At the Preliminary Inquiry/

In the Child Justice Court held at

Case no/File no.

Full names and surname

Sex

Full names and Surname / Name of Centre

Contact details of person / Centre

Physical address of person / Centre

Full names and Surname

Particulars of hospital or practice

Contact details

Since there is uncertainty as to the age of the child mentioned above, the child is referred to you in terms of section 14(2)(d) of the Child Justice Act, 2008 for an estimation of age.

......................................................................

Signature: Presiding Officer

Date:

Height

Weight

Condition of:

Face

Lungs

Heart

Teeth

Sight

Hearing

Speech

Bone structure

Neurological state

Intellect

Any diseases, infection, injuries or impairment (Indicate degree)

Nutrition

Adequate/deficient.

If deficient, provide details

Vaccinations

Yes/No

If yes, provide details

Physical development

Normal/abnormal.

If abnormal, provide details

Sexual organs

Breasts

Pubic hair

Genitals

Auxiliary

Substance abuse

Yes/No

If yes, provide details

Other Observations

Provide details

Medical or other treatment required/ recommended

Based on the above-examination and the child's general appearance—

(a)

The age of the child is assessed at being between .................... and ............. , the most probable age is ..............

(b)

The possible date of birth could be ...............................................................