BNS Form No.

1A
Philippine Plan of Action for Nutrition

FAMILY PROFILE

Purok/Zone:__________________________________ Municipality: ____

Barangay: ___________________________________ City/Province: ___

No. of Children Check If: Check If:

Nursing ≤ 6 mos. Old ch

No. of Educa-
HH HH <6 6-23 24-59 > 60 Name of Household tional Couple
Occupation
No Mem- mos. mos. mos. mos. Head/Spouse attain- Pregnant practice
bers ment Mother Family EBF Mixed
old old Old Old Feeding
Planning

(F)
(M)
(F)
(M)
(F)
(M)
(F)
(M)
(F)
(M)
Abbreviations
CF - Complementary (F) - Father Educational attainment Toilet Water source Food Production Activity
EBF - Exclusive (M) - Mother EU - Elem. Undergraduate WS - Water Sealed P - Pipe VG - Vegetable garden
HH - Household CU - College Undergraduate OP - Open Pit W - Well P/L - Poultry/ Livestock
EG - Elem. Graduate CG -
College
HU - HS Undergraduate O - Others S - Spring FP - Fishpond
EG - Elementary Graduate N - None CSP - Communal CVGP/L - Combi Veg. garde
HG - HS Graduate source piped Poultry/Livestock
CG - College Graduate water system NG - No Garden
V - Vocational MW - Mineral
O - Others water/water
dispensing
stores
Municipality: ________________________
City/Province: _______________________

Check If: Fill in: Check If:

sing ≤ 6 mos. Old child
(0-59
Food mos.) PSC
Toilet Water Production Garbage with HH using
type Source Activity (VG, Disposal disability Iodized
Bottle Others (WS, OP, (P, W, S, P/L, FP, (B/MGC, (E, OD, C,
Fed Salt
O, N) CSP, MW) CVGP/L, OCP) DM, VD,
NG) HD, DS, SI,
O)

roduction Activity Garbage Disposal Disability

getable garden E - Epilepsy
oultry/ Livestock B/MGC -Brgy./mun. OD - Orthopedic disabillity
garbage collection C - Cancer
OCP - Own compost pit DM - Diabetes Mellitus
L - Combi Veg. garden, VD - Visual Disability
Poultry/Livestock HD - Hearing Disability
o Garden DS - Down Syndrome
SI - Speech Impairment
O - Others