\ FAMILY MUAC TRAINING SKILLS ASSESSMENT FORM

(FOR COMMUNITY HEALTH WORKERS)

Name of Trainer/s: ___________________________________________ City/Municipality, Province: ___________________________
Total Number of MUAC Tapes Distributed: _________________________ Barangay: _________________________________________

Name of Mother/ Name of Date of Birth Address & Received Signature A. Baseline Skill B. Post Training Skill Community Health worker’s Remarks
Caregiver with Child Child (6-59 months of child Contact MUAC Assessment Assessment MUAC and Edema
(6-59 months old) old) 6-59 mos Number Tape (Mother/caregiver) (Mother/caregiver) Assessment*

(Last Name, First (✓ or X) (✓ or X) (✓ or X) (Rate 1 to 5)

Name Middle Name) (Last Name, First (dd/mm/yyyy)
Name Middle Name) A B
Use of Left Arm Use of Left Arm Use of Left Arm
Identification of Identification of Identification of
Midpoint of Midpoint of Midpoint of
Arm Arm Arm
MUAC MUAC MUAC
Measurement Measurement Measurement
MUAC MUAC MUAC
Interpretation Interpretation Interpretation
Edema Test Edema Test Edema Test
Use of Left Arm Use of Left Arm Use of Left Arm
Identification of Identification of Identification of
Midpoint of Midpoint of Midpoint of
Arm Arm Arm
MUAC MUAC MUAC
Measurement Measurement Measurement
MUAC MUAC MUAC
Interpretation Interpretation Interpretation
Edema Test Edema Test Edema Test
Use of Left Arm Use of Left Arm Use of Left Arm
Identification of Identification of Identification of
Midpoint of Midpoint of Midpoint of
Arm Arm Arm
MUAC MUAC MUAC
Measurement Measurement Measurement
MUAC MUAC MUAC
Interpretation Interpretation Interpretation
Edema Test Edema Test Edema Test
*5 – Excellent, 4 – Very Good, 3 – Good, 2 – Fair, 1 – Needs Improvement