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CASE WORK FORMAT |
PERSONAL INFORMATION
1. Name: V B
2. Age: 12
3. Sex: Male
4. Place of identification: A black mole on the left shoulder.
5. Address:
6. Education: Sixth standard
7. Name of Parent and Guardian:
8. Religion and Caste:
9. Date of admission:
10. Mother tongue: Telugu
LIFE TRANSITION
1. Causes of reaching this place:
a) By tradition
b) Deserted
c) Inaccessibility to education
d) Others
e) Parental Pressure
f) Peer influence
g) Poverty
h) Trouble or broken family
2. Frequency of moving from place to place: frequently/Rarely/Never
3. Provoking factors of moving: a) Exploitation by adults, b) lack of shelter, c) seeking for job, 4) others
4. Type of engagements: Begging/ Rag picking/ Hotel boys/ Others (specify)
5. Period of working: a) Below 4 years, b) 4 to 7 years, c) 8 to 10 years, d)more than 10 years
6. Working time: a) day, b) night, c) both
7. Place of sleeping at night: a) floor, b) bed, c) street
8. Place of stay: a) work site, b) rented house, c) streets
9. Whether apprehended by police at any time, if yes: yes/no
a) Ended up in police custody due to: Petty case, b) theft, c) violence, d) crime
HEALTH CONDITION
1. Illness identification: a) skin disease, b) epilepsy, c) head-ache, d) chronic infection, e) eye problem, f) asthma, g) heart disease, h) others
2. Infection found and treated earlier: a) Malaria, b) tuberculosis, c) skin disease, d) septicaemia, e)bronchitis, f) S T D, g) others
3. Habit of using drugs, if yes: Yes/No
a) Age at which first start using drug:
b) Type of drug using:
c) Quality of drug taken at a time:
d) Methods adopted to receiving drug: a) Steeling, b) begging, c) criminal activity, d) Exchange sex
4. Frequency in cleaning teeth: a) daily, b) Twice a week, c) Thrice a week, d) Never
5. Type of disease in teeth: a) caris teeth, b) ginger vitus, c) bad odour
6. Frequency of anxious or stress: a) Frequently, b) Occasionally, c) rarely, d) never
7. Frequency of feeling anger: a) Frequently, b) Occasionally, c) rarely, d) never
8. If any psychological problems noted specify:
9. Sexual activity find out: a) Hetero sexual, b) Homosexual, c) Nothing
10. Type of sexually transmitted disease at present: a) gonorrhoea, b)syphilis, c) HIV/AIDS, d) Others, e)Nothing
11. Any specific observation:
12. Recommendation:
