentive
(iv) Not affectionate
(v) Not attentive
(vi) Rejection ADOLESCENCE HISTORY (Between 12 and 18 years)
27. At what age did the child attain puberty?
28. Details of delinquent behaviour if any:
(i) Stealing
(ii) Pick pocketing
(iii) Arrack selling
(iv) Drug pedaling
(v) Petty offences
(vi) Violent crime
(vii) Rape
(viii) None of the above
(ix) Others (pl. specify)
29. Reason for delinquent behaviour:
(i) Parental neglect
(ii) Parental overprotection
(iii) Parents criminal behavior
(iv) Parents influence (negative)
(v) Peer group influence - To buy drugs/alcohol
(vi) Others (pl. specify) 262 LA GAZETTE DE L'ETAT [PART–II
30. Habits:
A B
(i) Smoking (i) Watching TV/movies
(ii) Alcohol consumption (ii) Playing indoor/outdoor games.
(iii) Drug use (specify) (iii) Reading books
(iv) Gambling (iv) Religious activities
(v) Begging (v) Drawing/painting/acting/ singing.
(vi) Any other (vi) Any other EMPLOYMENT DETAILS
31. Employment details of the child prior to entry into the Home:
Sl.No. Details of employment Timing and Duration Wages earned
(i) Cooly
(ii) Rag picking
(iii) Mechanic
(iv) Hotel work
(v) Tea shop work
(vi) Shoe polish
(vii) Household works
(viii) Others (pl specify)
32. Details of income utilization:
Sent to family to meet family need
(i) For dress materials
(ii) For gambling
(iii) For prostitution
(iv) For alcohol
(v) For drug
(vi) For smoking
(vii) Savings (pl. specify) 263PART–II] LA GAZETTE DE L'ETAT
33. Details of savings:
(i) With employers
(ii) With friends
(iii) Bank/Post Office
(iv) Others (pl. specify)
34. Duration of working hours:
(i) Less than six hours
(ii) Between six and eight hours
(iii) More than eight hours EDUCATIONAL DETAILS
35. The details of education of the child prior to the admission to Children's Home:
(i) Illiterate
(ii) Studied up to V Standard
(iii) Studied above V Std. but below VIII Standard
(iv) Studied above VIII Std. but below X Standard
(v) Studied above X Standard
36. The reason for leaving the School:
(a) Failure in the class last studied
(b) Lack of interest in the school activities
(c) Indifferent attitude of the teachers
(d) Peer group influence
(e) To earn and support the family
(f) Sudden demise of parents
(g) Rigid school atmosphere
(h) Absenteeism followed by running away from school
(i) There is no age appropriate school nearby
(j) Others (pl. specify)
37. The details of the school in which studied last:
(i) Corporation/Municipal/Panchayat
(ii) Government/SC Welfare School/BC Welfare School
(iii) Private management/ Convents
38. Medium instruction: Hindi/English/Urdu/Tamil/Malayalam/ Kannada/Telugu/Marathi/Gujarati/Bengali/Other language (pl. specify) 264 LA GAZETTE DE L'ETAT [PART–II
39. After admission to Children's Home, the educational attainment from the date of admission till date:
No. of years Class studied Promoted/detained
40. Vocational training undergone form the date of admission into Children's Home till date:
No. of years Name of Vocational Trade Proficiency Attained Details of certification?
41. Extra-curricular activities developed form the date of admission into the Children's Home till date:
(i) Scout
(ii) Sports (pl. specify)
(iii) Athletics (pl. specify)
(iv) Drawing
(v) Painting
(vi) Others (pl. specify) MEDICAL HISTORY
42. Height and weight at the time of admission:
43. Physical condition:
44. Medical history of child (gist):
45. Medical history of parent/guardian (gist):
46. Present health status of the child:
Sl.
No.
Annual Observation 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Date of Review Height Weight Nutritious diet given Stress Dental ENT Eye 265PART–II] LA GAZETTE DE L'ETAT
47. Height and Weight Chart:
Date, Month and Year Height Admissible Weight Actual Weight SOCIAL HISTORY
48. Details of friendship prior to admission into Children's Home:
(i) Co-workers
(ii) School/Classmate
(iii) Neighbours
(iv) Others (pl. specify)
49. Majority of the friends are:
(i) Educated
(ii) Illiterate
(iii) The same age group
(iv) Older in age
(v) Younger in age
(vi) Same sex
(vii) Opposite sex
50. Details of membership in group (pl. specify details):
(i) Associated with cine fans association
(ii) Association with religious group
(iii) Associated with arts and sports club
(iv) Associated with gangs
(v) Associated with voluntary social service league
(vi) Others (pl. specify).
51. The position of the child in the groups/league:
(i) Leader
(ii) Second level leader
(iii) Middle level functionary
(iv) Ordinary member
52. Purpose of taking membership in the group:
(i) For social service activities
(ii) For leisure time spending
(iii) For pleasure seeking activities 266 LA GAZETTE DE L'ETAT [PART–II
(iv) For deviant activities
(v) Others (pl. specify)
53. Attitude of the group/league:
(i) Respect the social norms and follow the rules
(ii) Interested in violating the norms
(iii) Impulsive in violating the rules
54. The location/meeting point of the groups:
(i) Usually at fixed place
(ii) Places are changed frequently
(iii) No specific places
(iv) Meeting point is fixed conveniently
55. The reaction of the society when the child first came out of the family:
(i) Supportive
(ii) Rejection
(iii) Abuse
(iv) Ill-treatment
(v) Exploitation
56. The reaction of the police towards children:
(i) Compassionate
(ii) Harsh
(iii) Aggressive and abusive
(iv) Exploitative
(v) Ill-treated
57. The response of the general public towards the child ………………………….
HISTORY OF THE CHILD (Brief)
(i) Education
(ii) Health
(iii) Vocational training
(iv) Extra curricular activities
(v) Others 267PART–II] LA GAZETTE DE L'ETAT Suggestion of Child Welfare Officer/Probation Officer after orientation to child and the response towards orientation.
Follow up by Child Welfare Officer/Probation Officer/Case Worker/ Social Worker.
Quarterly Review of Case History by Management Committee Date : PERSON IN-CHARGE/SUPERINTENDENT/ Place: CHILD WELFARE OFFICER/PROBATION OFFICER.
FORM–44 [Rule 86 (1)] RELEASE-CUM-RESTORATION ORDER (Name of the Child)……………….son/daughter of……………….
residence……………….………………. Case No./Profile Number………… who was ordered to be placed in an observation home/place of safety/ special home/Children's Home/ by the Juvenile Justice Board/ Children's Court/ Child Welfare Committee……………….under section……………….
of the Juvenile Justice (Care and Protection of Children) Act, 2015, for a term of………………. on the……………….day of…………… 20……………….and who is now in the…………………………….……………….
Institution, at……………….is directed to be released from the said………………………….…Institution and supervision and the authority of……………….………………. during the remaining period of stay as……………….reason for discharge).
This order is granted subject to the conditions hereon, upon the breach of any of which it shall be liable to be revoked.
Dated this the ……………….day of ……………….
Signature Juvenile Justice Board/Children's Court/Child Welfare Committee.
Place:
Conditions:
268 LA GAZETTE DE L'ETAT [PART–II
1. The discharged person shall proceed to………………. and live under the supervision and authority of………………. until the expiry of the period of his stay in Children's Homes or fit facility/detention in observation home/special homes/place of safety unless the remission is sooner cancelled.
2. He shall not, without the consent of the……………….remove himself from that place or any other place, which may be named by the said ……………….
3. He shall obey such instruction as he may receive from the said ……………….with regard to punctual and regular attendance at school/ vocation or otherwise.
4. He shall not get involved in any offence and shall lead a sober and industrious life to the satisfaction of………………………….…….
5. In the event of his committing a breach of any of the above conditions the remission of the period of stay in the Institution hereby granted shall be liable to be cancelled and on such cancellation he/she shall be dealt with under section 97 of the Juvenile Justice (Care and Protection of Children) Act, 2015.
I hereby acknowledge that I am aware of the above conditions which have been read over/ explained to me and that I accept the same.
(Signature or mark of the released child) Certified that the conditions specified in the above order have been read over/explained to (Name of child)……………….and that he/she has accepted them as the conditions upon which his/her release may be revoked.
Certified accordingly that the said child has been discharged on the……………….
Signature and Designation of the certifying authority i.e., Person-in-charge of the institution.
269PART–II] LA GAZETTE DE L'ETAT FORM–45 [Rules 86(4)] ESCORT ORDER Case No…………….
In the matter of Boy/Girl child ……….…………….…......………….… Aged about…....…………year taken The Parents of the boy/girl child are reported to be residing at………………………..
He/She therefore be sent under supervision of a proper Police/ recognized non-governmental organization escort to the………………………..
For tracing and for handing over to the parents or close relatives of the said Boy child/girl child residing at the aforesaid address or at other place which may be shown by the Child, if, no such parents or relative are traced or if traced, but, they are unwilling to take charge of the boy/ girl be kept in the custody of the Superintendent ………………………..
Children's Home/Place of Safety/Observation Homes of the said District and the said Boy/Girl child be produced before the concerned Child Welfare Committee/Juvenile Justice Board for further orders.
Orders Pending Escort, the said Boy/Girl child shall remain in Children's Home/Place of Safety/Observation Homes, residing at present at………………………..The State/District Child Protection Unit, or Police Department and recognized non-governmental organization/Childline shall positively make immediate arrangement not less than 15 days from the date of receipt of this order by him and send the said Boy child/ Girl child at his/her aforesaid place of residence.
Dated this the…………………..day of…………………..20………… Chairperson/Member Child Welfare Committee Juvenile Justice Board.
CC to:
1.The Person in charge, Child Care Institution.
2.The District Child Protection Unit or non-governmental organization or Childline.
Ref.: 1. Order of admission of minor…………………..born on…………………..Profile No…………………..
270 LA GAZETTE DE L'ETAT [PART–II FORM–46 [Rule 45(3) and 45 (9)] INSPECTION BY INSPECTION COMMITTEE (Fill as applicable) Date of visit:………………………… Time of visit: …………………… Name of the officials inspecting the Home:
1. ……………………………..
2. ……………………………..
3. ……………………………..
A. General Information :
(i) Name and address of the Organisation :
(ii) Registration No. (Under JJ Act, 2015) :
Date of issue :
Date of expiry :
(iii) Complete address of the CCI : :
(iv) Name of the Officer/Person-in-Charge: :
(v) Contact No:
Email Id:
:
(vi) Type of Home (Please tick one):
Observation Home/ Special Home/ Place of Safety/ Children’s Home/ Open Shelter / Any other (please specify):
:
(vii) If Aided/supported: by State Government, Name of the Department:
:
(viii) If run by Government: :
B. Status of Children:
(i) Sanction capacity of the Home :
(ii) Are the children of both sexes below 10 years kept in the same home If yes, number of such children as on today : Yes No
(iii) Are the bathing and sleeping facilities maintained separately for boys and girls in the age group of 5-10 years : Yes No
(iv) Are children segregated in the age group given below?
Give number of children in the age group of :
(i) 7-11 years : :
(ii) 12- 18 years: :
(iii) Are there children in the age group of 0-5 years staying there?
: Yes No If yes, Give numbers:
(iv) Are there children above 18 years staying there? : Yes No If yes, Give numbers:
(v). No. of new admissions in the current month :
(Under JJ Act, 2015) email Id:
271PART–II] LA GAZETTE DE L'ETAT
(i) Sanction capacity of the Home :
(ii) Are the children of both sexes below 10 years kept in the same home If yes, number of such children as on today : Yes No
(iii) Are the bathing and sleeping facilities maintained separately for boys and girls in the age group of 5-10 years : Yes No
(iv) Are children segregated in the age group given below?
Give number of children in the age group of :
(i) 7-11 years : :
(ii) 12- 18 years: :
(iii) Are there children in the age group of 0-5 years staying there?
: Yes No If yes, Give numbers:
(iv) Are there children above 18 years staying there? : Yes No If yes, Give numbers:
(v). No. of new admissions in the current month :
(vi) No. of children who have moved out/released :
(vii) No. of children referred by CWC/JJB during the month :
(viii) No. of children produced before CWC/JJB during the month :
(ix) No. of children as on last day of the previous month :
(x) No. of children with special needs, if yes, give details :
(xi) Interventions made for their rehabilitation: :
(xii) Are the Individual care plans prepared for every child?
: Yes No C. Infrastructure:
Building:
Rented:……………… Owned…………………………….
Are CCTV cameras installed at the entrance: Yes / No Security Adequate Inadequate Sufficient space to accommodate the children: Yes/No Space available:
No. of rooms/dormitories Details No. of rooms/dormitories Details Provision of sick room/medical unit Counseling room - Recreational/Activity room for Children 272 LA GAZETTE DE L'ETAT [PART–II No. of rooms / dormitories Details No. of rooms / dormitories Details Provision of sick room / medical unit Counseling room - Recreational / activity room for Children • Is there a TV set available with Cable network Yes No • How often are children allowed to view TV in the evenings or any time • Are children playing games indoors Yes No • What games are available to them age appropriate games or not • Are children playing games outdoors Yes No • Do they have equipments/ accessories to play Yes No • Do children go for picnics/excursions Yes No • Do they have interactions with eminent personalities • Is there a recreation room available to children Yes No Kitchen / Dining Room • Is the cooking area and pantry separate Yes No • Do children get individual thalis, mugs glasses Yes No • Are cooking utensils adequate and clean Yes No • Is there a fridge available for children Yes No • Is there a Oven available for children Yes No • Is there a Gas stove available in kitchen Yes No • Is there a chimney available Yes No • What is the arrangement to keep the gas cylinders safe/away from children or not • Adequate water supply for washing, cooking Yes No • Adequate drinking water available ( RO) Yes No • Is cooking done by machines or by cook Yes No Number of toilets & bathrooms for Children • Flush is working Yes No • Taps in the wash basin are functioning Yes No • Is the floor slippery Yes No • Drains clean Yes No • Drains are clogged Yes No • Fittings for hanging clothes/ towels in place Yes No • Cob webs are removed once or more in a day • Door has a latch Yes No • Door has peep holes Yes No • Frequency of bath a child is allowed Yes No • Water is adequately available Yes No • Adequate numbers of buckets and mugs Yes No • Personal toiletries are provided Yes No • Is washing powder or soap given Yes No • Do children wash their own clothes Yes No • Is there a washer man available Yes No • Is the washing machine functional Yes No Open space for outdoor activities 273PART–II] LA GAZETTE DE L'ETAT No. of rooms / dormitories Details No. of rooms / dormitories Details Provision of sick room / medical unit Counseling room - Recreational / activity room for Children • Is there a TV set available with Cable network Yes No • How often are children allowed to view TV in the evenings or any time • Are children playing games indoors Yes No • What games are available to them age appropriate games or not • Are children playing games outdoors Yes No • Do they have equipments/ accessories to play Yes No • Do children go for picnics/excursions Yes No • Do they have interactions with eminent personalities • Is there a recreation room available to children Yes No Kitchen / Dining Room • Is the cooking area and pantry separate Yes No • Do children get individual thalis, mugs glasses Yes No • Are cooking utensils adequate and clean Yes No • Is there a fridge available for children Yes No • Is there a Oven available for children Yes No • Is there a Gas stove available in kitchen Yes No • Is there a chimney available Yes No • What is the arrangement to keep the gas cylinders safe/away from children or not • Adequate water supply for washing, cooking Yes No • Adequate drinking water available ( RO) Yes No • Is cooking done by machines or by cook Yes No Number of toilets & bathrooms for Children • Flush is working Yes No • Taps in the wash basin are functioning Yes No • Is the floor slippery Yes No • Drains clean Yes No • Drains are clogged Yes No • Fittings for hanging clothes/ towels in place Yes No • Cob webs are removed once or more in a day • Door has a latch Yes No • Door has peep holes Yes No • Frequency of bath a child is allowed Yes No • Water is adequately available Yes No • Adequate numbers of buckets and mugs Yes No • Personal toiletries are provided Yes No • Is washing powder or soap given Yes No • Do children wash their own clothes Yes No • Is there a washer man available Yes No • Is the washing machine functional Yes No Open space for outdoor activities Class rooms space for vocational training Premises Does the home have a child friendly indoors? Yes/No How often is the sweeping, swabbing done? Twice a day or more Are the children involved in cleaning exercise during class hours?
Yes/No Are the facilities of coolers/heaters available for children? Yes/No Are the doors and windows maintained properly? Yes/No Are the rooms and dormitories well ventilated? Yes /No Is there an alternate provision for lights and fans when there is no electricity available? Yes/No Are the outdoors clean, pleasant and child friendly? Yes/No Clothing/Bedding/Lockers/Toiletries provided to the children:
Are the clothes provided as per size and season : Yes/No Frequency of changing undergarments : Yes/No New clothes are stitched or bought : stitched or bought Are the mattresses given individually : Yes/No Are pillows given individually : Yes/No Are the mattress and pillows clean : Yes/No Do children have separate cupboards :Yes/No Are bed sheets and Khes available : Yes/No 274 LA GAZETTE DE L'ETAT [PART–II Are blankets available in winters : Yes /No Number of sets provided on arrival : one/two/three/four Frequency of providing new clothes : Monthly/Quarterly Are these sets of same color or different colors? : Same/Different Are children provided with individual lockers to keep their personal i tems:Yes/No Other articles provided to the children: …………...............……………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… D. Services provided to the children:
Medical facilities/Maintenance of Health Cards: …………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… Nutrition/Special Diet: ………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… …………………………………………………………………………………… Provision of safe drinking water:…………..........………………… …………………………………………………………………………………… …………………………………………………………………………………… Daily Routine of Children:
Time Activities / Schedule Morning Day Time Afternoon Evening Late evening/Night 275PART–II] LA GAZETTE DE L'ETAT Education (Formal Education/NFE and Life Skill Training Programme):
……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… Computer/Internet/Phone Is the facility of Computer with internet available? Yes/No Is the facility functional? Yes/No Are the children allowed to use the facility? Yes/No Is the telephone for official purposes only : Yes/No Are the children allowed to use telephone : fixed timing/as and when required.
Is the number of Childline (1098) displayed near the phone : Yes/No Counseling/Guidance services/special educator/physiotherapist, etc.
provided :
……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… Vocational training: ............................................................................
……………………………………………………………………………………… Recreational facilities: ..........................................................................
...........................................................................................................................
Linkages developed with other agencies/ departments: .....................
...........................................................................................................................
“ Implementation of track the missing child programme: ....................
- Entries of children in track the missing child website: ..........................
............................................................................................................................
- User Id and password provided: ................................................
...........................................................................................................................
Other programmes and activities initiated: ...........................................
..............................................................................................................
...........................................................................................................................
276 LA GAZETTE DE L'ETAT [PART–II Sl.No. Name Designation Date of Joining Attendance at the time of visit Remarks 1 2 3 4 5 6 7 8 9 10 11 12 13 14 F. Children's Committee/Management Committee Formation of Children's Committee : Yes/No Age wise formation of Children's Committee :
Frequency of Children's Committee Meeting:
………………………………………………………………………..
Formation of Management Committee : Yes/No Date of constitution of Management Committee and frequency of meetings held :
………………………………………………………………………..
G. Record Maintenance:
Staff attendance register Children attendance register Central admission register Individual case file with individual care plan Communication with CWC/JJB Children’s suggestion book Children’s suggestion box Medical file / medical cards Personal belongings register Management Committee – minutes register Children’s Committee - minutes register Nutrition / Diet File Any other record maintained E. Staff Details:
Medical card 277PART–II] LA GAZETTE DE L'ETAT Observations/Remarks:
........................................................................................................................
Name of inspection Committee Member:
Signature :
Name of inspection Committee Member :
Signature :
Name of inspection Committee Member :
Signature :
Name of inspection Committee Member :
Signature :
Name of inspection Committee Member :
Signature :
Name of inspection Committee Member:
Signature :
Date :
Place :
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