Annex No. 2

Sample Form to Record Basic Information on Unaccompanied Child^*

(* adapted from "Unaccompanied Children in Emergencies", ISS, 1987)

1. Child: _________________________________ Registration No:_____
Family Name:________________________________________________
Given name/forename:________________________________________
Also known as:_______________________________________________
Date of Birth: __________ Place of Birth: __________________________
Age: ____ Sex: ___ Nationality:__________________________________
Religion: ________ Tribe/caste/ethnic origin: _____________________
Languages spoken:____________________________________________
Education/schools attended:____________________________________
Last permanent address:_______________________________________
Identifying features or marks:___________________________________
Personal belongings:___________________________________________

2. Accompanying brothers, sisters, other child relatives (names, sex, age, relationship):
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

3. Family members (include mother, father, brothers and sisters, grandparents, aunts, uncles, other relatives and household members):

Name:_______________________________________________________
Relationship: _____________ Age/Date of Birth:____________________
Address:_____________________________________________________
Present whereabouts:___________________________________________
_____________________________________________________________

Name:_______________________________________________________
Relationship: _____________ Age/Date of Birth:____________________
Address:_____________________________________________________
Present whereabouts:___________________________________________
_____________________________________________________________
If parents are dead, give date, place, and cause of death:______________

4. Guardian (with whom child lived/lives, if not parents):

Name:_______________________________________________________
Relationship (if any):___________________________________________
Address:_____________________________________________________

5. Circumstances when child was found/identified:__________________
When and where found (give dates, time and place):__________________
With whom was the child? (give names addresses and relationship to child):
_____________________________________________________________

6. Information concerning the child's separation from the family:_________
Date and place of separation:_______________________________________
Reason for separation:_____________________________________________
When and where did the child last see the parents or other family members?
______________________________________________________________
If the parents are presumed dead, why does the child believe this to be so?
_______________________________________________________________

7. Information about the child's life before separation (record places, people and important events the child remembers):
________________________________________________________________

8. What has happened to the child since separation?
________________________________________________________________
Where and with whom has the child lived, and for how long?
________________________________________________________________
Record places, people and events the child remembers:
________________________________________________________________

9. Description of the child's physical health and past medical history:
________________________________________________________________

10. Description of the child's present emotional state as well as relationships with other children and adults, daily care, and any specific needs which are not being met:
________________________________________________________________

11. Information on the child's wishes and plans for the future:
With whom does the child wish to be reunited?__________________________
_________________________________________________________________
What is their relationship?___________________________________________
Where and how might they be located?_________________________________

12. Please include other details relevant to tracing the child's family, i.e. names and addresses of significant persons who could provide information:
________________________________________________________________
________________________________________________________________

Signature of Interviewer:_________________ Place:______________________
Organization:_____________________________ Date:____________________