ACT

de examinare a condiiilor locative

din __________________________2013
A familiei_ ____________________________________________________________________
Domiciliul_s. Crihana Veche______________________________________________________
De ctre ______________________________________ ______________________________
______________________________________________________________________
______________________________________________________________________
n prezena prinilor ____________________________________________________________
Au fost examinate condiiile de trai ale minorului:_____________________________________
_____________________________________________________________________________
Prin examinare s-a constatat c familia este compus din:
Numele,
prenumele

Data, luna,
anul naterii

Statutul
social al
persoanei

IDNP

Legitimaia

Gradul de
rudenie

CONDIIILE DE TRAI
Statutul legal al spaiului locativ (de subliniat): locuin: de stat, proprietate privat, chirie.Tipul
de locuin: cmin, cas la sol, apartament la bloc. Altele specificai:
Numrul de odi_________________Suprafaa locativ_________ m2 _________________
Suprafaa total_______
m2____________________________________________________
Alt imobil_____________________________________________________________________
Pmnt agricol_____________

ha______Pmnt pe lng cas_________________________

Bunuri:televizor_________________main de splat____________(ani)__________________
Alte bunuri (autovehicol,maini agricole)_________(ani)________________________________
Condiii: Conectri: la reeaua de gaze__ ___,energie electric_______,energie termic______,
ap______. Altele_____________________________________________________________
Starea igienic sanitar:__________________________________________________________

ngrijire i asigurarea securitii copilului. (Spaiu rezervat pentru copil i asigurarea cu obiecte
de ngrijire i educaie_____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Venitul lunar al familiei: Indicai sursa i suma (salariile, pensiile, alocaiile pentru copil i
orice alt venit pe care l are familia): _______________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Patologii familiale (abuz de alcool, de droguri, violen domestic, abuz fa de copii, neglijarea
obligaiilor printeti)
__-------_______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Relaiile dintre membrii familiei:_ _________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Caracteristica prinilor__________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
n legtur cu care fapt a avut loc examinarea______________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Concluzii:_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Semnturile membrilor comisiei _____________________________________
________________________________