Household Care Plan

HOUSEHOLD CARE PLAN

Name of Household______________________________ Code of Household: _________________

Any change in the household in the last few months?  Moved Primary caregiver ill Primary caregiver bedridden
1. No
Yes (If yes, check all that apply):  Child died:_________ Parent/guardian Other:__________________
died:___________
Name Gender Date of Birth/Age Relationship to Child
Total number of adults living in household (over age M/F
18 years)? 1. 1. 1. 1.
2.
2. 2. 2. 2.
_____ (#)
3. 3. 3. 3.
4. 4. 4. 4.
5. 5. 5. 5.
Household Register

Mother  Father Grandparent Extended family Foster parent

3. Who is the primary caregiver?
Older sibling Child-headed household (no adult supervision)
Other__________________
*NOTE: (The primary caregiver is the person primarily responsible for physically taking care of
child’s needs (e.g., dressing, bathing, feeding, getting to school, etc.); not necessarily the
breadwinner.
Are there others in the household who provide care  No  Yes
4. for the child? Mother  Father Grandparent Extended family Foster parent
If yes: Check all that apply Older sibling Child-headed household (no adult supervision)
Other__________________
Name Gender Birth Date/Age Relationship to Primary
Total number of children living in household? M/F Caregiver
1. 1. 1. 1.
5.
______ (#) 2. 2. 2. 2.
3. 3. 3. 3.
Total number of children (0 to 8)? 4. 4. 4. 4.
5. 5. 5. 5.
______ (#)
6. 6. 6. 6.
Status Assessment Required Actions Outcome
Primary Caregiver Status
Action:
Primary caregiver is chronically ill (like HIV and TB) Yes No Person(s) Responsible:
Timeframe:
Action:
Child headed household Yes No Person(s) Responsible:
Timeframe:
Action:
Primary caregiver is elderly Yes No Person(s) Responsible:
Timeframe:

Action:
Primary caregiver receives support from family Yes No Person(s) Responsible:
members or community Timeframe:

Child Status
Action:
Child(ren) are not registered Yes No Person(s) Responsible:
Timeframe:

Action:
Child(ren) are physically disabled Yes No Person(s) Responsible:
Timeframe:

Action:
Child(ren) are chronically ill (such as HIV and TB) Yes No Person(s) Responsible:
Timeframe:

Action:
Child(ren) do not play with peers (not allowed or lack Yes No Person(s) Responsible:
friends) Timeframe:
Action:
Child(ren) are abused (physical, psychosocial, or sexual) Yes No Person(s) Responsible:
Timeframe:
Status Assessment Required Actions Outcome
Caregiving Environment
Action:
House is in need of major repairs Yes No Person(s) Responsible:
Timeframe:

Action:
Household has hazards e.g. open fire pit Yes No Person(s) Responsible:
Timeframe:

Action:
Sick/Bedridden person(s) living in household Yes No Person(s) Responsible:
Timeframe:

Action:
Household suffers from stigma and discrimination Yes No Person(s) Responsible:
Timeframe:

Note Any Other Issues Not Listed Above: Action:

Person(s) Responsible:
Timeframe:

Action:
Person(s) Responsible:
Timeframe:

Action:
Person(s) Responsible:
Timeframe: