MEDIA CAMPAIGN REPORT FORMAT

• Title of the campaign:

• Theme/Social Issue:

• Type of the media campaign:

• Starting Date & End Date:

• Introduction (150 words)

• Objectives of the Campaign (in points)

• Background of the targeted social issue (Minimum 200 words)

• Steps Taken (in points)

• Tools used to broadcast and publicize the content (Description of each in 200 Words)

• Reflections and Learnings (200 words)

• Conclusion

• Reference (If applicable)

• Annexure (Evidence should be enclosed):

Signature with Date Signature with Date

(Student Trainee) (Faculty Supervisor)
 SWOT ANALYSIS

Objectives

Internal Factors

Strengths (+) Weaknesses (-)

External Factors

Opportunities (+) Threats (-)

Evaluation Of Objectives

Summary of the SWOT Analysis (200 words)

 CASE STUDY FORMAT FOR CD SPECIALIZATION

• Name of the community:

• Type of the Community: (Urban/Rural/Sub urban/Slum/Tribal)
• Location
• Total Population: Male/Female
• Number of Households:
• Main Sources of Income:
• Number of Social Organization:
• Main Language of the Community:
• Major Problems and Needs:
• Sanitary Conditions: (Good/Average/Bad)
• Socio-economic-political-cultural background of the community:
• Identified the needs of the people:

Priority Base felt needs

Sr. No. Felt Duration Beneficiaries Cost Cost Possible

Needs Benefit Resources
Available

• Meeting with the Leaders

Sr. Name and Whether The Nature of

No. Address Politician/Social Services/Assistance that the
Worker/Youth Leader community could expect
from them

• Interventions Done
• Result and Discussion

Name of the Trainee Name of the Faculty

Signature Signature
 CLIENT SATISFACTION SURVEY
Centre Name:
1. Please answer the following demographic questions
Age Gender
2. Please note what concern(s) originally brought you to seek counselling/Treatment.
Primary Concern
Secondary Concern
3. Number of Completed Counselling/Treatment Sessions
4. Please use the rating scale below for the following questions regarding your overall
satisfaction

Strongly Disagree Neutral Strongly Agree

Disagree Agree
I felt the Counselling Centre
responded to my needs in a timely
manner
I felt the initial paperwork was
reasonable and clear.
I believe my counsellor keeps my
information confidential
My counsellor understood the
concerns I brought to counselling.
My counsellor helped me to feel
comfortable sharing my concerns
I felt my counsellor was sensitive
to issues of diversity (e.g. ethnicity,
culture, gender, sexual orientation,
religion, age, etc.)
My counsellor helped me to
develop better ways of coping with
my concerns
I gained insight into the problems I
presented in Counselling.
I gained a greater understanding of
myself and a clearer sense of my
identity
My understanding of my patterns
of behaviour grew as a result of
Counselling.
I would feel confident referring my
friends to the Counselling centre.
I am better prepared now to work
through future problems on my
own
I would feel confident referring my
friends to the Counselling centre
 5. Please rank your personal experience to the questions below

Very Low Low Average High Very high

Please rate your overall level of

distress when you first began
Counselling
Please rate the overall level of that
same distress at the time you
stopped Counselling
Please rate your level of confidence
in your own strengths and
resources when you first came to
Counselling.
Please rate your level of confidence
in your own strengths and
resources at the time you stopped
Counselling

6. Please indicate ways in which the Counselling Centre can better meet your needs.

Signature Signature Signature

Trainee Agency Supervisor Faculty Supervisor

Date and Place:

 COMMUNITY ASSESSMENT REPORT

• Name of the community

• Area/Locality
• Population of the community
• Details of the participants

Name Age Gender Family details

• Duration of Work:
• The identified need / problem
• Description of the nature and implications of the need /problem (100 words)
• Problem Analysis and Reason for prioritizing the need/problem (100 words)
• Support systems in the community (50 words)
• Alternatives to address the need / problem (50 words)
• Reason for selection of the appropriate approach (50 words)
• Action-Plan (describe the need, objective, plan of action, methodology involved,
financial aspects, collaborating bodies and the proposed outcome)
• Implementation of the action plan (record in detail the actual implementation in 200
words)
• Evaluation & feedback (100 words)
• Personal Reflections (50 words)
• Conclusion (100 words)
• References (MLA style)
• Annexure (attach any tools used or any other secondary information)

Signature of the trainee Signature of Faculty Supervisor

Date:
 CASE STUDY FORMAT
FOR WOMEN & CHILD WELFARE SPECIALIZATION

• Name of the Client: (Woman/Mother/Child/Both)

• Whether client is head of the household? Yes/ No
• Type of the Community: (Urban/Rural/Sub urban/Slum/Tribal
• Location/Address:
• Total number of family members:
• Number of Households in neighbourhood:
• Main Sources of Income of the head of the family :
• Number of Social Service Organizations family in touch with:
• Main Language of the family:
• Major Problems and Needs of the client in context of the family:
• General Health of the family members (including client):
• Sanitary Conditions: (Good/Average/Bad)
• Socio-economic-political-cultural background of the family:
• Identified the needs of the family members:
Priority Base felt needs
Sr. No. Felt Duration Beneficiaries Cost Cost Possible
Needs Benefit Resources
Available
to family

• Discussions with collateral contacts

Sr. Name and To what extent they can The Nature of

No. Address and their provide Services/Assistance that the
relation with the assistance/support family could expect from
family them

• Discussions with the other neighbours and community members

Sr. Name and To what extent they can The Nature of

No. Address of provide Services/Assistance that the
neighbours / assistance/support family could expect from
community them
members

• Interventions Done
• Result and Discussion

Name of the Trainee Name of the Faculty

Signature Signature
 FOCUSED GROUP DISCUSSION - REPORT

Objectives, Theme: (100 words)

Abstract (100 words)

Introduction (100 words)

Methods (50 words)

Results (in points)

Discussion (200 words: student trainee should write about his/her observation, evaluation and

analysis etc.)

References ( if any to be given in MLA style)

Appendix (Tool: structured/semi structured/ any other format)

Signature Signature Signature

Trainee Agency Supervisor Faculty Supervisor

Date and Place:

 MINI RESEARCH FORMAT

Title of the Study:

Introduction (150 words)

Objectives of the survey ( in points)

Review of Literature (Minimum 200 words covering a minimum of 15 citations)

Sample Profile (100 words)

Tools prepared (in points)

Data Analysis and Results

Reflections for future work (200 words)

Conclusion

Annexure: tools used for the survey

Signature Signature and Date

(Student Trainee) (Faculty Supervisor)
 PROJECT PROPOSAL FORMAT

1. Title of the Project:

2. Abstract: (Mention the summary in about 150-200 words)
A paragraph summarizing your topic of research, who or what will be the object of
data collection, how the data will be collected, how it will be analysed, and what
results you expect (possible outcomes).
3. Information of Project Proposer: ( as required)
Name:
Designation:
Organization:
Address:
Email: Mobile No.

4. Problem Identification (100 words)

5. Need assessment (100 words)
6. Introduction: (Introduce your project to external world in about 300-500 words; You
can include previous or similar projects and their outcomes; mention objectives
clearly)
7. Method (How to go about executing this project; describe target area, activities,
beneficiaries, ways & means to be adopted and other relevant details pertaining to
execution of the project: 150 words):
8. Expected Results (Mention concrete outcomes in about 100-200 words):
9. Estimated Budget
Give detailed break up under the following heads:

Budget Head Amount

10. Have you done some work or have some experience previously (Example:
Involvement in surveys, MRP, commissioned projects etc.)? If Yes, mention in 50- 60
words
 11. Expected Outcome: (100 words)

12. Timeline and Activity Calendar: (Matrix should drawn with weeks / month in a row
and activities mentioned in a column: Example is given below)

Timeline Baseline Problem Need Writing

Survey Identification Assessment Proposal

Feb

March

April

Remarks by the Supervisor (While Candidate is executing the project)

............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
...........................................................................................................................

(Name of the applicant)

Contact:
Email:
 PSYCHO-SOCIAL CASE HISTORY

Ref. Number (Client): ................ Date: ..................

Socio-demographic Details:

Name: ................................................................... Age: .............. Sex: ...............

Education: ............................................................ Occupation: ................................

Marital Status: ..................................................... Family type: ................................

No. of members: ...................

Religion: ................................

Mother Tongue: ................................

Socio economic Status: .......................................

Domicile: .............................................

Family Income: ....................................

Residence: ...........................................

Address for communication: ......................................................................................................

Telephone Numbers: .............................................

Father’s/ Husband’s/ Guardian’s Name: ....................................................................................

Relationship with patient: .....................................

Provisional Diagnosis: ......................................... Final Diagnosis: ..............................

Presenting Complaints (in chronological order with duration):

1.)

2.)

....................................................................................................................................................

Predisposing Factor (if any): .......................................................................................................

Precipitating Factor (if any): .......................................................................................................

Perpetuating Factor (if any): ......................................................................................................

Mode of onset: Abrupt/ Acute/ Insidious

Course of illness: Episodic/ Continuous/ Fluctuating/ Static/ Others

Progress: Static/ Improving/ Deteriorating/ Fluctuating

History of present illness:

Biological Functions:

Sleep: .....................................................

Appetite: ................................................

Sex: ……………………………….

Bowel & Bladder Functions: ............................................

Negative History: ...........................................................

History of past illness: ......................................................

Treatment History: ..........................................................

Compliance: ....................................................................

Medical: .....................................................................................................................................

............................................................................................................................................................
............................................................................................................................................

Neurological: .............................................................................................................................

............................................................................................................................................................
............................................................................................................................................

Psychiatric: ................................................................................................................................

............................................................................................................................................................
............................................................................................................................................

Family History:

Family Genogram (family of origin/ Procreation): .....................................................................

Family history of Medical/ Neurological/ Psychiatric illness: ....................................................

....................................................................................................................................................

Family composition: ...................................................................................................................

Attitude of family members towards patient’s illness: ..............................................................

Family interaction pattern: .........................................................................................................

(Family Development/ Stage/ Family Life Cycle):

(i) Married couples without children

(ii) Child bearing families (families with newly born babies)
(iii)Family with pre-school children (eldest child is 2.5 years to 6 years of age)
(iv) Family with school going children ((eldest child is 6 years to 13 years of age)
(v) Family with teenagers ((eldest child is 13 years to 20 years of age)
(vi) Family with launching young adults
(vii) Middle aged parents
(viii) Family with aging and retired parents

Family Dynamics:

(i) Boundary
(ii) Subsystems
(iii)Leadership and decision making
(iv) Role structure and functioning
(v) Communication
(vi) Reinforcement
(vii) Cohesiveness
(viii) Adaptive patterns
(ix) Social support systems

Primary Social support:

Secondary Social support:

Tertiary Social support:

Family burden:

General Pattern of living (Present living condition):

Personal History:

Educational History:

Occupational History:

Sexual History:

Marital History:

Forensic History:

Premorbid personality:

Mental Status Examination:

(i) General Appearance:

(ii) Attitude:
(iii)Motor behaviour:
(iv) Speech:
(v) Mood (Subjectively):
(vi) Mood (Objectively):
(vii) Affect:
(viii) Thought:

Cognitive Functions:

Insight:

Summary:

Diagnosis: