Annexure - V

CHILD STUDY REPORT

(To be submitted to the Court after being countersigned by the adoptive applicants)

Name and address
Of the Institution: -

I. GENERAL INFORMATION:

1. Name of the Child:
2. Reference No. as per general register of the Institution:
3. Present age and date of birth:
4. Sex:
5. Place of Birth :
6. Where was the child born (Name of the Hospital/Nursing Home)
7. Religion (if known):

II. LEGAL DATA:

(For Court Committed or remand Children only)

1. Is the Child on Remand or Committed to your Institution :
2. Name of the Committing Court/Board :
3. Age of the child at the time of Commitment :
4. Date of order of Commitment :
5. Period of Commitment :
6. Final date of release :
7. Date of Admission to your Institution (Please enclose a copy of the Court Commitment) :
   (If available, please enclose a copy of the Probation Officer’s report which he/she had submitted to the Child Welfare Committee at the time of Commitment of the child as also the commitment order).

III. SOCIAL DATA:

Please do not give identifying information as name and address of the natural parent.

1. Date of admission of the child to your institution :
2. How did the child come to your institution :
   a. Admitted directly by parent/or any other guardian:
   b. Placed on remand or court committed or referred by the police. (Name of the Committing Court     or police station should be given):
   c. Transferred from any other institution and if so which one:
   d. Any other source:
   e. A brief note about the social background of the child..
3. Circumstances under which the child has come to the original institution:
4. Reasons for seeking protection in the Institution:

IV. PHYSICAL AND EMOTIONAL DEVELOPMENT:

1. Attitude towards other inmates:
2. Relationship towards staff and other adults including strangers:
3. Intelligence (if and where possible, D.Q./ I.Q. report should be enclosed):
4. If the child is school going, give a detailed report about his/her standard, attendance, general interest in studies, progress, limitations if any :
5. General personality and description of the child :
6. lay activity and any specific talent:
7. Milestones of the child (for children below 18 months). Please mark Yes/No
   Does the child:
   a. Smile -------------------
   b. Turn over on its stomach -------------------
   c. Lift its head -------------------
   d. Grasp objects in its hand -------------------
   e. Crawl on its own -------------------
   f. Sit: with support -------------------
      without support -------------------
   g. Stand : with support / without support -------------------
   h. Walk: with support/ without support -------------------
8. Language development:
   a. Babbles incoherently -------------------
   b. Speaks few words incoherently -------------------
   c. Speaks few words clearly -------------------
   d. Speaks fluently -------------------
   e. Language/s spoken by the child -------------------
9. Dietary habits:
   Intake of: Liquid foods / Semi solids / Solids ------------------
10. Physical Examination report (appended)
    I, Dr. ________________ (Name of the Hospital / Nursing Home)__________________
    hereby certify that the information given in this form about the child is correct.
    Signature:
    Place: Name:
    Date: Designation:
    Registration No.:

We have read and understood the contents of this child study report and are willing to accept

_______________________________,(Child’s Name) as our adoptive child.
__________________________             ___________________________
(Signature of the male applicant)            (Signature of the female applicant)
_______________________                   _________________________
(Name of the male applicant)                  (Name of the female applicant)
Place:

Date of Acceptance of the Child :

Signature of the Professional Social Worker with Date

PHYSICAL EXAMINATION REPORT
(to be filled in by the Examining Physician)

Name of the child _________________
Sex: _______________ Date of Birth: ____________________
Colour: Skin: __________ Eyes___________ Hair: ____________
Height: ______________ Feet: _______________
(Circumference) (any defect)
Vision: ________________ Nose: ____________________
Teeth: _________________ Chest: ____________________
Posture: _______________ Heart: _____________________
Spine: _________________ Nervous System: ____________
Legs: __________________ Reflexes: __________________
Abdomen: ______________ Hearing: __________________
Any Defects: ____________ Any other: _________________

IMMUNISATIONS

B.C.G.: ______________ ______________ ______________
Measles: ______________ ______________ ______________
Triple Antigen: ______________ ______________ ______________
Poliomyelitis: ______________ ______________ ______________
Hepatitis “B” ______________ ______________ ______________

TESTS

(to be completed wherever possible and also attach reports of the tests)
VDRL
Tuberculosis
Chest X-Ray
Urine Analysis
Stool
Blood
HIV
Australian Antigen
Any other past medical problems, (if any) and treatment given:
Medical Evaluation: (Any pertinent information regarding physical condition of the child)
General Condition of mental and physical development (observations of the physician) and latest medical report to be annexed.
________________________
Doctor’s Signature
Date: ________________________
Registration No
Place:
We have read and understood the contents of this physical examination report and are willing to accept ________________________________ with his/her given condition.
(Name of the Child)
____________________________ ____________________________
(Signature of the male applicant) (Signature of the female applicant)
__________________________ __________________________
(Name of the male applicant) (Name of the female applicant)
Place:

 

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