PREFEITURA

DA CIDADE DO RIO DE JANEIRO

Secretaria Municipal de Educação

FICHA DE COMUNICAÇÃO DE CASOS SUSPEITOS OU CONFIRMADOS

DE VIOLÊNCIA CONTRA CRIANÇAS OU ADOLESCENTES
(Crianças e adolescentes até 18 anos incompletos, pessoas com deficiência até 21 anos)

I – Identificação da Unidade Escolar/ Unidade Administrativa/ Setor

Nome completo do Órgão:

Endereço do Órgão:

Bairro:

CEP: Tel/Fax:

Gestor do Órgão:
E-mail do Órgão:

II – Identificação da Criança/Adolescente

Nome completo:
Data de Nascimento: / / Idade: Sexo: M F

Nome da Unidade Escolar na qual a criança ou Adolescente está matriculada:

Onde vive: Instituição Família

Responsáveis legais: Grau de relacionamento:
1. 1.
2. 2.

Pessoas que cuidam da Criança: Grau de relacionamento:

1. 1.
2. 2.

Endereço:
Número: Complemento: Município:
Bairro: Telefones:

Referência para localização:

PREFEITURA
DA CIDADE DO RIO DE JANEIRO
Secretaria Municipal de Educação

III – Informações que suscitaram a suspeita ou dados sobre a confirmação

de violência contra a criança e adolescente:

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 IV – Tipos de Violência:

Física Sexual Psicológica Negligência /Abandono

Outro (especificar):

V – Ações Complementares

Encaminhamentos ou contatos:
Programa Saúde na Escola Data: / /

Especificar): _______________________________________________________________________
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Unidades de Saúde do Território Data: / /

Especificar): _______________________________________________________________________
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Centro de Referência Especializada de Assistência Social Data: / /

Especificar): _______________________________________________________________________
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Centro de Referência de Assistência Social Data: / /

Especificar): _______________________________________________________________________
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Coordenadoria Regional de Educação Data: / /

Especificar): _______________________________________________________________________
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 PREFEITURA
DA CIDADE DO RIO DE JANEIRO
Secretaria Municipal de Educação

VI – Informações sobre a remessa da comunicação

Conselho Tutelar da área

E/SUBE/ CRE
Envolvidos na elaboração da Ficha de Comunicação

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VII – Remessa e Fluxo

Data: / /

Assinatura e carimbo da Direção do Orgão

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Data:
 VIII – Ações a serem desenvolvidas a partir dos elementos que este caso suscita
para o processo de desenvolvimento e aprendizagem do aluno e da proposta
geral da Unidade Escolar.

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