No.

Date of Date of Birth SE Status Name of Child Sex Complete Name of Complete Child Protected at Birth (CPAB) Newborn (0-28 days old)
Registration (mm/dd/yy) 1: NHTS (First Name, Middle Initial, Last Name) (M or F) Mother Address (9) (10)
(mm/dd/yy) 2: Non-NHTS (LN, FN, MI) (Place a √)
(counts should be consistent with Maternal
Length Weight Status
TCL Livebirths) at Birth at birth (Birth
(cm) (kg) Weight)

TT2/Td2 TT3/Td3 to Total L: low:

given to TT5/Td5 (or (9a + 9b) <2,500gms
the mother TT1/Td1 to N: normal:
a month TT5/Td5) ≥2,500gms
prior to given anytime U: unknown
delivery prior to
(9a) delivery
(9b)

(1) (2) (4) (5) (6) (7) (8)

10

11

12

13

14

15

16

17
 Newborn (0-28 days old) 1-3 months old
(10) (Col 11)
Initiated Immunization Nutritional Status Assessment Low birth weight Immunization
breast given Iron (Write the date)
feeding (Write the date)
immediately
after birth
lasting for 90 BCG Hepa Age in Length Weight Status 1 mo 2 mos 3 mos DPT-HiB-HepB OPV PCV
minutes (date) B-BD months (cm) (kg) UW = underweight
(date) (date) & date & date S = stunted
taken taken W = wasted
O = obese/ 1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose
overweight 1 ½ mos 2 ½ mos 3 ½ mos 1 ½ mos 2 ½ mos 3 ½ mos 1 ½ mos 2 ½ mos 3 ½ mos
N = normal
 1-3 months old 6-11 months old
(Col 11) (12)
Exclusive Breastfeeding* Nutritional Status Assessment Exclusively Introduction of Complementary Vitamin A MNP
Place a check (√) Breastfed* Feeding** at 6 months old (date given) (date when
During the following immunization visits of the child at 1 ½, up to 6 90 sachets
2 ½ and 3 ½ months old (or at 4-5 mos.), ask the mother if months given)
the child continues to be exclusively breastfed. Place a (Y or N)
IPV check (√) on each column Age in Length Weight Status Y or N 1 - With continuous
months (cm) (kg) UW = underweight breastfeeding
& date & date S = stunted 2 - no longer
taken taken W = wasted breastfeeding or
O = obese/ never breastfed
3 1/2 mos 1 ½ mos. 2 ½ mos. 3 ½ mos. 4-5 mos.
overweight
N = normal
 12 months old CIC Remarks
(13) (date)
MMR Nutritional Status Assessment MMR FIC***
Dose 1 at 9th month Dose 2 at 12th (date)
(date given) month
(date given)

Age in months Length (cm) Weight (kg) Status

& date taken & date taken UW = underweight
S = stunted
W = wasted
O = obese/ overweight
N = normal

(14) (15)
No Date of Date of SE Status Name of Child Sex Complete Name of Complete Length / Weight 12-23 Months Old
Registratio Birth 1: NHTS (First Name, Middle Initial, (M or F) Mother Address Height (kg) (11)
n (mm/dd/yy) 2: Non-NHTS Last Name) (Last Name, First Name, (cm)
Nutritional Nutrition Services
(mm/dd/yy) Middle Initial)
Status Micronutrient
Indicate if: Supplementation
UW = Deworming
underweight MNP Services
S = stunted (Date Vitamin A
W = wasted (Date Given)
O = obese/
when 180
overweight sachets
N = normal given) 1st 2nd 1st 2nd Child Given
dose dose dose dose 2 doses of
(date (date
given) given)
deworming
drug
Put a (√) check

(1) (2) (4) (5) (6) (7) (8) (9) (10)

10

11

12

13

14

15

16
17
 24-35 Months Old 36-47 Months Old 48-59 Months Old Remarks
(12) (13) (14)
Nutritional Nutrition Services Nutritional Nutrition Nutritional Nutrition Services
Status Micronutrient Status Services Status Micronutrient
Indicate if: Supplementation Indicate if: Micronutrient Indicate if: Supplementation
UW = Deworming UW = Supplementation Deworming UW = Deworming
underweight Services underweight Services underweight Services
S = stunted Vitamin A S = stunted Vitamin A S = stunted Vitamin A
W = wasted (Date Given) W = wasted (Date Given) W = wasted (Date Given)
O = obese/ O = obese/ O = obese/
overweight overweight overweight
N = normal
1st dose 2nd dose 1st 2nd Child N = normal
1st dose 2nd dose 1st 2nd Child N = normal
1st dose 2nd dose 1st 2nd Child
dose dose Given 2 dose dose Given 2 dose dose Given 2
(date (date (date (date (date (date
given) given)
doses of given) given)
doses of given) given)
doses of
deworming deworming deworming
drug drug drug
Put a (√) Put a (√) Put a (√)
check check check
(15)
No. Date of Date of Family SE Status Name of Child Sex Complete Name of Mother Complete Address
Registration Birth Serial 1: NHTS (First Name, Middle Initial, (M or F) (Last Name, First Name, Middle
(mm/dd/yy) (mm/dd/yy) Number 2: Non-NHTS Last Name) Initial)

(1) (2) (3) (4) (5) (6) (7) (8)

10

11

12

13

14

15

Page 9 of 17
 Deworming Services Remarks
(9)
5 Years Old 6 Years Old 7 Years Old 8 Years Old 9 Years Old
1st 2nd Child given 1st 2nd Child given 1st 2nd Child given 1st 2nd Child given 1st 2nd Child given
dose dose 2 doses of dose dose 2 doses of dose dose 2 doses of dose dose 2 doses of dose dose 2 doses of
(date (date deworming (date (date deworming (date (date deworming (date (date deworming (date (date deworming
given) given) drug given) given) drug given) given) drug given) given) drug given) given) drug
Put a (√) Put a (√) Put a (√) Put a (√) Put a (√)
check check check check check

(10)

Page 10 of 17
No. Date of Date of SE Status Name of Adolescent Sex Complete Name of Mother Complete
Registration Birth 1: NHTS (First Name, Middle Initial, (M or F) (Last Name, First Name, Middle Address
(mm/dd/yy) (mm/dd/yy) 2: Non-NHTS Last Name) Initial)

(1) (2) (4) (5) (6) (7) (8)

10

Page 11 of 17
 Deworming Services
(9)
10 Years Old 11 Years Old 12 Years Old 13 Years Old 14 Years Old
1st 2nd Adolescent 1st 2nd Adolescent 1st 2nd Adolescent 1st 2nd Adolescent 1st
dose dose given 2 dose dose given 2 dose dose given 2 dose dose given 2 dose
(date (date doses of (date (date doses of (date (date doses of (date (date doses of (date
given) given) deworming given) given) deworming given) given) deworming given) given) deworming given)
drug drug drug drug
Put a (√) check Put a (√) check Put a (√) check Put a (√) check

Page 12 of 17
14 Years Old
2nd Adolescent
dose given 2
(date doses of
given) deworming
drug
Put a (√) check

Page 13 of 17
 Deworming Services
(9)
15 Years Old 16 Years Old 17 Years Old 18 Years Old 19 Years Old
1st 2nd Adolescent 1st 2nd Adolescent 1st 2nd Adolescent 1st 2nd Adolescent 1st
dose dose given 2 dose dose given 2 dose dose given 2 dose dose given 2 dose
(date (date doses of (date (date doses of (date (date doses of (date (date doses of (date
given) given) deworming given) given) deworming given) given) deworming given) given) deworming given)
drug drug drug drug
Put a (√) check Put a (√) check Put a (√) check Put a (√) check

Page 14 of 17
 Remarks

19 Years Old
2nd Adolescent
dose given 2
(date doses of
given) deworming
drug
Put a (√) check

(10)

Page 15 of 17
 No. Date of Family Name of Child Date of Sex Complete Name of Complete Address SE Status Vitamin A Supplementation**
Registration Serial (First Name, Middle Initial, Birth (M or F) Mother 1: NHTS
(mm/dd/yy) Number Last Name) (mm/dd/yy) (Last Name, First Name, 2: Non-NHTS
Middle Initial) (9)
Put a (√)

6-11 mos. 12-59 mos.

(1) (2) (3) (4) (5) (6) (7) (8)

10
** Recommended Vitamin A Supplementation Given to High Risk/
* Diagnosis/Findings:
A = Measles Diagnosis Preparation/Capsule
B = Severe Pneumonia
C = Persistent Diarrhea Measles cases 100,000 IU for infants 6-11 months old
D = Severely Underweight
200,000 IU for children 12-59 months old
E = Xerophthalmia
F = Night Blindness Severe pneumonia, persistent diarrhea and severely underweight 100,000 IU for infants 6-11 months old
G = Bitot's spots
H = Corneal Xerosis 200,000 IU for children 12-59 months old
I = Corneal Ulcerations Cases with Xerophthalmia, including night blindness, Bitot's spots, corneal xerosis, 100,000 IU for infants 6-11 months old
J = Keratomalacia corneal ulcerations and keratomalacia
K = Corneal Scar 200,000 IU for children 12-59 months old
tamin A Supplementation** Diarrhea Cases Seen and Given Pneumonia Cases Seen Remarks
Treatment and Given Treatment
(9) (10) (11)
Diagnosis/ Date Given Age in Date Given Age in Date Given
Findings* Months Months Treatment
(Use Code)
ORS Oral zinc
drops or
syrup
(12)

plementation Given to High Risk/Sick Children

aration/Capsule
or infants 6-11 months old
children 12-59 months old
or infants 6-11 months old
children 12-59 months old
or infants 6-11 months old
children 12-59 months old
Vitamin A Dosage and Schedule of Administration
Give one capsule upon diagnosis regardless of when the last dose of vitamin A capsule
(VAC) was given. Give another capsule after 24 hours
Give one capsule upon diagnosis, except when the child was given VAC less than 4
weeks before diagnosis.
Give one capsule immediately upon diagnosis. Give one capsule the next day, and 1
capsule 2 weeks after.