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FAP Proforma

Family Adoption

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Aryan Kumar
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50 views

FAP Proforma

Family Adoption

Uploaded by

Aryan Kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 7

FAMILY 1

Name of the Village: Nearest Bus stop:

Ward: Nearest school:

Panchayat/Municipality: Nearest Anganwadi centre:

Nearest PHC:

Nearest Tertiary Care Referral Centre:

Area Map:

House map: Cross sectional at window level


I. DEMOGRAPHIC DETAILS:

Name of the head of the family:

Address:

Migrated: Yes/ No
If yes details: Duration: Previous Place: Reason for Migration:
Religion: 1. Hindu 2. Muslim 3. Christian 4. Jain 5. Others

Contact No:

Aadhar card number (HOF):

II. DETAILS OF THE FAMILY:

1. Family type: 1. Nuclear 2. Joint 3. Three generation 4. Others:

2. No. of members in the family:

3. Income (per capita per month):

4. Class (According to updated BG Prasad Scale - Refer Annexure I)

A. Upper class B. Upper middle class C. Middle class


D. Lower middle class E. Lower class

5. Expenditure pattern:

Item Amount spent per Item Amount spent per


month month

Rent Electricity

Food/Groceries Savings

Health care Transport

Education Others
6. Family Composition:

S. Name Relation to Age Gender Marital Status Education Occupation Income Personal Medico-social
No the Head (M/S/W/D) * (per Habit** conditions***
of the month)
family

*M- Married, S- Single, W- Widow, D-Divorced

**1. Tobacco 2. Smoking 3. Alcohol 4. Others 5. None

***Medico social conditions


Physiological conditions: Infants, Pregnancy, Lactation, old age
Medical conditions: Leprosy, TB, cancer, hypertension, diabetics, HIV, COVID-19, etc
Present Treatment of any medical conditions if any:
Socio conditions: Disability, mental retardation, psychiatric conditions, alcoholic, unwed pregnancy, divorce,
infertility etc.
7. Pedigree chart:

8. Vital events in the past 1 year:

Marriage / Divorce Birth Death Adoption

Yes/No Yes/No Yes/No Yes/No

If yes, registered or If yes, registered or If yes, registered or If yes, registered or


not: not: not: not:

III. ENVIRONMENT

EXTERNAL / MACRO ENVIRONMENT:

Accident prone area: Yes / No If Yes How? ------

Vector breeding sites: Present / Absent If yes what? -----

Street light: Present / Absent

Stray animals: Present / Absent If yes what? -----

Other Significant Observations if any:

INTERNAL / MICRO ENVIRONMENT:


Details Type Findings Remarks / Others
House
Ownership Own / Rented
Setback Adequate/ Inadequate/ Nil

PAGE \* MERGEFORMAT 28
House Pucca / Semi-pucca / Kutcha
Floor 1. Even/ Uneven
2. Mud/cement/ Tiles
3. Infestation of rodents/ visible
cracks & crevices
Roof Thatched/tailed/RCC-sheets
/asbestos sheet/others
Walls Cracks and Crevices: present/
absent
Dampness Present/ absent
Overcrowding Yes / No

1. Number of living rooms:

2. Per capita space in the house


(square feet per person)

3. Social (Sex separation)


Lighting Natural (Adequate/ Inadequate)
Artificial (Adequate/ Inadequate)
Ventilation Adequate/ Inadequate

1. No of windows (with
measurement)

2. No of doors (with
measurement)

3. Total floor space


Cross Present / Absent
Ventilation
Water supply
Water supply Hand Pump / House Tap / Well /
for household Street Tap / Tank/ Others
use
Water Supply Hand Pump / House Tap / Well /
for drinking Street Tap / Tank/ Others
Storage of Pot / Plastic / Steel container,

PAGE \* MERGEFORMAT 28
water Open /closed
Purification of Boiling / RO filter / None
water
Toilet and bathing area
Toilet Own / Community Toilet / Open
Type of latrine Indian / Western

Connected to A septic tank/ municipal sewerage


system/other
Toilet Continuous water supply/
Maintenance Lighting availability
Hand washing Without soap/ with soap / No
practices handwashing
Bathing area Present/ absent
privacy
Accident Present/ absent
proneness
Drainage Open/ closed
Waste disposal
Solid Waste Open Dumping/ Panchayat
Disposal collection/ Others
Frequency of Daily, weekly
disposal
Segregation of Present/ absent
waste
Waste Lid/No lid
containers
Kitchen
Separate Yes / No
Kitchen
Platform used Yes/ No
for kitchen

PAGE \* MERGEFORMAT 28
Fuel for Firewood / Gas / Kerosene /
cooking other
Smoke outlet in Present/ Absent
the kitchen
Storage of food Present/absent,
items
if present method of storage for
Raw food :

Cooked food :

Biological environment
Rodent/ vector Yes/ No
infestation If yes, what
Cattle shed Present/ Absent. If present, at
what distance?
Pet Animals Yes / No

PAGE \* MERGEFORMAT 28

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