BANARAS HINDU UNIVERSITY
FACULTY OF EDUCATION (K), VARANASI
B.Ed Special Education (Visual Impairment)
Session:............................................................
Case Study Report
1. Individual Details of the Student
Name of Student__________________________________________________________________________
Age__________________________ Sex___________________ Date of Birth_________________________
Name of the School:_______________________________________________________________________
Class________________________ Section_____________________________________________________
2. Present Situation of the Student
Age of Onset: ___________________Years_______________________Months_________________Days
Type of Visual Impairment: Blind Low Vision Other _____________________________
Cause of Visual Impairment : Prenatal Peri-natal Postnatal Not Specified
Diseases/ Trauma/ Accident _________________________
Present Issues of the Student: i. _____________________________________________________________
ii._____________________________________________________________
iii. ____________________________________________________________
iv. ____________________________________________________________
v. _____________________________________________________________
3. Medical History
Whether Medical Treatment was done? Yes No
if yes then mention the list of doctors: i. ____________________________________________________
ii._____________________________________________________
iii. ____________________________________________________
iv. ____________________________________________________
v. _____________________________________________________
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4. Family Background
A. Parent's Information
Father's Name:____________________________ Mother's Name:_________________________
Occupation:_______________________________ Occupation:_____________________________
Education:________________________________ Education:______________________________
Address:________________________________________________________________________________
B. Total Monthly income of the Family (In INR):______________________________________________
C. Family Structure: Joint Nuclear Broken Orphan
D. Family residence: Rural Urban Town Slum
E. Religion: Hindu Muslim Christian Any Other
F. Language: Hindi Regional Mother Tongue Any Other
List of Family Members:
S.# Name Relation Age Education Occupation Health Income
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
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5. Pre- Natal Background
A. Genetic Causes Yes No Unknown
B. Malnutritional Issue in Mother Yes No Unknown
C. Infection in Mother's Body Yes No Unknown
Cause__________________________________
D. Mother Suffering from Incurable Disease Yes No Unknown
Disease Name_________________________________
E. Adverse effect of Medicines Taken by Mother Yes No Unknown
F. Intake of Toxic Substances by Mother Yes No Unknown
G. Injury during Pregnancy Yes No Unknown
H. Disorder in Eye Structure during Pregnancy Yes No Unknown
Type of Disorder_______________________________
I. Any Other Cause ________________________________________________
6. Peri- Natal Background
A. Place of Child Birth Home Hospital Any Other
B. Pregnancy Time Mature Immature Unknown
C. Duration of labour pain Normal Extreme Unknown
D. Type of Delivery Normal Abnormal Cesarean
E. Weight of The infant Normal High Low
F. Any Accident occur during child birth Yes No Unknown
G. Any Other Cause ________________________________________________
7.Post- Natal Background
A. Infection in Infant Yes No Unknown
Cause________________________________
B. Jaundice in Infant Yes No Unknown
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C. Malnutrition Yes No Unknown
D. Immunization Yes No Unknown
E. Strokes Yes No Unknown
F. Any Common Eye Disease Yes No Unknown
Name of Eye Disease___________________
G. Accident Yes No Unknown
Cause________________________________
8. Details of the School
A. Type of School Special School General School Inclusive School
Age at the time of Admission _________________________
B. Performance in School Good Satisfactory Average Non- Satisfactory
C. Attendance in Class Regular Irregular
D. Reason for Being Absent Personal Economical Behavioral Poor Performance
No Support from School
9. Level of Skills
A. Daily Living Skills Good Satisfactory Average Non- Satisfactory
B. Orientation & Mobility Skills Good Satisfactory Average Non- Satisfactory
C. Knowledge of Assistive Devices Good Satisfactory Average Non- Satisfactory
D. Braille Reading Good Satisfactory Average Non- Satisfactory
E. Braille Writing Good Satisfactory Average Non- Satisfactory
F. Knowledge of Social Skills Good Satisfactory Average Non- Satisfactory
G. Sensory Training Good Satisfactory Average Non- Satisfactory
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H. Subject knowledge
English Good Satisfactory Average Non- Satisfactory
Hindi Good Satisfactory Average Non- Satisfactory
Sanskrit Good Satisfactory Average Non- Satisfactory
Mathematics Good Satisfactory Average Non- Satisfactory
Science Good Satisfactory Average Non- Satisfactory
Social Science Good Satisfactory Average Non- Satisfactory
Any Other Good Satisfactory Average Non- Satisfactory
10. Child Level in Sports
A. Child Behavior During Sports Good Satisfactory Average Non- Satisfactory
B. Cause of Non- Participation Poor Sports Environment Low peer group interaction
Introvert Avoidance Any Other _____________
C. Performance Good Satisfactory Average Non- Satisfactory
D. Knowledge of Game Rules Good Satisfactory Average Non- Satisfactory
E. Behavior with other students ________________________________________________________
11. Adjustment with Family
A. Father Excellent Good Satisfactory Non- Satisfactory
B. Mother Excellent Good Satisfactory Non- Satisfactory
C. Brother Excellent Good Satisfactory Non- Satisfactory
D. Sister Excellent Good Satisfactory Non- Satisfactory
12. Social Adjustment
A. Peer Group Excellent Good Satisfactory Non- Satisfactory
B. Relatives Excellent Good Satisfactory Non- Satisfactory
C. Other members of Society Excellent Good Satisfactory Non- Satisfactory
Signature of the Supervisor Signature of Teacher's Trainee
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