DIGITAL IMAGE CASE STUDY

(please print)
1 2 3 4 5 6 Circle One: Child Number: Child Name: Birthdate: / / (day / month / year ) Sex: Male Female (circle only one) New Child or Update on Child Case Worker: Date Prepared: / / (day/month/year)

CHRISTIAN ACTIVITIES
(circle all that apply) 7 8 Sunday School/Church Vacation Bible School Youth Group Choir Bible Class Other: Camp

FAMILY DUTIES
(circle all that apply) 9 10 11 12 Washing Clothes Cleaning Sewing Kitchen Help Gardening/Farming Animal Care Gathers Firewood Other: Running Errands Carries Water Teaching Others Making Beds Child Care Buying/Selling in Market

HOBBIES AND SPORTS

(circle all that apply) 13 14 15 16 17 18 19 Dolls Play House Jacks Hide and Seek Reading Singing Musical Instrument: Group Games Rolling a Hoop Marbles Cars Art/Drawing Listening to Music Soccer/Football Baseball Basketball Volleyball Ping Pong Other Ball Games Other: Bicycling Walking Swimming Running Jump Rope Story Telling

Version 1.0 11-JUL-1986

HEALTH
(circle all that apply) Physical Handicaps / Chronic Illnesses: 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 Sight: Hearing: None Epilepsy Asthma Polio Mentally Retarded or or or or or or or disease disease disease disease disease disease disease disease disease defective defective defective defective defective yes yes no no Other: or or or or or or or or or or or or or or birth defect birth defect birth defect birth defect birth defect birth defect birth defect birth defect birth defect mute deaf deaf blind blind Crippled: Spine due to . . . . . . . . injury Left Foot due to . . . . . injury Right Foot due to . . . . injury Left Hand due to . . . . injury Right Hand due to . . . injury Left Leg due to . . . . . . injury Right Leg due to . . . . . injury

Left Arm due to . . . . . . injury or Right Arm due to . . . . . injury or Speech: . . . . . . . . . . . . . . . . . . . . . Left Ear . . . . . . . . . . . . . Right Ear . . . . . . . . . . . . Left Eye . . . . . . . . . . . . Right Eye . . . . . . . . . . . . Is this child receiving regular medical treatment? Is this child receiving regular medication?

SCHOOLING
37 38 Is the child attending school? If not attending, give reason: If attending, fill in the level for one of the following types of school: yes no

COUNTRY LEVEL
39 40 41 42 43 44 45 46 47 Pre-School Kindergarten Primary School Middle School High School Vocational School Level Apprenticeship Level College/University Level Other School Level

U.S. EQUIVALENT(circle one)

K 7 1 8 2 9 3 10 4 11 5 12 6 13

Give course of study: Give course of study: Give course of study: Give course of study:

SCHOOLING continued
School Performance: (circle only one) 48 49 Below Average Average Above Average What is the childs best subject? Future Plans: 50 51 52 53 54 High School College / University Bible School Vocational Training Other: Date child expects to enter: (day/month/year) / / / / / / / / / / Course of study:

GUARDIANS
(circle all that apply) Child is living under supervision of: 55 56 57 58 Father Mother Uncle Aunt Brother Sister Grandfather Grandmother Stepfather Stepmother Godfather Godmother Friends Institutional Workers Foster Parents Other Relatives

NATURAL PARENTS
59 60 61 62 63 64 Are the natural parents together now? Circle the marital status of the natural parents: Now married Were married, now separated by death. Were married, now divorced or permanently separated. Were never married. Unknown. yes no unknown

NATURAL FATHER
65 66 67 68 69 70 71 Is the natural father: alive yes no unknown living with this child? yes no contributing financially to this child? yes no handicapped? (how? ) yes no unknown chronically ill? (how? ) yes no unknown mentally ill? yes no unknown in prison? yes no unknown

NATURAL MOTHER
Is the natural mother: alive yes no unknown living with this child? yes no contributing financially to this child? yes no handicapped? (how? ) yes no unknown chronically ill? (how? ) yes no unknown mentally ill? yes no unknown in prison? yes no unknown

FATHER or MALE GUARDIAN

Circle one: 72 73 74 75 The father or male guardian is regularly employed The father or male guardian is sometimes employed The father or male guardian is not employed There is no father or male guardian Circle all that describe the father or male guardian: 76 77 78 79 80 81 82 farmer sells in market church worker project worker teacher laborer: other:

MOTHER or FEMALE GUARDIAN

Circle one: The mother or female guardian is regularly employed The mother or female guardian is sometimes employed The mother or female guardian is not employed There is no mother or female guardian Circle all that describe the mother or female guardian: farmer sells in market church worker project worker teacher laborer: other:

FAMILY SIZE
Number of family members in home under 18 years of age: (including this child) 83 84 Boys: Brothers and sisters registered with Compassion: (child name, please print) (child name, please print) Girls:

GENERAL COMMENTS
(include any additional information details of medical, school, family, etc.) 85 86 87 88 89 90 91 92 93 94

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