ORDER OF SOCIAL INVESTIGATION REPORT
To The Probation Offi cer Reference No/Case No/Profi le No: Police Station/Crime No/u/s Whereas a report/complaint has been received/inquiry is under process in Child Welfare Committee/Juvenile Justice Board __________________________(District Name) u/s ___________________________of the Juvenile Justice (Care and Protection of children) Act, 2015/_________________________________(any other legal provision) in respect of_____________________________(name of the child), son/daughter of ______________________________approximate age _____________ residing at___________________________________________________________________ You are hereby directed to enquire into the social antecedents, family background andcircumstances of the alleged offence by the said child / circumstances of the child for needing care and protection if so, and submit your social investigation report on or before ________________________ or within such time allowed to you by the Board. You are also hereby directed to consult an expert in child psychology / psychiatric treatment / counselling for their expert opinion if necessary and submit such report along with your Social Investigation Report.
Dated this _______________________________day of __________________20_____.
(Signature) Principal Magistrate, Juvenile Justice Board/ Children's court
(Signature)
Chairperson / Member,
32
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 33
Child Welfare Committee Form IV
[See rule 9 (xxxii)]
SUPERVISION ORDER
(The child is placed under the care of a parent, guardian or other fi t person/fi t facility) Profi le No. _________________________ of _________________________ 20 ____. Whereas __________ (name of the child) has this day been found to have committed an offence and has been placed under the care of _________________________________(name) residing at_____________________________________________ ________________(address) on executing a bond by the said ______________________________________________and the Board is satisfi ed 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__________________ probation offi cer/case worker, for a period of ___________________________ subject to the following conditions:-
1. that the child along with the copies of the order and the bond executed by the said ________________________________ __________________ shall be produced before the probation offi cer/case worker named therein
2. that the child shall be submitted to the supervision of the aforesaid probation offi cer / case worker.
3. that the child shall not be allowed to quit the district jurisdiction of _________without the permission of the probation offi cer/ case worker.
4. that the child shall not be allowed to associate with bad characters.
5. that the child shall live honestly and peacefully; and will go to school regularly / endeavour to earn an honest livelihood.
6. that the child shall attend the attendance centre regularly.
7. that the person under whose care the child is placed shall arrange for the proper care, education and welfare of the child.
8. 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.
9. that the child shall be prevented from taking narcotic drugs or psychotropic substances or any other intoxicants.
10. that the person under whose care the child is placed shall arrange / endeavour for the implementation of individual care plan
11. that the directions given by the probation offi cer/case worker from time to time, for the due observance of the conditions mentioned above, shall be carried out.
Dated this______________________day of______________________ 20___.
Principal Magistrate, Juvenile Justice Board
33
34 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
• Additional conditions, if any may be inserted by the Juvenile Justice Board
Form V [See rule 9 (XL), 14(6), 15(7)(vi), 15 (8)(ii), 24(l)(i), 37(7)]
INDIVIDUAL CARE PLAN
(Child in Confl ict with Law / Child in Need of Care and Protection) (tick whichever is applicable)
Name of Case Worker/Child Welfare Offi cer/Probation Offi cer……………………………............................................................. Date of preparing the ICP ……………………………………………………………………………………..................................……… Case/Profi le No……………of 20…………………
FIR No……………………………………………………….
U / Sections (Type of offence),applicable in case of Children in Confl ict with Law……
Police Station…………………………………………………………......................…………………………………………………………..
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…………………………….....................................………………………
14. Based on the results of Case History, Social Investigation Report and interaction with the child, give details on following
34
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 35
areas of concern and interventions required, if any
| Sl. No. |
Category |
Areas of concern |
Proposed Interventions |
| 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 signifi cant experiences which may have impacted the development of the child like traffi cking, domestic violence, parental neglect, bullying in school, etc. (Please specify) |
|
|
B. PROGRESS REPORT OF THE CHILD ( to be prepared every fortnight for fi rst three months and thereafter to be prepared once a month)
[Note: Use different sheet for Progress Report]
1. Name of the Probation Offi cer/Case Worker/Child Welfare Offi cer……………………………………….
2. Period of the report…………………………………………………………………………………………………………
3. Admission No…………………………………………………………………………………………………………………
4. Board or Committee………………………………………………………………………………………………………..
5. Profi le No……………………………………………………………………………………………………………………….
6. Name of the child……………………………………………………………………………………………………………
7. 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)
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.
| S.No. |
Category |
Proposed Interventions |
Progress of the child |
| 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 |
|
|
35
36 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
| 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 signifi cant experiences which may have impacted the development of the child like traffi cking, domestic violence, parental neglect, bullying in school, etc. (Please specify) |
|
|
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 fi t person under whose care the child is to live after the supervision is over……………………………………………
Date of report…………………Signature of the Probation Offi cer…………………..
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.No. |
Category |
Rehabilitation and restoration plan of the child |
| 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 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 signifi cant experiences which may have impacted the development of the child like traffi cking, domestic violence, parental neglect, bullying in school, etc. (Please specify) |
|
6. Date of release/transfer/repatriation…………………………………………………………………………………
7. Requisition for escort if required………………………………………………………………………………………
8. Identifi cation proof of escort such as driving license, Aadhar Card, etc………………………………..
36
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 37
9. Recommended rehabilitation plan including possible placements/sponsorships……………………..
10. Details of Probation Offi cer/non-governmental organization for post-release follow up ……………………………………… ……………………………………………………………………………………………
11. Memorandum of Understanding with non-governmental organisation identifi ed for post release follow up (Attach a copy) …………………………………………………………………………..
12. Details of sponsorship agency/individual sponsor, 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/RESTORASTION REPORT OF THE CHILD
1. Status of Bank Account : Closed / Transferred
2. Earnings and belongings of the child: handed over to the child or his parents / guardians - Yes / No
3. First interaction report of the Probation Offi cer/Child Welfare Offi cer/Case Worker / Social Worker/Non-Governmental Organisation identifi ed for follow-up with the child post-release ………………………………………………………………… ……………………………………………………….……
4. Progress made with reference to Rehabilitation and Restoration Plan………………………………................................…..
5. Family's behavior/attitude towards the child………………………………………………………………..........................……..
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 School or vocation? Give date and name of the school/institute/any other agency Yes/No…………………………………………………………………...................................................…
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]
IDENTITY CARDS Present status (Please tick whichever Action taken is applicable)
Yes No
Birth Certifi cate School Certifi cate Caste Certifi cate BPL Card
Disability Certifi cate Immunization Card Ration Card
Aadhar Card
Received compensation from Govern- ment
Signature of the Probation Offi cer/Child Welfare Offi cer
37
38 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
Stamp and Seal Form VI
[See rule 10 and 36 (3) (xiii)]
QUARTERLY REPORT OF JUVENILE JUSTICE BOARD
District Quarterly report for the period From to Details of Juvenile Justice Board
Sl.No Details Date of appointment Training attended
1 Principal Magistrate
2 Member-1
3 Member-2
VISIT TO HOMES BY PRINCIPAL MAGISTRATE
Date of Visit :
Name and Address of Home :
Remarks :
VISIT TO JAILS BY PRINCIPAL MAGISTRATE
Date of Visit Whether any Children found Action Taken
CASES INSTITUTED DURING THE QUARTER
PETTY SERIOUS HEINOUS TOTAL
Number of cases Number of Children Children granted bail Children sent to Observation Home
Number of cases where preliminary reports were sub- mitted in stipulated time
PENDENCY OF CASES
Nature of Old cases New cases Disposal Current Pendency case
Less than 4 Months to 6 6 Months to More
4 Months Months 1 Year than 1Year
PETTY
SERIOUS
HEINOUS
38
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 39
TOTAL
FINAL ORDER
Total number of fi nal orders passed Discharged Transfer to Abated Transferred Declared com- Terminated Acquitted/ Finding other JJB on Death to Children's pounded and fi le under rule ------ of commission in Court consigned offence
(post produc-
tion process)
Nature of Dispositional orders where child has committed offence (mention the number of orders)
| COMPLAINT /SUGGESTION, IF ANY, RECEIVED AND ACTION TAKEN REMARK/SUGGESTION BY BOARD Principal Magistrate Member-1 Member-2 |
| Principal Magistrate (Metropolitan Magistrate / Judicial Magistrate) |
Member-1 |
Member-2 |
39
40 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
Form VII [See rule 11 (5)] UNDERTAKING / BOND TO BE EXECUTED BY A PARENT / GUARDIAN/ RELATIVE / FIT PERSON IN WHOSE CARE A
CHILD IN CONFLICT WITH LAW IS PLACED
(When the child is released in a case where the apprehension is not warranted) Whereas I ___________________________ being the parent, guardian, relative or fi t person under whose care ___ __________________________________(name of the Child) has been ordered to be placed by Child Welfare Police Offi cer/Special Juvenile Police Unit/ Offi cer-in Charge of Police Station of _____________________( Police Station concerned) and I have been directed by the said Offi cer to execute an undertaking / bond with surety for a sum of Rs. ________ (Rupees_______________________________________) or without surety. I hereby bind myself on the said ____________________________(name of the child) being placed under my care. I shall have the said child properly taken care of and I do further bind myself to be responsible for the good behaviour of the said child and to observe the following conditions:-
1. that I shall not change my place of residence without giving previous intimation in writing to the police station concerned
2. that I shall be present and produce the said child in my care on the dates during enquiry or proceedings before the Juvenile Justice Board_________________(District)
3. that I shall inform the police if the behavior of the said child restored in my care is beyond my control.
4. that I shall arrange for the proper care, education and welfare of the child.
5. that I shall take the preventive measures to see that the child does not commit any offence punishable by any law in India.
6. In the event of my making default herein, I undertake to produce myself before the Board for appropriate action or bind myself, as thecase may be, to forfeit to Government the sum of Rs.__________ (Rupees_______________________________________).
Dated this __________________________day of __ ______20.
Signature of person executing the Undertaking/Bond.
40
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 41
(Signed before me)
Signature of the CWO/SJPU/ Offi cer-in Charge of P.S. Form VIII
[See proviso to rule 14 (2)]
REQUESITION FOR TEMPORARY ADMISSION OF CHILD IN CONFLICT WITH LAW IN OBSERVATION HOME / PLACE OF
SAFETY
Whereas (Name of the Child) -----------------------------------Son/Daughter of ---------------------- aged ------ had been taken charge on --------------at (time) ------------------------------------------from (place)
Please receive the said child and keep in your institution for night stay on ---------- (date) until or upto such time produced before the Juvenile Justice Board functioning at --------.
I assure you that I shall take charge of the child and produce before the Board at its fi rst sittings of the Board immediately thereafter on -----------(Date)
Reason for taking charge of the child
with relevant provisions and a brief
History of the incident.
Descriptive or Identifi cation marks
of the child.
1. ---
2. ---
Date Name & Designation, Signature of the CWO/ Offi cer in Charge of Police Station To
41
42 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
The Offi cer in Charge of the Observation Home/ Place of Safety,
FORM IX
[See rule 15(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 confl ict 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 ……………………………………………………………...……………………………...……………………………………………………… ………….…………………………………
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, fl uctuating.
IV. Orientation (Inquired) - Possible questions: • "What is your full name?" • "Where are we at (fl oor, 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?"
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
42
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 43
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, fl ow and coherence of thought in response to general questioning during the interview. - Possible descriptors: goal-directed, 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.
RECOMMENDATIONS (including whether the person may be released or released on conditions or requires further institutionalization with justifi cation)
DATE : / /
PLACE :
NAME :
DESIGNATION :
SIGNATURE :
Recommendations/Findings: …………….……
Signature / Seal
43
44 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
Prepared by: ……………………………………..…
(Probation Offi cer ……..../……./………….… (date)
FORM X
[See rule 15(8) (vi) (c) (cd)]
REHABILITATION CARD
FIR No. /Case No. U/Sections
Police Station Nature of Offence: heinous, serious or petty (in case of child in confl ict with law) Name of Probation Offi cer/Child Welfare Offi cer/Rehabilitation cum Placement Offi cer:
………………………………………………..
Name of the child:
Age:
Sex:
Father's name:
Mother's name:
Admission No.
Date of Admission:
Date of Provisional Release / Release:
Services availed under Individual Care Plan -
| 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 : |
44
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 45
| Fourth Month |
Plan : Outcome : |
|
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 : |
45
46 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
| Fourth Month |
Plan : Outcome : |
| 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 signifi cant experiences which may have impacted the development of the child like traffi cking, domestic violence, parental neglect, bullying in school etc. |
| First Month |
Plan : Outcome : |
| Second Month |
Plan : Outcome : |
| Third Month |
Plan : Outcome : |
| Fourth Month |
Plan : Outcome : |
Other services provided to the child, including compensation, other benefi ts etc.
Report of the detailed psychiatric assessment done by certifi ed psychiatrist to be attached along with Rehabilitation card
Date of report and reason for conducting the said assessment (Provisional Release / Release/ Any other)
1. Overall progress shown by the child on the above mentioned aspects of the Individual Care Plan
2. Child's acceptance and understanding of his actions and its consequences 3.Child's willingness to reform
4. Child's behavior and conduct
5. Offence committed by the child , if any reported by family or neighbourhood, in case of a child in confl ict with law who is not
46
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 47
placed in a Child Care Institution
Signed by JJB/ CWC
FORM XI
[See rule 22(i)]
REPORT TO BE SUBMITTED AT TIME OF PRODUCTION OF CHILD BEFORE THE CHILD WELFARE 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:
Name of the person …………….…………….
Age…………………………………………………..
Sex……………………………….……..……………
Address …………………………………….………
Contact number………………………….………
Occupation/ designation…………….……….. Name of the organization/Child Care Institution/ Specialised Adoption Agency ………………….
2. The child who is being produced:
Name (if any)………………………..…………….. Age (stated age/ age based on appearance) …………… Sex …………
Identity mark/s…………………………………..……
Language used by the child………………………..
3. Details of parents / guardians (if available):
Name ………………………..….……………
Age……………………………..…...………..
Address…………………………..………….
Contact number…………….…………….
Occupation……………….…………………
4. Place where the child was found…………………………….
5. The details of the person (if any) with whom the child was found:
Name …………………………..……..……
Age……………………………….………….
Address…………………………………….
Contact number……………….…………
47
48 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
Occupation………………………..……….
6. Circumstances under which the child was found……………………….
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 Child Care Institution/Specialised Adoption Agency ………………………….
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 offi cer / Railway Police/Probation Offi cers/
48
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 49
any public servant/Social Welfare Organization/Social Worker/ Person in-charge of CCI/ SAA/ any citizen/Child himself/herself (fi ll as applicable)
FORM XII
[See rule 22 (vi)]
CASE SUMMARY MAINTAINED BY THE CHILD WELFARE COMMITTEE
Case No…………………………………………………..
1) Name of the Child
2) Father's / Mother's /Guardian's Name
3) Date of production of the child
4) Name of the 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) Declaration that child is in need of care and protection / Finding on age of child / Medical Examination Interim custody
Undertaking (by parent, guardian or fi t person, if applicable)
Order appointing NGO etc.
Order for compensation / recovery of wages (if applicable)
Transfer order
Final Order (concluding inquiry)
Any other order
Medical Records including but not limited to age verifi cation…………………………………… Social Investigation Report……………………………………………………………………...……………
Individual Care Plan……………………………………………………………………………………………..
Case History ……………………………………………………………………………………………….………
All details, documents and records with regards to Sponsorship / Foster Care /Adoption services (if applicable)
Date:
49
50 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
Place: (Signatures) Child Welfare Committee.
FORM XIII
[See rule 22 (x)]
ORDER FOR PLACEMENT OF CHILD UNDER THE CARE OF A PARENT, GUARDIAN OR FIT PERSON
PENDING INQUIRY
Case No. ……………. of ……………… 20……………… 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 satisfi ed 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 (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 identifi ed) 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 confl ict 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 …………………… day of ……………… 20………………….
(Signature) Chairperson / Member Child Welfare Committee.
50
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 51
• Additional conditions, if any may be inserted by the Child Welfare Committee.
FORM XIV
[See rule 22 (x)] UNDERTAKING BY THE PARENT/GUARDIAN OR 'FIT PERSON' TO WHOM CHILD IS PLACED WITH PENDING INQUIRY / RESTORATION (to Child Welfare Committee)
I -----------S/o------------- residing at -----------(full address)--------------- being -----------------(relationship) do hereby declare that I am willing to take charge of ------------(name of the child) ----- aged-------- under the orders of the Child Welfare Committee --------(District) subject to the following terms and conditions:
(i) If his/her conduct is unsatisfactory, I shall at once inform the Committee.
(ii) I shall do my best for the welfare, Education, Health Care of the said child as long as he / she remains in my charge and shall make proper provision for his/her maintenance.
(iii) I undertake to produce him/her before the competent authority as and when required.
(iv) I shall inform the change of residence to the Child Welfare Committee.
(v) I shall do my best for the implementation of the individual care plan by the Child Welfare Committee.(if any) Dated this ………………day of ………………..20
Signature Signature and address of witness (es) (Signed before me)
Chairperson, Child Welfare Committee
• Additional conditions, if any may be inserted by the Child Welfare Committee
51
52 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
FORM XV
[See rule 22 (xi)]
ORDER OF RESTORATION/PLACEMENT OF A CHILD IN AN INSTITUTION
Case No. To
The Offi cer-in-Charge Whereas on the _____________________ day of ____________________20 _______ (name of the child) ______________________________, son/daughter of ________________ aged _____ residing at _______________________ __________________________________ being in need of care and protection under section 36(3) of the Juvenile Justice (Care and Protection of Children) Act, 2015 (Central Act 2 of 2016) is ordered by the Child Welfare Committee _________________________, to be kept in the Children's Home / Fit Facility / Specialized Adoption Agency ____________________(Name and address of the Institution) for a period of________________ as per section 37(1)(c) of the Juvenile Justice (Care and Protection of Children) Act,
2015.
This is to authorize and request you to receive the said child in your charge, and to keep him/her in the Children's Home/ Fit Facility for the aforesaid order to be carried into execution according to law.
Given under my hand and the seal of Child Welfare Committee.
This ______________________ day of _____________ 20.
(signature) Chairperson/ Member Child Welfare Committee
Encl:
Copy of the orders, particulars of home and previous record, case history and individual care
52
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 53
plan, whichever is applicable:
Form XVI [See rule 22 (xiv)]
QUARTERLY REPORT OF CHILD WELFARE COMMITTEE
District Quarterly report for the period From To Details of CWC
S.No Details Date of appointment Training attended
1 Chairperson
2 Member-1
3 Member-2
4 Member-3
5 Member -4 Details of Cases with CWC
Sl.No. Number of Number of Number of Number of cases Reasons for pen- cases at the cases received cases disposed pending at the end dency beginning of during the of during the of quarter Quarter quarter quarter
FINAL ORDER
Total number of fi nal orders passed during the quarter Released to Transfer Ordered Declared Recommended Recommended Initiate process parents / Guard- to other to stay in legally free for Foster care to JJB for fi l- of compensation ian / Fit person/ CWC CCI for adoption /Sponsorship / ing FIR to Child, if eligible Fit facility After care
VISIT TO HOMES BY CHAIRPERSON / MEMBERS
Date of visit Name and address of Home visited Remark/suggestion of the Committee
Signature of Chairperson
53
54 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
Seal
FORM XVII
[See rule 22 (xvii)] SOCIAL INVESTIGATION REPORT (for Child in need of Care and Protection)
Sl. No________________ Case No. and Child Welfare Committee :______________________________________ Name of the child: Religion
Nick name of the Child Caste
Father's Name Date of birth/Age
Permanent Address Sex
Address of last residence/
Who does the child stay with:
Previous institutional/case history and individual care plan, if any
FAMILY DETAILS
| Relationship to the Child |
Name |
Age |
Education |
Occupation |
In- come |
Health Status |
Disabili- ties if any |
Others/ Social habits |
| Father |
|
|
|
|
|
|
|
|
| Step Father |
|
|
|
|
|
|
|
|
| Mother |
|
|
|
|
|
|
|
|
| Step Mother |
|
|
|
|
|
|
|
|
| Siblings |
|
|
|
|
|
|
|
|
| Guardian/ Relative/ Others |
|
|
|
|
|
|
|
|
Overall Economic status of Family
BPL Poor Lower Middle Class Upper Middle Class Well-to-do
Description of Home & Living Conditions
Type of house: ______________________________
No. of Rooms: ________________
Toilet facilities: Yes No
Drinking Water: Yes No
Environment: Unhealthy Overcrowded Clean
If married, relevant particulars____________________________________________________
Other relatives or agencies interested______________________________________________
Attitude towards religion, normal
and ethical code of the home etc._________________________________________________
Social and economic status_______________________________________________________
Delinquency record of members
of family if any ________________________________________________________________
54
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 55
Inter - Personal Relationship among the family members
Relationship between Father and Mother Parents and the Child
Siblings and the Child
Other factors of importance if any_________________________________________________
CHILD'S HISTORY
Mental condition (Present and past)______________________________________________________________ Physical condition
(Present and past)______________________________________________________________ Habits, interests
(moral, recreational etc.,)___________________________________________________ Outstanding characteristics and
personality traits__________________________________________________________ Companions and their infl uence______________________________________________ Truancy from home, if any
Educational Details
Education level/attainment …………………………………………………………… Name and Locality of the School ………………………………………………………. Reason for leaving school, if so ………………………………………………………… Interest in Extra-curricular activities ......………………………………………………..
Vocational training Details
Vocational interests…………………………………………………………………………………………………………. Training undergone……………………………………………………………………………………………….………… Jobs held, reason for leaving……………………………………………………………………………………………. Attitude towards employment…………………………………………………………………………………………… Parent attitude towards discipline
in the home and child's reaction………………………………………………………………………………………… Neighbours report……………………………………………………………………………………………………………. Any other remarks
RESULT OF INQUIRY (Descriptive)
Emotional factors :
Physical condition :
Intelligence :
Social and economic factors :
Reasons for child's need for care and protection :
Opinion of experts consulted :
Recommendation of the Probation Offi cer :
Signature of the Probation Offi cer or
of the person assigned
55
56 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
FORM XVIII
[See rule 22 (xxi)]
ORDER FOR RESTORATION TO PARENTS / GUARDIAN THROUGH ESCORT
The Child Welfare Committee ………………………(District) on completion of the enquiry and based on the records / fi eld enquiry reports had decided to restore the child …………………… to his/her parents/guardians……………………………(name) residing at ……………………………… ……………………………………. (address). The said parents/guardians had not appeared before the Child Welfare Committee.
Hence, the Offi cer in charge of the ………………………………….Home ……………………………. (Place) is hereby ordered to restore the said child to the above mentioned parents/guardians through proper escort after verifying the identity of the parents/ guardians.
Ordered this the ……..day of …………………20
56
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 57
Child Welfare Committee
(Seal)
FORM XIX
[See rule 22 (xxix)] MONTHLY REPORT OF OPEN SHELTERS TO CHILD WELFARE COMMITTEE/ DISTIRCT CHILD PROTECTION UNIT
Name of the Open Shelter…………….……… Name of the In-charge ……………………..… Registration No……………………………………. Address of the Home……………………………. Period of the Report…………………………….. Details of children available on
Sl. Name of the Father's Address of Date of Reason Duration Facilities- Produced- Remarks, No child name the Child, if admis- for of stay availed before if any available sion admission CWC
(Yes/No)
Total number of children admitted during the month………………………… Total number of children in the Open Shelter on the last day of the month……. Total number of children who availed the facilities of the Open Shelter during the month…………………………………………. Out of these the number of children who availed the services only during the day in the month:
57
58 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
Signature
In-charge of the Open Shelter Home
FORM XX
[See rule 24 (i)]
CASE HISTORY OF CHILD
(for Child Care Institution)
Case/Profi le No.______________ Affi x a latest photograph here Date & Time_________________
A. PERSONAL DATA
1. Name
2. Male / Female 3 . Age at the time of admission 4 . Category: Separated from family/abandoned/deserted/victim of exploitation and violence (give detail)/run-away/any other
5. Religion : Hindu/Muslim/Christian/Other - (OC/BC/SC/ST) (pl. specify)
6. Native District & State:
7. By whom the juvenile was brought before the Child Welfare Committee / Juvenile Justice Board (tick as applicable):
i. Police-Local Police/Special Juvenile Police Unit/Railway Police/Women Police
ii. Probation Offi cers
iii. Social Welfare Organization iv Social Worker
v. Parents(s)/Guardian (please specify the relationship)
8. Reasons for leaving the family:
i. Abuse by parent(s) / guardian(s) / step parent(s)
ii. In search of Employment
iii. Peer group infl uence
iv. Incapacitation of parents
v. Criminal behaviour of parents
vi. Separation of Parents
vii. Demise of parents viii Poverty
ix. Others (please specify)
9. Types of abuse met by the child:
a) Verbal abuse - (parents/siblings/employers/others (pl. specify)
b) Physical abuse -
c) Sexual abuse parents/siblings/employers/others (Pl. specify)
d) Others - parents/siblings/employers/others (pl. specify)
58
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 59
10. Types of ill-treatment met by the child:
a) Denial of food - parents/siblings/employers/others (pl. specify)
b) Beaten mercilessly - parents/Siblings/employers/others (pl. specify)
c) Causing injury - parents/siblings/employers/others (pl. specify)
d) Others (pl. specify) - parents/siblings/ employers/others (pl. specify)
11. Exploitation faced by the child:
i. Extracted work without payment
ii. Little(low) wages with longer duration of work
iii. Others (pl. specify)
12. Health status of the child before admission:
| i |
Respiratory disorders |
present / not known / absent |
| ii |
Hearing impairment |
present / not known / absent |
| iii |
Eye disease |
present / not known / absent |
| iv |
Dental disease |
present / not known / absent |
| v |
Cardiac Disease |
present / not known / absent |
| vi |
Skin disease |
present / not known / absent |
| vii |
Sexually transmitted disease |
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 |
13. With whom the child was staying prior to admission:
i. Parent(s)- Mother/Father/ Both
ii. Guardian(s) - Relationship
iii. Friends
iv. On the street
v. Night Shelter
vi. Orphanages / Hostels / Similar Homes
vii. Others (pl. specify)
14. Visit of the parents to meet the child
i) Prior to institutionalization - Frequently / Occasionally / Rarely / Never
ii) After institutionalization - Frequently / Occasionally / Rarely / Never
15. Visit of the child to his family Frequently / Occasionally / Rarely /During festival times / During summer holidays
i) Prior to institutionalization - Frequently / Occasionally / Rarely/During festival times / During summer holidays
ii) After institutionalization - Frequently / Occasionally / Rarely /During festival times / During summer holidays
16. Correspondence with parents - (mark as Frequently / Occasionally / Rarely /During festival times / During summer holidays)
B CHILDHOOD HISTORY (up to the age of 12 years)
17. Birth details
i) Normal delivery / prolonged delivery / caesarian
59
60 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
ii) Under weight / normal weight/ over weight
18. Details of immunization provided
19. Details of handicap
a) Hearing impairment By birth/ After accident/ diseases
b) Speech impairment By birth/ After accident/ diseases
c) Physical handicap By birth/ After accident/ diseases
d) Mental handicap By birth/ After accident/ diseases
e) Others (please specify)
C. FAMILY DETAILS:
20. Household Composition:
Sl. Name & Age Sex Education Occupa- Income Health History of Handicap Habit Social- No Relationship tion Mental ill- ization
ness
21. Type of family : Nuclear family / Joint family / Broken family
22. Relationship among the family members:
| i |
Father & mother |
Cordial / Non cordial / Not known |
| ii |
Father & child |
Cordial / Non cordial / Not known |
| iii |
Mother & child |
Cordial / Non cordial / Not known |
| iv |
Father & siblings |
Cordial / Non cordial / Not known |
| v |
Mother & siblings |
Cordial / Non cordial / Not known |
| vi |
Juvenile & siblings |
Cordial / Non cordial / Not known |
23. History of crime committed by family members:
S.No Relationship Nature of crime Arrest if any Period of confi ne- Punishment made ment awarded
Father Step Father Mother
Step Mother Brother
Sister
Child
Others
24. Movable and Immovable Properties owned by the family:
60
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 61
25. Parental care towards juvenile before admission:
i. Over protection
ii. Affectionate
iii. Attentive
iv. Not affectionate
v. Not attentive
vi. Rejection
D. ADOLESCENCE HISTORY (Between 12 and 18 years)
26. Puberty
27. 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 (please specify)
28. Reason for delinquent behavior as assessed
i. Parental neglect
ii. Parental overprotection
iii. Parents criminal behavior
iv. Parents infl uence (negative)
v. Peer group infl uence
vi. To buy drugs
vii. Alcohol
viii. Others (pl. specify)
29. Habits (negative)
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
30. Skills and Talent (Pl Specify)
61
62 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
E. EMPLOYMENT DETAILS:
31. Employment details of the juveniles prior to entry into the Home:
Sl.No. Details of employment Time 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)
F. EDUCATIONAL DETAILS:
32. The details of education of the juvenile 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
33. The reason for leaving the 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 infl uence
v. To earn and support the family vi Sudden demise of parents vii Absenteeism followed by running away from school viii Others (pl. specify)
34. The details of the school in which studied last:
i. Corporation
ii. Municipal
iii. Panchayat Union
iv. Government
v. Welfare School vi Private management
35. Medium of instruction:
Hindi/English/Urdu/Tamil/Malayalam/Kannada/Telugu/Other language (please specify)
36. Vocational training undergone from the date of admission into Children's Home till date.
i. No. of years
ii. Name of Vocational Trade
iii. Profi ciency Attained
iv. Details of Certifi cation
62
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 63
37. Extra curricular activities developed from the date of admission into the Children's Home till date
i. Scout
ii. Sports (please specify)
iii. Athletics (please specify)
iv. Drawing
v. Painting vi Others (pl. specify)
G. MEDICAL HISTORY
38. Height and weight at the time of admission:
39. Physical condition:
40. Medical history of the child (gist):
41. Medical history of the parent/guardian (gist):
42. 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 |
|
|
|
|
|
Dental |
|
|
|
|
|
ENT- Tonsils |
|
|
|
|
|
External eye problem: vision |
|
|
|
|
43. Height and Weight Chart:
Date, Month & Year Height Admissible weight Actual weight
H. SOCIAL HISTORY
44. Details of friendship prior to admission into Children's Home:
i. Co-workers
ii. School Friend
iii. Neighbours
iv. Others (pl. specify)
45. Majority of the friends are
i. Educated
ii. Illiterate
iii. same age group
iv. Older in age
63
64 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
v. Younger in age
vi. Same sex
vii. Opposite sex
46. Details of membership in group (please 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 (please specify)
47. The position of the child in the groups/league
i. Leader
ii. Second level leader
iii. Middle level functionary
iv. Ordinary member
48. Purpose of taking membership in the group:
i. For social service activities
ii. For leisure time spending
iii. For pleasure seeking activities
iv. For deviant activities
v. Others (please specify)
49. Attitude and meeting place 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
50. The location/meeting point of the groups
i. Usually at fi xed place
ii. Places are changed frequently
iii. No specifi c places
iv. Meeting point is fi xed conveniently
51. The reaction of the society when the child fi rst came out of the family
i. Supportive
ii. Rejection
iii. Abuse
iv. Ill-treatment
v. Exploitation
64
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 65
52. The reaction of the police towards children
i. Passionate
ii. Cruel
iii. Abuse
iv. Exploitation
v. Ill-treatment
53. The response of the general public towards the child………………………………………..
HISTORY OF THE CHILD (Brief)
(i) Education
(ii) Health
(iii) Vocational training
(iv) Extracurricular activities
(v) Others Suggestion of Child Welfare Offi cer/ Probation Offi cer after orientation to juvenile/child and the response towards orientation Follow up by Child Welfare Offi cer/ Probation Offi cer/ Social Worker
Quarterly Review of Case History by Management Committee
SUPERINTENDENT/CHILD WELFARE OFFICER/
PROBATION OFFICER
65
66 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
FORM XXI
[See rule 26 (1)]
APPLICATION FOR FIT FACILITY
1 Detail of Institution / Agency / Organisation which seeks recognition as fi t facility
1. a Name of the Institution / Agency / Organisation 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 fi t 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 land mark
4 Infrastructure 4.a No. of Rooms (Mention with measurement)
66
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 67
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-Certifi cate 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 Staffi ng 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-Certifi cate of registration)
67
68 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
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.
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 I have read and understood the Juvenile Justice (Care and Protection of Children Act), 2015 and the Tamil Nadu Juvenile Justice (Care and Protection of Children) Rules, 2017.
……………………………. (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 Tamil Nadu Juvenile Justice (Care and Protection of Children) Rules, 2017.
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 / State Act, Rules, Guidelines and Notifi cations 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.
Signature of the authorized signatory: …………………
Name:
Designation:
Address:
District:
Date:
Offi ce Stamp:
Signature of:
Witness No.1……………………………….
Witness No.2 ……………………………….
68
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 69
Form XXII [See rule 26 (2)] Certifi cate of Recognition of Fit Facility
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 Tamil Nadu Juvenile Justice (Care and Protection of Children) Rules, 2017 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 ………………………… day of …………………… 20……………………
(Signature) (Seal)
Dated this ……………………….. day of ………………………20……………………
(Signature)
Chairperson, Child Welfare Committee / Principal Magistrate, Juvenile Justice Board.
69
70 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
Form XXIII [See rule 33(1)(i) and 33 (4)] APPLICATION FOR REGISTRATION/RENEWAL OF CHILD CARE INSTITUTION UNDER THE JUVENILE JUSTICE
(CARE AND PROTECTION OF CHILDREN) ACT, 2015
1. Name and address of the child care Institution :
Phone Number
Fax No
e.mail
2. Registered Offi ce of the NGO (Full Address) :
3. Nature of the home :
4. Name and address of the contact person :
5. Details of the governing body (managing committee/ :
Executive committee)
Registration number and date of Registration of the Institution / Organisation under the relevant Act.
6. Under which act the registration is made :
i) Number, date and place of registration
ii) If renewed, the renewal details
7. Total accommodation capacity of the Child Care Institution :
(Girls and Boys)
8. Total number of children at present :
i) Girls
ii) Boys
9. Infrastructure available in the Child Care Institutions :
i) Total area of campus
ii) Total living area of Building inclusive of the Living area provided to each child, Kitchen, Dining Hall, Store Room, Sick Room, First aid room, Library, separate bathrooms and toilets for girls and boys
iii) Plinth area of each fl oor of the building
iv) Number of fl oors
v) Play ground
vi) Details of building available for academic Programme with specifi cations
vii) Details of facilities available for
i) Vocational
ii) Socio-cultural recreational
iii) Eco friendly programmes with specifi cations
viii) Buildings stability certifi cate and sanitation certifi cate Obtained either from Public Works Department/ Registered Chartered Engineer/ Registered Chartered Architect (mention the validity period)
ix) Certifi cate from Fire Service and Rescue Department
70
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 71
10. i) Number of rooms allotted for girls in the age group of 5 to 10
ii) Number of rooms allotted for girls in the age group of 11 to 18
11. i) Number of rooms allotted for boys in the age group of 5 to 10
ii) Number of rooms allotted for boys in the age group of 11 to 18
12. Details of the offi cer in-charge of the Child Care Institution
i) Name
ii) Age
iii) Educational Qualifi cation
iv) Experience
13. Details of entry and exit points in the institution
14. Details of security personnel provided for the institution
15. i) Specify locations where the CCTV cameras have been installed
ii) If not installed, action taken to install the same
16. Details of menu provided
17. Details of rooms allocated for offi ce in-charge of the Child Care Institution
18. Details of the compound Wall Fencing etc., available for Restricted entry
19. Bathroom / toilet facilities provided
20. Details of the children going to schools
21. Details of registers maintained in the institution
22. Details of the visitors room and visiting hours
23. Details of the supervision of the visitors during the visiting hours
24. Whether identity cards issued to the warden or care taker/care giver of security personnel by the institution
25. Whether the mobile number of the offi cer in-charge of Child Care Institution is prominently displayed.
26. Whether Child Help Line number 1098 displayed in the institution
27. The details of the children registered in Track Child website
28. Source of the income to maintain the Child Care Institution
29. Other facilities
i) Medical facilities
ii) Other social activities run by the institution
30. Linkage with other institutions (Details) Minimum of 40 Sq.ft of fl oor area of dormitory for each child, one bathroom for ten children and one toilet for seven children are mandatory.
I declare that the facts mentioned above is absolutely true to the best of my knowledge. Place:
Date & Seal:
Signature of the Applicant
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72 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
Form XXIV [See rule 33(1) (i)] ACKNOWLEDGEMENT/RECEIPT OF APPLICATION FOR REGISTRATION OF CHILD CARE INSTITUTION
Name and address of the applicant NGO :
Name and address of CCI : District :
Application for registration of Child Care Institution from the above mentioned organization is received in the O/o --------------------
--------- on-----(date).
Signature :
Designation :
Seal:
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TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 73
Form XXV [See rule 33 (2)]
CERTIFICATE OF REGISTRATION
Name and Address of Certifi cate Issuing Authority/Department
CERTIFICATE OF REGISTRATION
No. Dt.
This certifi cate of Registration is awarded to -------as an institution for children in need of care and protection vide S.No. / DSD/ under section 41(1) of the Juvenile Justice (Care and Protection of Children) Act, 2015. This certifi cate of registration is valid for …… from the date of issue and is subject to the following conditions:-
1. The Management should run the institution in accordance with Juvenile Justice (Care and Protection of Children) Act, 2015
2. Based on the infrastructure available at present, the institution shall admit a maximum of ……. children only.
3. This certifi cate should be displayed prominently for the information of parents/general public in the offi ce room.
4. The following words may be mentioned in the name board of the Institution. ----------is registered by the State Government under Juvenile Justice (Care and Protection of Children) Act 2015.
5. The services to the children shall be provided by the institutions registered under the Act as per section 53 of Juvenile Justice (Care and Protection of Children) Act, 2015.
6. The institution shall have a Management Committee in accordance with these Rules to manage the institution and monitor the progress of every child.
7. Institution should follow rules / regulations issued by State Government / Director/Commissioner of Social Defence from time to time.
8. The Institution is subject to inspection by the inspection authorities under the Act and by the persons / offi cers authorized by the State Government / District Child Protection Society / Child Welfare Committee.
9. Orders should be obtained from Child Welfare Committees for all admissions and discharge.
10. Any admission / death / repatriation of the children in the institution and any discharge of children from the institution should be intimated to the concerned District Child Protection Offi cer and Child Welfare Committee in accordance with Tamil Nadu Juvenile Justice (Care and Protection of Children) Rules, 2017.
11. The registration certifi cate is valid for the period mentioned therein and is subject to the condition that all the required certifi cates / NOC are renewed in time before expiry and a copy has to be furnished to the District Child Protection Offi cer of concerned District and to the Directorate of Social Defence.
12. The Institution should provide proper infra-structure facilities including suffi cient accommodation to children.
13. To ensure proper education, child rights and necessary safeguards from child abuses.
14. To provide health facilities, toilet facilities and bathroom facilities.
15. To ensure water and sanitation and also safe drinking water.
16. Suffi cient supervisory and sub - staff should be appointed.
17. To maintain the kitchen in a hygienic manner.
18. To follow daily menu chart and ensure both quality and quantity in diet.
19. To arrange recreation and motivation activities.
20. Necessary fi re safety facilities should be installed.
21. Rain Water harvesting facilities should be made in the Institution.
22. The Institution should not have any Thatched structure.
23. Required number of fi refi ghting equipment should be installed and personnel also should be trained in handling them. The registration shall be subjected to the conditions laid down in the Juvenile Justice (Care and Protection of Children) Act, 2015 and the Rules made thereunder. The institution should comply with Rules / Regulations / Instructions issued by the State Government / Director of Social Defence from time to time.
Dated this………………………..day of………………20
Signature and Seal of the Authority
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74 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
FORM XXVI
[See rule 51 (2)]
APPLICATION FOR SURRENDER OF CHILD BEFORE CHILD WELFARE COMMITTEE
Name of the Child :
Date of Birth / Age :
Sex :
Place of Birth :
Name of the Father :
Name of the Mother :
Details of Siblings :
Medical History of the Child :
Medical History of the Parents :
I ----------------- S/o-------------------aged ------- residing at---------------------------------being ----------------------------------
(relationship with the child) of the child whose particulars are furnished above, unable to provide proper care to the said child due to reasons ------------------------------------------------------------------------------------------------------ (to be mentioned). Hence, I hereby submit the application for surrendering the said child to the Child Welfare Committee--------------------- and I am fully aware of the consequences of surrendering the child and willing to execute the surrender deed as per law. I shall have no objection if the child is given in adoption.
Encl
1. Birth Certifi cate
2. Child Health Records
3. Proof of Identity of Parents
Signature of the Applicant
Name and Address :-
To
The Child Welfare Committee, Dist………
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TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 75
FORM XXVII
[See rule 51(2)]
DEED OF SURRENDER
Declaration by person surrendering the child or children
Case No………….. I/We, the undersigned………………Family name / First name(s)………residing at, surrender the child (named)……….aged……… having date of birth…………………for the reason:……………………
(i) I/we are surrendering my/our child or children on our own and without any coercion, compulsion, threat, payment, consideration, compensation of any kind;
(ii) 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.
(iii) I/we have been made aware of the implications of surrender and are conscious of the fact that after the 60thday from date of the surrender deed, the legal parent-child relationship between my/our child or children and me/us will be terminated.
(iv) 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.
(v) 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.
(vi) 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.
(vii) 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)]
Declaration by Witnesses We the undersigned have witnessed the above surrender. Signature, Name and Address of the fi rst witness
...........................................................................
Signature, Name and Address of the second witness
...........................................................................
3. Certifi cation of child welfare committee We hereby certify that the person and the witness(es) named or identifi ed above appeared before me this date and signed this document in our presence.
Done at ................ on..............
Signature & Seal of Members/ Chairperson
Child Welfare Committee
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76 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
Form XXVIII [See rule 53(6)]
ORDER OF SPONSORSHIP PLACEMENT
The child ___________________________________________ approximate age____________ D/o or S/o Mr.____ ____________________________ and Mrs.__________________________or Ms.______________________________ residing at (address)_____________________________________________________________ being found in Reference No. ____________ has been identifi ed by the State / District Child Protection Unit as a child in need of care and protection and support under the sponsorship programme.
On the basis of the Inquiry Report submitted by the State Child Protection Society / District Child Protection Unit / Child Welfare Offi cer / Social Worker / Probation Offi cer it is established that the said child needs sponsorship support for education/ health/nutrition/ other developmental needs_______________________________(please specify).
The State Child Protection Society / District Child Protection Unit is requested to explore the possibility of sponsorship for the need of child.
Principal Magistrate, Juvenile Justice Board/Children's court Chairperson/Member, Child Welfare Committee Copy to:
State Child Protection Society /District Child Protection Unit or Concerned Department of the State Government
76
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 77
FORM XXIX
[See rule 55(7)]
HOME STUDY REPORT FOR PROSPECTIVE FOSTER PARENTS
DATE OF REGISTRATION -
AADHAR CARD No. of Prospective Foster Parent : -
NAME OF THE SOCIAL WORKER -
DATE OF HOME VISIT
- Part-I of the format shall be fi lled up by the prospective foster parents and Part-II of the template shall be fi lled up by the Social Worker to submit an assessment report along with his/her observation about suitability of the prospective adoptive / foster parents.
PART-I : SELF ASSESSMENT
A. Information about the prospective foster parents and their family background 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 Qualifi cation
Employment/occupation
Name & Address of the present Employer/Business concern Annual Income
Health Status
B. Family background information:
(1) Give a short description of social status and background of the prospective foster parents along with the following information:-
| Details about Parents of the Applicants |
|
Father |
Mother |
| Name in full |
|
|
| Age |
|
|
| Nationality/Citizenship |
|
|
| Occupation |
|
|
| Previous occupation |
|
|
| Presently residing with |
|
|
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78 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
(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.
Name of the Child Sex Date of Birth Educational Status
(3) If there are other members residing, please furnish the following information in respect of them.
Name Nature of Age Gender Occupation Relationship
(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):
| Foster Father |
| Organisation |
Employer Details (Name & Address) |
Job Title |
From |
To |
| Foster Father |
| Organisation |
Employer Details (Name & Address) |
Job Title |
From |
To |
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……………………
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:
Provide a companion to your other children;
Provide a child with a happy home;
Others, please specify ……………………………….
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TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 79
(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:
They will be less lonely;
They will learn to be more accommodating;
They will become more empathetic;
Not applicable as I have no other children;
Others, please specify ______________________________________
G. Attitude of grandparents/extended family members, other relatives and signifi cant 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 diffi culties, please describe the steps that you plan to take to ease his/her transition into the family?
(5) Would you be prepared to utilize family counselling if the child continues to have diffi culties in adjusting?
(a) Yes
(b) No
(6) Would you be willing to support fi nancially 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?
Signature of the Prospective Foster Parents Date
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80 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
PART-II: ASSESSMENT REPORT OF THE SOCIAL WORKER
(To be used by the Social Worker to prepare the assessment report) (The information/facts fi lled in the template shall be kept confi dential by the agencies /authorities.)
1. Factual Assessment
(i) Have you verifi ed the contents of the facts mentioned in Part I of the template?
Yes/No
(ii) Are you satisfi ed about the facts mentioned in the documents vis-à-vis observation during interviews and visits?
Yes/No
2. Psycho-social 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 fi ndings
(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?
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 children 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 fi nancial status of the prospective foster parents? Are they fi nancially sound to welcome another member into their family?
(ii) Have you observed any fi nancial situation which is hidden in the template?
(iii) Would you recommend any fi nancial 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 rational for recommending the prospective foster parents for foster care.
3.2. In case, you do not recommend the prospective foster parents for foster care, cite appropriate reasons for taking such decision.
Signature, name, designation and offi cial seal
80
TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY 81
FORM XXX
[See rule 58(5)]
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 fi t for foster-care placement of the child after considering the Individual Care Plan, Child Study Report and Home Study Report.
OR
Child Care Institution (Name and address)…………………………is declared fi t 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 Offi cer/Social Worker (name and contact)………………………………………...............
Chairperson/ Member Child Welfare Committee
FORM XXXI
[See rule 59(1)] 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:
(1) If the conduct of the child is unsatisfactory I/we shall at once inform the Committee
(2) 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.
(3) In the event of his illness, he shall have proper medical attention in the nearest hospital and a report of it followed by a fi tness certifi cate shall be submitted before the Committee.
(4) I/We shall inform the Committee about any change of address.
(5) I/We shall do my best to ensure that the child will not be subjected to any form of abuse.
(6) I/We agree to adhere to the conditions laid by the Committee.
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82 TAMIL NADU GOVERNMENT GAZETTE EXTRAORDINARY
(7) I/We undertake to produce him before the Committee as and when required.
(8) I/We undertake to inform the Committee immediately if the child goes out of my charge or control. Dated this ………………day of ………………..20
Signature and address of 2 witnesses Signature of Applicant(s) (Signed before me)
Chairperson/Member, Child Welfare Committee
K. MANIVASAN,
Principal Secretary to Government.
PRINTED AND PUBLISHED BY THE DIRECTOR OF STATIONERY AND PRINTING, CHENNAI
ON BEHALF OF THE GOVERNMENT OF TAMIL NADU
82