Professional Documents
Culture Documents
Child Information Sheet
Child Information Sheet
1. Facility
Location
Name of Facility* Barangay* City / Municipality* Province* Region*
3. Sex* Male Female 4a. Birth Order* 4b. No. of siblings* 5a. Date of Birth*
YYYY - MM - DD
6. Birthplace 5b. Birth Registered?* Yes No
Barangay City / Municipality Province Region
7. Home
Address
No. & Street Address Barangay* City / Municipality* Province* Region*
8. Religion 9. Ethnicity
12. The child underwent the following: (check all applicable and fill details) 13. The child has the following disabilities / impairments:
b. Cause
a. Disability / Impairment (e.g. hearing, speech, visual)
(e.g.inborn,illness)
Breastfeeding - breastfed for
1
months
2
Supplemental Feeding - supplemented for 3
days 4
5
Food for School (Rice Distribution) - weekly allotment of
14. The child has the following past ECCD experiences:
kg a. Service Type* b. Service* c. From (Start Date) d. To (End Date)
(e.g. Center, Community) (e.g. Child Minding,Day Care Mother) (YYYY-MM-DD)* (YYYY-MM-DD)*
17. Attendance*
Accomplished By:* Date Accomplished*
15b. Parents’ Counterpart*
Continuing
Cash Dropped Out
In Kind 20
If drop out, reason:
None YYYY - MM - DD
Illness
Transfer of Residence Encoder ID
Others (specify):
Name and Signature of ECCD Service Provider*
__________________
Rev. 01.18.09 Profile ID (copy from 1st page)
Republic of the Philippines
Department of Social Welfare and Development
Early Childhood Care and Development
Child Information Sheet
V. Health Services Have the Health Service Provider sign beside each entry (use additional sheets as necessary)
17a. Health Service* b.Date YYYY - MM – DD* a. Health Service* b.Date YYYY - MM – DD*
1 Newborn Screening 25
8 Deworming 32
9 Dental Checkup 33
10 Physical Checkup 34
11 Micronutrient Supplement 35
12 36
13 37
14 38
15 39
16 40
17 41
18 42
19 43
20 44
21 45
22 46
23 47
24 48
VI. Nutritional Status (use additional sheets as necessary) VII. Developmental Status (Using the ECCD Checklist)
st nd rd
18a. Date YYYY - MM - DD* b.Age* c. Weight kg* d. Nutritional Status* 19. Evaluation* 1 Evaluation 2 Evaluation 3 Evaluation
1 Evaluation Date*
(YYYY-MM-DD)
Domains Raw Score Scaled Score Raw Score Scaled Score Raw Score Scaled Score
2
a. Fine Motor Dev’t
3
b. Gross Motor
4
c. Self-Help
5
d. Receptive Language
6
e. Expressive Language
7
f. Cognitive
8
g. Socio-Emotional
9
10
11 Overall Interpretation
12
14 1 Highly Advanced
1 <-2SD Underweight 2 Slightly Advanced
15 2 -2SD to +2SD Normal 3 Average Development
3 >+2SD Overweight 4 Development to be mentioned after 6 months
16 5 Development to be mentioned after 3 months
17
20
20
21 YYYY - MM - DD
22 Encoder ID
23
Name and Signature of ECCD Service Provider
24