OPT Plus Form 1B.

List of Affected/At-risk Preschoolers 0-59 Months old

Philippine Plan of Action for Nutrition

Barangay: _____________________ Province: ______________________

City/Municipality: _______________ Year/Period of Measurement: ____________

Instructions:
In column 1, copy the household number from the Family Profile
In column 2, write the family name first, followed by name of the household head.
In column 3, write the first name of the preschool child.
In column 4, write "B" for boy and "G" for girl.
In column 5, specify if household member belongs to an indigenous people group, write "N/A" if not applicable
In column 6, indicate the age in months based on last completed month.
In column 7-14, check the appropriate nutritional status.
For the TOTAL row, add all the values in each column.

Household Name of Household Head/ Name of Preschooler Sex Indigenous Age in Nutritional Status
Number Mother Caregiver Group months UW SUW St SSt W SW OW Ob
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)

TOTAL

Prepared by: ______________________________________ Checked: _____________________ Approved: _________________________________

Name and Signature of Barangay Nutrition Scholar Name and Signature of Midwife/ Name and Signature of Barangay Captain,
Nurse/District/City Nutrition Program BNC Chairperson
Date: ________________ Coordinator
Date: ________________ Date: ________________