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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