Annex C Children Summary General Intake Sheet

Republic of the Philippines ECCDSID to be filled up by the encoded

Department of Social Welfare and
Development Children Served Profile
Early Childhood Care and Development

I. Children Facility LocationNOTE: Fields with (*) asterisk are required fields

Region District/Province Municipality Barangay Name of Facility

II. Children Served
2. Children w/ Disability 3. Children Provided with Other Services 4. Indigenous People’s 5. Muslim 6. Total Children
Children Served Children Served Dropped Out
1a. Age 1b. Gender Total 2b. Physical 2c. Mental
Group Served OH VI H Other UT/EMR WA IMP WADHD SL W D SF MNS D Others
I G W S
3 yrs. Male
old Female
4 yrs. Male
Old Female
5 yrs. Male
old Female
6 yrs. Male
old Female
7 yrs. Male
old Female
8 yrs. Male
old Female
9 yrs. Male
old Female
10 yrs. Male
old Female
Children with Disability Keys Children Provided with Services Keys

OH – Orthopedically Handicapped WG – Weigned 7a. Accomplished by: 7b. Date Accomplished*

VI – Visually Impaired DW – Dewormed ______________________________
HI – Hearing Impaired SF – Provided with Supplemental Feeding
Other – Other Handicap – Speech Defect MNS – Provided with Micro Nutrient Supplementation YYY – MM - DD
Hunchback,Cleft Palate – Harelip DS – Provided with Dental Services
UT/EMR – Upper Trainable/Educable Mentally Retarded Other – Other Services 7b. Name and Signature of Day Care Supervisor* 7C. Encode ID*
IMP – Improved Mental Patient
WA – With Autism
WADHD – With attention Deficit Hyperactive Disorder
SL – Slow Learners