Prontuário SUAS

N do Pronturio:
Nome da Pessoa de
Referncia na Famlia:
PRONTURIO SUAS
Tipo de Unidade:
|__| CRAS
|__| CREAS
N da Unidade: |__|__|__|__|__|__|__|__|__|__|__|__|
Nome da Unidade: ____________________________________________________________________________
Registro Simplificado do Acompanhamento

N
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Data de
Atendimento
_ _/_ _/_ _ _ _
_ _/_ _/_ _ _ _
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Descrio Sumria
Nome do Tcnico Responsvel
Prezado(a) Profissional, leia com ateno esta pgina antes de iniciar o uso desse instrumento
Aps a leitura, destaque esta pgina para facilitar o manuseio do Pronturio
O Pronturio SUAS um instrumento tcnico que tem como objetivo

contribuir para a organizao e qualificao do conjunto de informaes necessrias
ao diagnstico, planejamento e acompanhamento do trabalho social realizado com
as famlias/indivduos. Permite aos profissionais da Unidade registrar as principais
caractersticas da famlia e as aes realizadas com a mesma, preservando assim todo
o histrico de relacionamento da famlia com os servios da Unidade. A sua Unidade
recebeu o Manual de Instrues para utilizao do Pronturio SUAS, leia-o com
ateno e consulte-o sempre que achar necessrio.
As anotaes realizadas no Pronturio devem ser efetuadas de forma
gradativa, seguindo o fluxo prprio dos atendimentos no decorrer do processo de
acompanhamento familiar. importante notar que o aspecto central e mais
importante desse instrumento possibilitar o registro organizado de informaes
relativas ao processo de acompanhamento da famlia. Dessa maneira, o Pronturio ,
sobretudo, um instrumento para realizar anotaes sobre riscos, vulnerabilidades e
potencialidades da famlia, e sobre o planejamento e evoluo do processo de
acompanhamento. Isso significa que esse instrumento nunca deve ser utilizado como
um questionrio a ser aplicado ao usurio. Toda informao anotada/registrada
(inclusive dos campos fechados) deve ser fruto do processo natural de dilogo e de
escuta qualificada que so prprios do trabalho social com as famlias.
Para as famlias j inseridas no Cadastro nico de Programas Sociais, algumas
informaes socioeconmicas do domiclio e das pessoas j foram coletadas por
profissionais do prprio municpio, portanto sugere-se que o formulrio do Cadnico
seja impresso e anexado ao Pronturio, dispensando assim a duplicao de esforos
na obteno e registro das mesmas informaes. No caso de famlias que ainda no
estejam cadastradas, mas que tenham perfil Cadnico (renda familiar per capita at
salrio mnimo, ou renda familiar total at 3 salrios mnimos) deve-se sempre
providenciar o cadastramento da mesma.
Por fim, lembre-se sempre de que esse Pronturio contm informaes
pessoais e sigilosas. As anotaes e a leitura de seu contedo devem ser realizadas
apenas pela equipe de referncia da Unidade, e exclusivamente para as aes
pertinentes ao atendimento e acompanhamento da famlia. Os Pronturios devem
guardados em local seguro e de acesso restrito (armrio ou arquivo com chave em
sala que no seja de acesso pblico).
Data de Abertura do Pronturio: |__|__| / |__|__| / |__|__|__|__|
Identificao da Pessoa de Referncia e Endereo da Famlia

Nome Completo da Pessoa de Referncia: _______________________________________________________________
Apelido (caso seja relevante): _________________________________________________________________________
Nome da me: ______________________________________________________________________________________
NIS da Pessoa de Referncia: |__|__|__|__|__|__|__|__|__|__|
CPF: |__|__|__|__|__|__|__|__|__|__|__|
RG: |__|__|__|__|__|__|__|__|__|__|__|__| rgo: _______ UF: |__|__| Data de emisso: :____ / ____ / ______
Endereo (Rua, Av.): ________________________________________________________________________________
Nmero: __________ Complemento: _______________________ Bairro:____________________________________
Municpio: _____________________________________________ UF: _______ CEP: |__|__|__|__|__|-|__|__|__|
Ponto de Referncia: ________________________________________________________________________________
Telefones de Contato: ________________________________________________________________________________
Localizao do Domiclio: |__| Urbano
|__| Rural
( )Assinale caso o endereo seja de um Abrigo
ATUALIZAO DO ENDEREO
Data de atualizao:____ / ____ / _______
Endereo (Rua, Av.): ________________________________________________________________________________
Nmero: __________ Complemento: _______________________ Bairro:____________________________________
Municpio: _____________________________________________ UF: _______ CEP: |__|__|__|__|__|-|__|__|__|
Ponto de Referncia: ________________________________________________________________________________
Telefones de Contato: ________________________________________________________________________________
Localizao do Domiclio: |__| Urbano
|__| Rural
( )Assinale caso o endereo seja de um Abrigo
Forma de ingresso na unidade e motivo do primeiro atendimento

De que forma a famlia (ou membro da famlia) acessou a Unidade para o primeiro atendimento?
|__|Por demanda espontnea
|__|Em decorrncia de Busca Ativa realizada pela equipe da unidade
|__|Em decorrncia de encaminhamento realizado por outros servios/unidades da Proteo Social Bsica
|__|Em decorrncia de encaminhamento realizado por outros servios/unidades da Proteo Social Especial
|__|Em decorrncia de encaminhamento realizado pela rea de Sade
|__|Em decorrncia de encaminhamento realizado pela rea de Educao
|__|Em decorrncia de encaminhamento realizado outras polticas setoriais
|__|Em decorrncia de encaminhamento realizado pelo Conselho Tutelar
|__|Em decorrncia de encaminhamento realizado pelo Poder Judicirio
|__|Em decorrncia de encaminhamento realizado pelo Sistema de Garantia de Direitos (Defensoria Pblica,
Ministrio Pblico, Delegacias)
|__|Outros encaminhamentos
Sempre que o acesso for decorrente de algum encaminhamento, identifique detalhadamente o Nome e Contato do
rgo/unidade que encaminhou o usurio: ________________________________________________________________
______________________________________________________________________________________________
Quais as razes, demandas ou necessidades que motivaram este primeiro atendimento?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Assinale abaixo caso a famlia, ou algum de seus membros, seja beneficiria de algum dos seguintes Programas Sociais:
|__| Bolsa Famlia
|__| BPC
|__| PETI
|__| Outro(s) Programa(s) prioritrio(s): ___________________

___________________________________________________
___________________________________________________
Composio Familiar
N de
Ordem
(Data da Anotao: ____ / ____ / _______ )
Nome Completo
Sexo
(Sempre comear a lista pela Pessoa de Referncia)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
(
(
(
(
(
(
(
(
(
(
(
(
(
(
)M
)M
)M
)M
)M
)M
)M
)M
)M
)M
)M
)M
)M
)M
(
(
(
(
(
(
(
(
(
(
(
(
(
(
Data de Nascimento
)F
)F
)F
)F
)F
)F
)F
)F
)F
)F
)F
)F
)F
)F
Idade
* Parentesco
com a pessoa
de Referncia
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
Assinale em
caso de
Pessoa com
Deficincia
(
(
(
(
(
(
(
(
(
(
(
(
(
(
)
)
)
)
)
)
)
)
)
)
)
)
)
)
**Assinale caso seja identificada

necessidade de providenciar
documentao civil da pessoa
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
|_|CN |_| RG |_|CTPS |_|CPF |_|TE
* Cdigos de Parentesco: 1-Pessoa de Referncia; 2-Cnjuge/ companheiro(a); 3-Filho(a); 4-Enteado(a); 5-Sobrinho(a); 6-Pai/ Me; 7-Sogro(a); 8-Neto(a), Bisneto(a); 9-Irmo/irm; 10-Cunhado(a); 11-Outro parente; 12-No parente
** Documentao:
CN=Certido de Nascimento
RG= Carteira de Identidade
CTPS=Carteira de Trabalho e Previdncia social
CPF=Cadastro de Pessoa Fsica
TE= Ttulo de Eleitor
Ateno: Caso necessite excluir uma pessoa da composio familiar (separao/diviso da famlia, bito etc) marque um X sobre o nmero de ordem e realize na pgina ao lado as
observaes relativas data e motivo da excluso.
Perfil Etrio do Grupo Familiar

Faixas Etrias
Pessoas de 0 a 6 anos
Pessoas com 70 anos ou mais
Total de Pessoas na Famlia
Especificidades sociais, tnicas ou culturais da famlia

Qtd de Pessoas
|__| Famlia/pessoa em situao de rua

|__| Famlia quilombola
|__| Famlia ribeirinha
|__| Famlia Cigana|__| Famlia indgena residente em aldeia/reserva
Especifique o povo/etnia: _____________________________________________
|__| Famlia indgena no residente em aldeia/reserva
Especifique o povo/etnia: _____________________________________________
Composio Familiar
Outras observaes referentes ao diagnstico da composio famliar
(Ateno! Toda anotao includa neste espao deve ser precedida da data, nome e funo do profissional responsvel pela mesma)
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Condies Habitacionais da Famlia
(No se aplica a famlias/pessoas residentes em abrigos ou em situao de rua)
Caractersticas do Domiclio
a. Tipo de residncia
Prpria
Alugada
Cedida
Ocupada
b. Material das paredes externas do domiclio
Alvenaria ou madeira aparelhada
Madeira aproveitada, taipa ou outros materiais precrios
b. Acesso a Energia eltrica
Sim, com Medidor prprio
Sim, com Medidor compartilhado
Sim, sem medidor
No possui Energia Eltrica no domiclio
d. Possui gua canalizada
Sim
No
e. Forma de abastecimento de gua
Rede geral de distribuio
Poo ou nascente
Cisterna de captao de guas de chuva
Carro pipa
Outra
f. Escoamento sanitrio
Rede coletora de esgoto ou pluvial
Fossa sptica
Fossa rudimentar
Direto para vala, rio, lago ou mar
Domiclio sem banheiro
g. Coleta de lixo
Sim, coleta Direta
Sim, coleta Indireta
No possui coleta
h. Qual o nmero total de cmodos do domiclio
Nmero de Cmodos
i. Qual o n de cmodos utilizados como dormitrio
Nmero de dormitrios
j. Quanto n de pessoas do domiclio dividido pelo n de dormitrios ?
Nmero mdio de pessoas por dormitrio
k. O domiclio est localizado em rea de risco de desabamento ou alagamento?
Sim
No
l. O domiclio est localizado em rea difcil acesso geogrfico?
Sim
No
m. O domiclio est localizado em rea com forte presena de conflito/violncia?
Sim
No
Marque o item
correspondente
Utilize para
atualizao do
domiclio
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Data da Anotao: ____ / ____ / _____
____ / ____ / _____
Condies Habitacionais da Famlia
(No se aplica a famlias/pessoas residentes em abrigos ou em situao de rua)
Outras observaes referentes ao diagnstico das condies habitacionais da famlia

(Ateno! Toda anotao includa neste espao deve ser precedida da data, nome funo do profissional responsvel pela mesma)
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Condies Educacionais da Famlia

N de
Ordem
Primeiro Nome
(Liste as pessoas obedecendo
sempre o mesmo n de Ordem)
Data da Primeira Anotao: ____ / ____ / ________
Idade
(
(
(
(
(
(
(
(
(
(
(
(
(
(
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
(
(
(
(
(
(
(
(
(
(
(
(
(
(
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
(
(
(
(
(
(
(
(
(
(
(
(
(
(
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
(
(
(
(
(
(
(
(
(
(
(
(
(
(
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
Atualizao
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
Qtd de pessoas entre 0 e 5 anos que no esto frequentando escola ou creche

Qtd de pessoas entre 06 e 14 anos que no esto frequentando escola
Qtd de pessoas entre 15 e 17 anos que no esto frequentando escola
Qtd de pessoas entre 10 e 17 anos que no sabem ler/escrever
Qtd de pessoas entre 18 e 59 anos que no sabem ler/escrever
Qtd de pessoas com 60 anos ou mais que no sabem ler/escrever
(
(
(
(
(
(
(
(
(
(
(
(
(
(
1 Anotao
Atualizao
Cdigos de
Escolaridade
Atualizao
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
0 Educao Infantil/creche
1 1 ano E. Fundamental
10 1 ano E. Mdio
11 2 ano E. Mdio
12 3 ano E. Mdio
13 Superior Incompleto
14 Superior Completo
19 EJA
20 Nunca freqentou escola
Anotaes sobre descumprimento de condicionalidades de Educao

no Programa Bolsa Famlia
Identificao de Vulnerabilidades Educacionais

Caractersticas de Vulnerabilidade Educacional
(ltima srie concluda com aprovao)
Atualizao
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
Data de Atualizao: ____ / ____ / _______
Escolaridade
Frequenta escola atualmente?
Sabe ler e
escrever?
1 Anotao
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Quantidade
de pessoas
Quantidade
de pessoas
Quantidade
de pessoas
(Atualizao)
(Atualizao)
N de
Ordem
Data da ocorrncia
(Ms/Ano)
____ / _____
____ / _____
____ / _____
____ / _____
____ / _____
____ / _____
____ / _____
____ / _____
____ / _____
Efeito*
(Cdigo)
* Cdigos para os Efeitos

gerados por descumprimento
de Condicionalidades
1. Advertncia
2. Bloqueio
3. Primeira Suspenso
4. Segunda Suspenso
5. Cancelamento
Condies Educacionais da Famlia

Outras observaes referentes ao diagnstico das condies educacionais da famlia
(Ateno! Toda anotao includa neste espao deve ser precedida da data e do nome do profissional responsvel pela mesma)
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Condies de Trabalho e Rendimentos da Famlia

N de
Ordem
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Primeiro Nome
(Liste as pessoas obedecendo
sempre o mesmo n de Ordem)
Idade
Possui
Carteira
de
Trabalho?
(
(
(
(
(
(
(
(
(
(
(
(
(
(
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
(
(
(
(
(
(
(
(
(
(
(
(
(
(
Data da Primeira Anotao: ____ / ____ / ________
Condio de Ocupao
1 Anotao
Atualizao
Atualizao
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
Possui
qualificao
profissional?
(
(
(
(
(
(
(
(
(
(
(
(
(
(
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
)S
(
(
(
(
(
(
(
(
(
(
(
(
(
(
Renda Mensal (R$)

Caso sim, qual?
Aqui no devem ser considerados recursos

recebidos de Programas Sociais, tais com
BPC ou Bolsa Famlia
1 Anotao Atualizao
Atualizao
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
)N
Cdigos da Condio de Ocupao: 0 No Trabalha; 1 Desempregado ; 2 Conta prpria/autnomo/bico; 3 Empregado com Carteira; 4 Empregado sem Carteira; 5 Empregador; 6 Estagirio/Aprendiz
Renda total da famlia: (Sem considerar a renda recebida de programas sociais)

R$ _______________
Atualizaes: R$ _______________ / R$ _______________
Para famlias que recebem o BPC, indique o nmero de ordem da(s) pessoa(s)
Beneficiria(s):
N de Ordem da(s) pessoa(s): ____________________________
Renda familiar per capita (Sem considerar a renda recebida de programas sociais)
R$ _______________
Atualizaes: R$ ________________ / R$ ________________
Algum membro da famlia aposentado ou pensionista?

|__| No |__| Sim. Se sim, indique o n de ordem da(s) pessoa(s):_________________
A famlia recebe dinheiro de algum Programa Social?

|__| No |__| Sim
Qual a renda total da famlia, incluindo o valor recebido de programas sociais?

R$ __________________
Atualizaes: R$ _______________ / R$ _______________
Anote o valores recebidos pela famlia por meio de Programas Sociais
Qual a Renda familiar per capita, includo o valor recebido de programas sociais?
R$ ________________
Atualizaes: R$ ________________ / R$ ________________
|__|Bolsa Famlia - Valor: R$__________ Atualizaes: R$___________ R$__________

|__|BPC
- Valor: R$__________ Atualizaes: R$___________ R$__________
|__|PETI
- Valor: R$__________ Atualizaes: R$___________ R$__________
|__|Outros
- Valor R$__________ Atualizaes: R$___________ R$__________
Ateno! Fique atento para identificar famlias potencialmente elegveis aos programas
de transferncia de renda e que ainda no recebem o benefcio ao qual tm direito.
Condies de Trabalho e Rendimentos da Famlia

Outras observaes referentes ao diagnstico das condies de trabalho e rendimentos da famlia
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Condies de Sade da Famlia

Caso haja presena de pessoa com deficincia na famlia, preencha o quadro abaixo:
Necessita de cuidados
N de
*Tipo(s) de
Primeiro Nome
constantes de outra
Ordem
deficincia(s)
pessoa
( )Sim ( )No
( )Sim ( )No
( )Sim ( )No
( )Sim ( )No
( )Sim ( )No
* Tipos de deficincia: 1. Deficincia visual
2. Deficincia auditiva
3. Deficincia fsica
5. Sndrome de Down
6. Transtorno/doena mental
Quem o responsvel pelo

cuidado
4. Deficincia mental ou intelectual

7. Deficincias mltiplas
A famlia possui algum integrante que, devido envelhecimento ou doena, necessite de cuidados constantes de outra pessoa para
realizar atividades bsicas, tais como, tomar banho, alimentar-se, ficar s em casa, locomover-se dentro de casa etc.?
|__| No
|__| Sim.
Caso sim, registre o N de Ordem e/ou nome(s) da(s) pessoa(s): __________________________________
Quem responsvel pelo cuidado: __________________________________________________________
A famlia declara, ou fornece indcios, de que vivencia situao de insegurana alimentar devido a insuficincia de alimentos?
|__| No
|__| Sim.
(Data da anotao: ___ / ___ / ____)
Algum membro da famlia portador de alguma doena grave?

|__| No
|__| Sim.
Caso sim, registre o N de Ordem e/ou nome(s) da(s) pessoa(s) e o(s) tipo(s) de doena(s):________
_________________________________________________________________________________
Algum membro da famlia faz uso de remdios controlados (tarja preta) para transtornos mentais?
|__| No
|__| Sim. Caso sim, registre o N de Ordem e/ou nome(s) da(s) pessoa(s): _____________________________
Algum membro da famlia faz uso abusivo de lcool? (Data da anotao: ___ / ___ / ____)
|__| No
|__| Sim.
Caso sim, registre o N de Ordem e/ou nome da(s) pessoa(s): ______________________________
Algum membro da famlia faz uso abusivo de Crak ou outras drogas (cocana, maconha etc)? (Data da anotao: ___/___/___)
|__| No
|__| Sim. Caso sim, registre o N de Ordem e/ou nome(s) da(s) pessoa(s) e o(s) tipo(s) de substncia(s):______
_________________________________________________________________________________
Registre a presena de gestante(s) na famlia:

N de
Quantos meses
Primeiro Nome
Ordem
de Gestao?
J iniciou Pr-Natal
(
(
(
(
(
)Sim
)Sim
)Sim
)Sim
)Sim
(
(
(
(
(
)No
)No
)No
)No
)No
Data da anotao
_____ / _____ / ________
_____ / _____ / ________
_____ / _____ / ________
_____ / _____ / ________
_____ / _____ / ________
Anotaes sobre descumprimento de condicionalidades de sade no Programa Bolsa Famlia

* Cdigos para os Efeitos gerados por
N de
Semestre de ocorrncia
Primeiro Nome
*Efeito
Ordem
(Semestre/Ano)
descumprimento da Condicionalidades
1. Advertncia
______ / _______
2. Bloqueio
______ / _______
3. Primeira Suspenso
______ / _______
4. Segunda Suspenso
______ / _______
5. Cancelamento
______ / _______
Condies de Sade da Famlia

Outras observaes referentes ao diagnstico das condies de sade da famlia
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Sempre que possvel, identifique e registre nessa pgina a Unidade Bsica de Sade que referencia esta famlia e o nome do Agente
Comunitrio de Sade que costuma visit-la. Essa informao pode ser til para futuras trocas de informaes intersetoriais no nvel local.
Acesso a Benefcios Eventuais

Utilize o Quadro abaixo para registrar os Benefcios Eventuais concedidos para a Famlia por esta Unidade.
Registro de concesso de Benefcios Eventuais da Assistncia Social

Data
Tipo de
Benefcio
(Cdigo)
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
___/___/____
|___|
Cdigos para os Tipos de Benefcio:
N do Registro de
Nascimento da criana
(apenas para auxlio
Natalidade)
Observao
1 Auxlio Natalidade;
4-
2 Auxlio Funeral;
;5-
3;6-
N do CPF da pessoa
falecida
(apenas para auxlio
funeral)
Acesso a Benefcios Eventuais

Outras observaes referentes ao acesso a Benefcios Eventuais
(Ateno! Toda anotao includa neste espao deve ser precedida da data e do nome e funo do profissional responsvel pela mesma)
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Convivncia Familiar e Comunitria

H pessoas dependentes (crianas, idosos dependentes ou pessoas com deficincia) que permanecem perodos do dia em
casa sem a companhia de um adulto?
|__| No
|__| Sim. Caso sim, utilize a pgina ao lado para anotar as informaes que sejam relevantes.
A famlia, ou algum de seus membros, vtima de ameaas ou de discriminao na comunidade onde reside?
|__| No
H quantos anos a famlia mora neste estado: |__|__| anos
( ) a famlia sempre morou no estado
H quantos anos a famlia mora no municpio: |__|__| anos
( ) a famlia sempre morou no municpio
H quantos anos a famlia mora no bairro atual: |__|__| anos
( ) a famlia sempre morou no mesmo bairro
A famlia possui parentes que residam prximo ao seu local de moradia e que constituam rede de apoio e solidariedade?
|__| Sim. Caso sim, utilize a pgina ao lado caso queira anotar o nome, parentesco e contato destes parentes mais prximos.
|__| No
A famlia possui vizinhos que constituam rede de apoio e solidariedade?
|__| Sim. Caso sim, utilize a pgina ao lado caso queira anotar o nome e contato de algum vizinhos mais prximo.
|__| No
A famlia, ou algum de seus membros, participa de grupos religiosos, comunitrios ou outros grupos/instituies que
constituam rede de apoio e solidariedade?
|__| No
Existe alguma criana ou adolescente do grupo familiar que no tem acesso a atividades de lazer, recreao e convvio social?
|__| Sim
|__| No
|__| No se aplica (famlia sem criana/adolescente)
Existe algum idoso do grupo familiar que no tem acesso a atividades de lazer, recreao e convvio social?
|__| Sim
|__| No
|__| No se aplica (famlia sem idoso)
Relaes intrafamiliares *
Percepo/Avaliao do tcnico sobre as relaes conjugais na famlia, se for o caso
Nome do Tcnico
Data
(Ms/Ano)
( )Conflituoso, com violncia ( )Conflituoso, sem violncia ( )Sem conflitos relevantes
____ / ____
____ / ____
____ / ____
Percepo/Avaliao do tcnico sobre as relaes entre pais/responsveis e os filhos

inclusive entre o padrasto ou madrasta com o(s) enteados(as), se for o caso
Nome do
Tcnico
Data
(Ms/Ano)
____ / ____
____ / ____

Percepo/Avaliao do tcnico sobre as relaes entre os irmos, se for o caso
____ / ____
Nome do
Tcnico
Data
(Ms/Ano)
____ / ____
____ / ____
____ / ____
* A descrio ou detalhamento dos conflitos intrafamiliares, quando pertinente, poder ser realizada na pgina ao lado.
Indique se h relaes conflituosas envolvendo outros indivduos que residam no domiclio?
|__| Sim, com presena de violncia. Caso sim, utilize a pgina ao lado para anotar as informaes relevantes
|__| Sim, sem presena de violncia. Caso sim, utilize a pgina ao lado para anotar as informaes relevantes.
|__| No h conflitos relevantes envolvendo outros indivduos que residam no domiclio
Convivncia Familiar e Comunitria

Outras observaes referentes ao diagnstico das condies de convivncia familiar e comunitria
(Ateno! Toda anotao includa neste espao deve ser precedida da data, nome e funo do profissional responsvel pela mesma)
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Convivncia Familiar e Comunitria Situaes de Violncia e Violaes de Direitos
QUADRO 1
Histrico de situaes de violncia e violaes de direitos vivenciadas pela famlia
|__| Trabalho Infantil
( ) Sim
( ) No
Data da
Anotao
(Ms/Ano)
____/____
|__| Explorao Sexual

|__| Abuso/Violncia Sexual
|__| Violncia Fsica
( ) Sim
( ) Sim
( ) Sim
( ) No
( ) No
( ) No
____/____
____/____
____/____
( ) Sim
( ) Sim
( ) Sim
( ) No
( ) No
( ) No
____/____
____/____
____/____
|__| Violncia Psicolgica

|__| Negligncia contra idoso
|__| Negligncia contra criana
( ) Sim
( ) Sim
( ) Sim
( ) No
( ) No
( ) No
____/____
____/____
____/____
( ) Sim
( ) Sim
( ) Sim
( ) No
( ) No
( ) No
____/____
____/____
____/____
|__| Negligncia contra PCD

|__| Trajetria de Rua
( ) Sim
( ) Sim
( ) No
( ) No
____/____
____/____
( ) Sim
( ) Sim
( ) No
( ) No
____/____
____/____
|__| Discriminao
( ) Sim
( ) No
____/____
( ) Sim
( ) No
____/____
A situao ainda
persiste?
Situao
(ATUALIZAO)
A situao ainda
persiste?
( ) Sim ( ) No
(ATUALIZAAO)
Data da
Atualizao)
____/____
QUADRO 2 - EXCLUSIVO PARA UTILIZAO PELO CRAS

Caso a famlia esteja, ou j tenha estado, sob acompanhamento de um CREAS, registre o perodo em que isso ocorreu
e o CREAS que realizou o acompanhamento
Data Incio
(Ms/Ano)
Data Final
(Ms/Ano)
____/____
____/____
____/____
____/____
____/____
____/____
____/____
____/____
Identificao do CREAS
QUADRO 3 - EXCLUSIVO PARA UTILIZAO DO CREAS

Registro obrigatrio de situaes de violncia e violaes de direitos identificadas no grupo familiar
Utilize este Quadro para registrar situaes de violncia e/ou violao de direitos, atuais ou recentes, ocorridas com membros da famlia.
Estas situaes podem ter sido detectas pelo profissional do CREAS durante o atendimento da famlia/indivduo, ou j serem de
conhecimento prvio, no caso em que constituem a razo pela qual a famlia foi includa em acompanhamento pelo PAEFI.
N de Ordem
* Cdigo da
Data do Registro
da pessoa
Indcio ou Confirmada
* Cdigo de Situaes
Situao
(ms/ano)
vitimada
( )Indcio
( ) Confirmada
1. Trabalho Infantil
______ / ________
( )Indcio
( ) Confirmada
2. Explorao Sexual
______ / ________
( )Indcio
( ) Confirmada
3. Abuso/Violncia Sexual
______ / ________
( )Indcio
( ) Confirmada
4. Violncia Fsica
______ / ________
( )Indcio
( ) Confirmada
5. Violncia Psicolgica
______ / ________
( )Indcio
( ) Confirmada
6. Negligncia *
______ / ________
( )Indcio
( ) Confirmada
7. Trajetria de Rua
______ / ________
( )Indcio
( ) Confirmada
8. Discriminao
______ / ________
( )Indcio
( ) Confirmada
______ / ________
( )Indcio
( ) Confirmada
______ / ________
Todo registro includo neste quadro deve ser transposto, sem a identificao da pessoa, para o Mapa Consolidado de
Registros Obrigatrios deste CREAS. Alm disso, o profissional deve ficar atento para a sua responsabilidade de notificar os
rgos do Sistema de Garantia de Direitos, e preencher a Ficha de Notificao nos casos em que for pertinente.
Convivncia Familiar e Comunitria Situaes de Violncia e Violaes de Direitos

Outras observaes referentes ao diagnstico de violncia e violaes de direitos
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Convivncia Familiar e Comunitria Servios de Convivncia e Fortalecimento de Vnculos

Participao de membros da famlia em Servios de Convivncia e Fortalecimento de Vnculos
N de
Ordem
Primeiro Nome
* Tipo de
Servio
Data de
ingresso
(ms/ano)
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
Data de
desligamento
(ms/ano)
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
____/______
* Cdigos do Tipo de Servio de

Convivncia e Fortalecimento de
Vnculos
1. SCFV para crianas de 0 a 6 anos

2 .SCFV Situao de Trabalho Infantil
3. Outro SCFV para 6 a 15 anos
4. SCFV Projovem Adolescente
5. Outro SCFV para 15 a 17 anos
6. SCFV para idosos
7. Outros grupos de convivncia
desenvolvidos pelo PAIF
Outras observaes referentes participao de membros da famlia em Servios de Convivncia e Fortalecimento de Vnculos
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Convivncia Familiar e Comunitria Servios de Convivncia e Fortalecimento de Vnculos

Outras observaes referentes participao de membros da famlia em Servios de Convivncia e Fortalecimento de Vnculos
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Convivncia Familiar Comunitria Histrico de Cumprimento de Medias Socioeducativas

Histrico de Aplicao de Medidas Socioeducativas para Adolescentes
N de
Ordem
Primeiro Nome
*Tipo de
Medida
Nmero do
Processo
Data de Incio
(Ms/Ano)
Data de Fim
(Ms/Ano)
*Cdigos dos Tipos de Medida

Socioeducativa
1 Liberdade Assistida (LA)
2 Prestao de Servios Comunidade
3 Advertncia
4 Obrigao de Reparar o Dano
5 Semi-Liberdade
6 Internao
Caso atualmente esteja cumprindo medida socioeducativa de LA ou PSC, o adolescente est tendo em acompanhamento
pelo CREAS?
N de ordem: _____
N de ordem: _____
N de ordem: _____
N de ordem: _____
N de ordem: _____
N de ordem: _____
N de ordem: _____
N de ordem: _____
|__| Sim
|__| Sim
|__| Sim
|__| Sim
|__| Sim
|__| Sim
|__| Sim
|__| Sim
|__| No
|__| No
|__| No
|__| No
|__| No
|__| No
|__| No
|__| No
Data da anotao: ___/____/ _______

Data da anotao: ___/____/ _______
Data da anotao: ___/____/ _______
Data da anotao: ___/____/ _______
Data da anotao: ___/____/ _______
Data da anotao: ___/____/ _______
Data da anotao: ___/____/ _______
Data da anotao: ___/____/ _______
Caso esteja cumprindo medida socioeducativa de PSC, registre os contatos relativos ao local de prestao do servio e do
orientador responsvel ?
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Convivncia Familiar Comunitria Histrico de Cumprimento de Medias Socioeducativas

Outras observaes referentes ao histrico de cumprimento de medidas socioeducativas
As anotaes relativas ao processo de acompanhamento do adolescente em cumprimento de Medida Socoeducativa pelo CREAS devem ser
registradas no bloco Planejamento e Evoluo do Acompanhamento Familiar
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Convivncia Familiar e Comunitria Histrico de Acolhimento Institucional ou Familiar

Utilize o quadro abaixo para registrar eventuais situaes de acolhimento institucional vivenciadas por algum
membro do grupo familiar, sejam situaes atuais ou ocorridas no passado.
Histrico de acolhimento:
N de
Ordem
Perodo do Acolhimento
Primeiro Nome
Data de Incio
(Ms/Ano)
Data de Fim
(Ms/Ano)
Motivo
Sempre que possvel, identifique e registre na pgina ao lado instituio na qual a pessoa foi acolhida
Caso o grupo familiar, em seu conjunto, j tenha vivenciado alguma situao de acolhimento institucional (abrigamento)
decorrente da perda, temporria ou definitiva do domiclio, quer em funo de catstrofe natural ou de fatalidade
pessoal, registre o perodo em que o fato ocorreu e o motivo/fato que levou ao acolhimento:
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Caso alguma criana/adolescente da famlia esteja, ou j tenha estado, sob guarda (legal ou informal) de outra pessoa no
residente no domiclio (famlia extensa, amigos, patres etc), registre o perodo em que o fato ocorreu, a razo pela qual
ocorreu, a pessoa que esteve com a guarda e o nome ou nmero de ordem da criana/adolescente.
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Outras situaes de afastamento do convvio familiar:

|__| Assinale caso a famlia possua algum membro adulto (pais ou filhos) em instituio prisional.
|__| Assinale caso a famlia possua algum membro adolescente cumprindo medida socioeducativa de internao
Convivncia Familiar Comunitria Histrico de Acolhimento Institucional

Observaes referentes s situaes de Acolhimento Institucional vivenciadas pela famlia
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PLANEJAMENTO E EVOLUO DO ACOMPANHAMENTO FAMILIAR

Registro de Incluso e de Desligamento da Famlia no Acompanhamento Familiar do PAIF ou PAEFI
Assinale a
Incluso
Data de Incluso
|__|
Assinale o
Desligamento
Data de
Desligamento
*Razo do
Desligamento
* Cdigos de Razes para

Desligamento da Famlia
____/____/______
|__|
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|__|
1 Avaliao tcnica
|__|
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|__|
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|__|
2 Evaso ou recusa da Famlia
|__|
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|__|
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|__|
|__|
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|__|
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|__|
3 Outros
PLANEJAMENTO INICIAL:
O planejamento inicial deve ser elaborado de forma dialogada com a famlia/indivduo e considerar de forma particularizada as
necessidades e as potencialidades de cada famlia. Nele se identificam os objetivos a serem perseguidos e as possveis aes e estratgias
para alcan-los. Embora no deva ser encarado de forma rgida, o planejamento inicial ajuda a nortear o trabalho a ser desenvolvido com
a famlia/indivduo e a avaliar sua evoluo.
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PLANEJAMENTO INICIAL:
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EVOLUO DO ACOMPANHAMENTO FAMILIAR

Entende-se por evoluo do acompanhamento familiar todo o processo que se segue ao contato inicial com a famlia/indivduo, por meio
do qual o profissional aprofunda seu conhecimento sobre a realidade especfica daquela famlia, planeja e realiza aes para alcance de
determinados objetivos e avalia os resultados alcanados.
Este espao do Pronturio destinado s anotaes qualitativas sobre aspectos importantes da vida familiar que venham a ser
identificados durante o processo de acompanhamento. Deve, tambm, ser utilizado para anotaes pertinentes aos procedimentos e
atividades desenvolvidas com a famlia e para avaliao dos resultados obtidos.
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FORMULRIOS DE CONTROLE DE ENCEMINHAMENTOS
FORMULRIOS DE CONTROLE DOS ENCAMINHAMENTOS REALIZADOS

NO PROCESSO DE ACOMPANHAMENTO DA FAMLIA
Registro de Encaminhamento
rea para a qual est sendo feito o
encaminhamento:
|_|Outra Unidade/Servio da Assist. Social
|_|Sade
|_|Educao
|_|INSS
|_|Habitao
|_|Defensoria Pblica
|_|Outra
Especifique o rgo/Unidade para o qual

est sendo feito o encaminhamento:
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Objetivo/Motivo:
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Data: ____/____/_______
Registre no verso deste canhoto o resumo das
informaes de acompanhamento deste
encaminhamento
encaminhamento:
|_|Sade
|_|Educao
|_|INSS
|_|Habitao
|_|Outra

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Objetivo/Motivo:
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Data: ____/____/_______
encaminhamento
Formulrio de Encaminhamento SUAS

SISTEMA NICO DE ASSISTNCIA SOCIAL SUAS
(Para informaes bsicas de contra-referncia, utilize o verso desta ficha)
Encaminho o Sr(a) _________________________________________

e
solicito
ateno
para
seu
atendimento,
no(a)
_____________________________________________________
localizado(a) na _________________________________________
______________________________________________________
tendo em considerao as necessidades identificadas pela Assistncia
Social e expostas a seguir no presente formulrio.
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Data: ____/____/_______
Nome da Unidade responsvel pela origem do encaminhamento:
___________________________________________________
Telefone para contato: __________________________________________
Nome do Profissional: __________________________________________
Formulrio de Encaminhamento
Encaminho o Sr(a) _________________________________________

e
solicito
ateno
para
seu
atendimento,
no(a)
_____________________________________________________
localizado(a) na _________________________________________
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Data: ____/____/_______
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Anotaes de Contra-Referncia
(Para informaes bsicas de contra-referncia, utilize esta lado da ficha)
Acompanhamento do Encaminhamento
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|_|Outra

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Objetivo/Motivo:
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Data: ____/____/_______
encaminhamento
encaminhamento:
|_|Sade
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|_|Outra

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Objetivo/Motivo:
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Data: ____/____/_______
encaminhamento

Encaminho o Sr(a) _________________________________________

e
solicito
ateno
para
seu
atendimento,
no(a)
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Data: ____/____/_______
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Encaminho o Sr(a) _________________________________________

e
solicito
ateno
para
seu
atendimento,
no(a)
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localizado(a) na _________________________________________
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encaminhamento:
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|_|Outra

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Objetivo/Motivo:
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Data: ____/____/_______
encaminhamento
encaminhamento:
|_|Sade
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|_|INSS
|_|Habitao
|_|Outra

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Objetivo/Motivo:
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Data: ____/____/_______
encaminhamento

Encaminho o Sr(a) _________________________________________

e
solicito
ateno
para
seu
atendimento,
no(a)
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localizado(a) na _________________________________________
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Data: ____/____/_______
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Encaminho o Sr(a) _________________________________________

e
solicito
ateno
para
seu
atendimento,
no(a)
_____________________________________________________
localizado(a) na _________________________________________
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encaminhamento:
|_|Sade
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|_|Habitao
|_|Outra

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Data: ____/____/_______
encaminhamento
encaminhamento:
|_|Sade
|_|Educao
|_|INSS
|_|Habitao
|_|Outra

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Objetivo/Motivo:
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Data: ____/____/_______
encaminhamento

Encaminho o Sr(a) _________________________________________

e
solicito
ateno
para
seu
atendimento,
no(a)
_____________________________________________________
localizado(a) na _________________________________________
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Data: ____/____/_______
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Encaminho o Sr(a) _________________________________________

e
solicito
ateno
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atendimento,
no(a)
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encaminhamento:
|_|Sade
|_|Educao
|_|INSS
|_|Habitao
|_|Outra

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Objetivo/Motivo:
_________________________________
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Data: ____/____/_______
encaminhamento
encaminhamento:
|_|Sade
|_|Educao
|_|INSS
|_|Habitao
|_|Outra

_________________________________
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Objetivo/Motivo:
_________________________________
_________________________________
_________________________________
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Data: ____/____/_______
encaminhamento

Encaminho o Sr(a) _________________________________________

e
solicito
ateno
para
seu
atendimento,
no(a)
_____________________________________________________
localizado(a) na _________________________________________
______________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
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_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Data: ____/____/_______
___________________________________________________
Encaminho o Sr(a) _________________________________________

e
solicito
ateno
para
seu
atendimento,
no(a)
_____________________________________________________
localizado(a) na _________________________________________
______________________________________________________
_________________________________________________________
_________________________________________________________
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Data: ____/____/_______
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Prontuário SUAS

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Prontuário SUAS

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N do Pronturio:

Nome da Unidade: ____________________________________________________________________________

Registro Simplificado do Acompanhamento

Nome do Tcnico Responsvel

O Pronturio SUAS um instrumento tcnico que tem como objetivo

Data de Abertura do Pronturio: |__|__| / |__|__| / |__|__|__|__|

Identificao da Pessoa de Referncia e Endereo da Famlia

Forma de ingresso na unidade e motivo do primeiro atendimento

|__| Outro(s) Programa(s) prioritrio(s): ___________________

(Data da Anotao: ____ / ____ / _______ )

(Sempre comear a lista pela Pessoa de Referncia)

**Assinale caso seja identificada

Perfil Etrio do Grupo Familiar

Especificidades sociais, tnicas ou culturais da famlia

|__| Famlia/pessoa em situao de rua

Condies Habitacionais da Famlia

(No se aplica a famlias/pessoas residentes em abrigos ou em situao de rua)

Data da Anotao: ____ / ____ / _____

____ / ____ / _____

Condies Habitacionais da Famlia

(No se aplica a famlias/pessoas residentes em abrigos ou em situao de rua)

Outras observaes referentes ao diagnstico das condies habitacionais da famlia

Condies Educacionais da Famlia

Data da Primeira Anotao: ____ / ____ / ________

Qtd de pessoas entre 0 e 5 anos que no esto frequentando escola ou creche

Anotaes sobre descumprimento de condicionalidades de Educao

Identificao de Vulnerabilidades Educacionais

(ltima srie concluda com aprovao)

Data de Atualizao: ____ / ____ / _______

Frequenta escola atualmente?

Data de Atualizao: ____ / ____ / _______

* Cdigos para os Efeitos

Condies Educacionais da Famlia

Condies de Trabalho e Rendimentos da Famlia

Data da Primeira Anotao: ____ / ____ / ________

Data de Atualizao: ____ / ____ / _______

Data de Atualizao: ____ / ____ / _______

Renda Mensal (R$)

Aqui no devem ser considerados recursos

Renda total da famlia: (Sem considerar a renda recebida de programas sociais)

Algum membro da famlia aposentado ou pensionista?

A famlia recebe dinheiro de algum Programa Social?

Qual a renda total da famlia, incluindo o valor recebido de programas sociais?

Anote o valores recebidos pela famlia por meio de Programas Sociais

|__|Bolsa Famlia - Valor: R$__________ Atualizaes: R$___________ R$__________

Condies de Trabalho e Rendimentos da Famlia

Condies de Sade da Famlia

Quem o responsvel pelo

4. Deficincia mental ou intelectual

(Data da anotao: ___ / ___ / ____)

Algum membro da famlia portador de alguma doena grave?

Caso sim, registre o N de Ordem e/ou nome da(s) pessoa(s): ______________________________

Registre a presena de gestante(s) na famlia:

Anotaes sobre descumprimento de condicionalidades de sade no Programa Bolsa Famlia

Condies de Sade da Famlia

Acesso a Benefcios Eventuais

Registro de concesso de Benefcios Eventuais da Assistncia Social

Cdigos para os Tipos de Benefcio:

Acesso a Benefcios Eventuais

Convivncia Familiar e Comunitria

( ) a famlia sempre morou no estado

H quantos anos a famlia mora no municpio: |__|__| anos

( ) a famlia sempre morou no municpio

H quantos anos a famlia mora no bairro atual: |__|__| anos

Data de Abertura do Pronturio: ||| / ||| / |||||

|| Outro(s) Programa(s) prioritrio(s): _________________

(Data da Anotao: / / ___ )

Data da Anotao: / / _

/ / _

Data da Primeira Anotao: / / ____

Data de Atualizao: / / ___

Data de Atualizao: / / ___

Data da Primeira Anotao: / / ____

Data de Atualizao: / / ___

Data de Atualizao: / / ___

||Bolsa Famlia - Valor: R$__ Atualizaes: R$_ R$______

(Data da anotao: _ / _ / ____)

H quantos anos a famlia mora no municpio: ||| anos

H quantos anos a famlia mora no bairro atual: ||| anos

Data da anotao: _// _____