No.

Date of Date of Family SE Status Name of Child Sex Complete Name of Mother Complete Address Child Protected at Birth
Registration Birth Serial 1: NHTS (First Name, Middle Initial, Last Name) (M or F) (LN, FN, MI) (CPAB)
(mm/dd/yy) (mm/dd/yy) Number 2: Non-NHTS (9)
(Place a √)
(counts should be consistent with
Maternal TCL Livebirths)

TT2/Td2 given to TT3/Td3 to

the mother a TT5/Td5 (or
month prior to TT1/Td1 to
delivery TT5/Td5) given
(for mothers to the mother
pregnant for the anytime prior to
first time delivery
(9a) (9b)

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

10

Page 1 of 38
 Newborn (0-28 days old) 1-3 months old
(10) (Col 11)
Length Weight Status Initiated Immunization Nutritional Status Assessment Low birth weight Immunization Exclusive Breastfeeding*
at Birth at birth (Birth breast given Iron (Write the date) During the following immunization visits of the child
(cm) (kg) Weight) feeding (Write the date) at 1 ½, 2 ½ and 3 ½ months old (or at 4-5 mos.),
immediately ask the mother if the child continues to be
exclusively breastfed. Write Y if still EBF or N if no
after birth
L: low: 1 mo 2 mos 3 mos DPT-HiB-HepB OPV PCV IPV longer EBF then write the date below when the
lasting for 90 BCG Hepa Age in Length Weight Status
infant was assessed.
<2,500gms minutes (date) B-BD months (cm) (kg) S = stunted
N: normal: (date) (date) & date & date W-MAM = wasted-MAM
≥2,500gms taken taken W-SAM = wasted-SAM
U: unknown O = obese/ overweight 1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 1 ½ mos. 2 ½ mos. 3 ½ mos. 4-5 mos.
N = normal 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 3 ½ mos

* Exclusively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively breastfed."
**Complementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeeding
*** Fully Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR at 12 months.

Page 2 of 38
 6-11 months old 12 months old CIC Remarks
(12) (13) (date)
Nutritional Status Assessment Exclusively Introduction of Vitamin A MNP MMR IPV Nutritional Status Assessment MMR FIC***
Breastfed* Complementary Feeding** (date given) (date when Dose 1 at Dose 2 at Dose 2 at (date)
up to 6 at 6 months old 90 sachets 9th month 9th month 12th month
months given) (date given) (date given) (date given)
Write Y if Yes
Age in Length Weight Status or N if No then Y or N 1 - With Age in Length Weight Status
months (cm) (kg) S = stunted write the date continuous months (cm) (kg) S = stunted
& date & date W-MAM = wasted-MAM below when the breastfeeding & date & date W-MAM = wasted-MAM
taken taken W-SAM = wasted-SAM infant was 2 - no longer taken taken W-SAM = wasted-SAM
assessed. breastfeeding or
O = obese/ overweight O = obese/ overweight
never breastfed
N = normal N = normal

(14) (15)

* Exclusively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively breastfed."
**Complementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeeding
*** Fully Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR at 12 months.

Page 3 of 38
No. Date of Date of Family SE Status Name of Child Sex
Registration Birth Serial 1: NHTS (First Name, Middle Initial, Last Name) (M or F)
(mm/dd/yy) (mm/dd/yy) Number 2: Non-NHTS

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

1
26-Jul-22 13-Jul-22 Caamod Jessica F
2
26-Jul-22 24-Jun-23 Decayman, Richelle F
3
06-Jul-22 05-Jul-22 Bolastig, Jhon Bert M
4
14-Dec-22 02-Oct-22 Bonula, Raiceky F
5
18-Jan-23 21-Nov-22 Encila, Ezekiel M
6

10
Complete Name of Mother Complete Address Child Protected at Birth Newborn (0-28 days old
(LN, FN, MI) (CPAB) (10)
(9) Length Weight
(Place a √)
(counts should be consistent with
at Birth at birth
Maternal TCL Livebirths) (cm) (kg)

TT2/Td2 given to TT3/Td3 to

the mother a TT5/Td5 (or
month prior to TT1/Td1 to
delivery TT5/Td5) given
(for mothers to the mother
pregnant for the anytime prior to
first time delivery
(9a) (9b)

(7) (8)

Moloboco, Monica

TT4

Catalan, Jinky

Lindayao, Jillian

* Exclusively Breastfed: No other food (includin

**Complementary Feeding: Infants 6 months ol
*** Fully Immunized Child (FIC): A child who ha
 Newborn (0-28 days old)
(10)
Status Initiated Immunization Nutritional Status Assessment Low birth weight
(Birth breast given Iron
Weight) feeding (Write the date)
immediately
after birth
L: low: lasting for 90 BCG Hepa Age in Length Weight Status 1 mo 2 mos 3 mos
<2,500gms minutes (date) B-BD months (cm) (kg) S = stunted
N: normal: (date) (date) & date & date W-MAM = wasted-MAM
≥2,500gms taken taken W-SAM = wasted-SAM
U: unknown O = obese/ overweight
N = normal

7/6/2022

###

61.2 6.3
### 3 ### ### N
57.2 5.1
### 2 ### ### N

usively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively brea
mplementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeeding
lly Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB,
 1-3 months old
(Col 11)
Immunization Exclusive Breastfeedi
(Write the date) During the following immunization vis
at 1 ½, 2 ½ and 3 ½ months old (or
ask the mother if the child contin
exclusively breastfed. Write Y if still E
DPT-HiB-HepB OPV PCV IPV longer EBF then write the date bel
infant was assessed.

1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 1 ½ mos.
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 3 ½ mos

8/10/2022 8/10/2022 8/10/2022

12/14/2022 1/18/2023 12/14/2022 1/18/2023 12/14/2022 1/18/2023

1/18/2023 1/18/2023 1/18/2023

breastfeeding is still "exclusively breastfed."

anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR at 12 months.
 6-11 months old
(12)
Exclusive Breastfeeding* Nutritional Status Assessment Exclusively Introduction of
During the following immunization visits of the child Breastfed* Complementary Feeding**
at 1 ½, 2 ½ and 3 ½ months old (or at 4-5 mos.), up to 6 at 6 months old
ask the mother if the child continues to be months
exclusively breastfed. Write Y if still EBF or N if no Write Y if Yes
longer EBF then write the date below when the
Age in Length Weight Status or N if No then Y or N
infant was assessed. write the date
months (cm) (kg) S = stunted
& date & date W-MAM = wasted-MAM below when the
taken taken W-SAM = wasted-SAM infant was
assessed.
2 ½ mos. 3 ½ mos. 4-5 mos. O = obese/ overweight
N = normal

64.7 6.5
7 ### ### N

* Exclusively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed
**Complementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeed
*** Fully Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1
1 months old 12 months old
(12) (13)
Introduction of Vitamin A MNP MMR IPV Nutritional Status Assessment
Complementary Feeding** (date given) (date when Dose 1 at Dose 2 at
at 6 months old 90 sachets 9th month 9th month
given) (date given) (date given)

1 - With Age in Length Weight Status

continuous months (cm) (kg) S = stunted
breastfeeding & date & date W-MAM = wasted-MAM
2 - no longer taken taken W-SAM = wasted-SAM
breastfeeding or O = obese/ overweight
never breastfed
N = normal

given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively breastfed."
id or soft foods to complement breastfeeding
antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR
old CIC Remarks
(date)
MMR FIC***
Dose 2 at (date)
12th month
(date given)

(14) (15)

at 9 months, and 1 dose of MMR at 12 months.

No. Date of Date of Family SE Status Name of Child Sex
Registration Birth Serial 1: NHTS (First Name, Middle Initial, Last Name) (M or F)
(mm/dd/yy) (mm/dd/yy) Number 2: Non-NHTS

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

10
Complete Name of Mother Complete Address Child Protected at Birth Newborn (0-28 days old
(LN, FN, MI) (CPAB) (10)
(9) Length Weight
(Place a √)
(counts should be consistent with
at Birth at birth
Maternal TCL Livebirths) (cm) (kg)

TT2/Td2 given to TT3/Td3 to

the mother a TT5/Td5 (or
month prior to TT1/Td1 to
delivery TT5/Td5) given
(for mothers to the mother
pregnant for the anytime prior to
first time delivery
(9a) (9b)

(7) (8)

* Exclusively Breastfed: No other food (includin

**Complementary Feeding: Infants 6 months ol
*** Fully Immunized Child (FIC): A child who ha
 Newborn (0-28 days old)
(10)
Status Initiated Immunization Nutritional Status Assessment Low birth weight
(Birth breast given Iron
Weight) feeding (Write the date)
immediately
after birth
L: low: lasting for 90 BCG Hepa Age in Length Weight Status 1 mo 2 mos 3 mos
<2,500gms minutes (date) B-BD months (cm) (kg) S = stunted
N: normal: (date) (date) & date & date W-MAM = wasted-MAM
≥2,500gms taken taken W-SAM = wasted-SAM
U: unknown O = obese/ overweight
N = normal

usively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively brea
mplementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeeding
lly Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB,
 1-3 months old
(Col 11)
Immunization Exclusive Breastfeedi
(Write the date) During the following immunization vis
at 1 ½, 2 ½ and 3 ½ months old (or
ask the mother if the child contin
exclusively breastfed. Write Y if still E
DPT-HiB-HepB OPV PCV IPV longer EBF then write the date bel
infant was assessed.

1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 1 ½ mos.
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 3 ½ mos

breastfeeding is still "exclusively breastfed."

anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR at 12 months.
 6-11 months old
(12)
Exclusive Breastfeeding* Nutritional Status Assessment Exclusively Introduction of
During the following immunization visits of the child Breastfed* Complementary Feeding**
at 1 ½, 2 ½ and 3 ½ months old (or at 4-5 mos.), up to 6 at 6 months old
ask the mother if the child continues to be months
exclusively breastfed. Write Y if still EBF or N if no Write Y if Yes
longer EBF then write the date below when the
Age in Length Weight Status or N if No then Y or N
infant was assessed. write the date
months (cm) (kg) S = stunted
& date & date W-MAM = wasted-MAM below when the
taken taken W-SAM = wasted-SAM infant was
assessed.
2 ½ mos. 3 ½ mos. 4-5 mos. O = obese/ overweight
N = normal

* Exclusively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed
**Complementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeed
*** Fully Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1
1 months old 12 months old
(12) (13)
Introduction of Vitamin A MNP MMR IPV Nutritional Status Assessment
Complementary Feeding** (date given) (date when Dose 1 at Dose 2 at
at 6 months old 90 sachets 9th month 9th month
given) (date given) (date given)

1 - With Age in Length Weight Status

continuous months (cm) (kg) S = stunted
breastfeeding & date & date W-MAM = wasted-MAM
2 - no longer taken taken W-SAM = wasted-SAM
breastfeeding or O = obese/ overweight
never breastfed
N = normal

given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively breastfed."
id or soft foods to complement breastfeeding
antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR
old CIC Remarks
(date)
MMR FIC***
Dose 2 at (date)
12th month
(date given)

(14) (15)

at 9 months, and 1 dose of MMR at 12 months.

No. Date of Date of Family SE Status Name of Child Sex
Registration Birth Serial 1: NHTS (First Name, Middle Initial, Last Name) (M or F)
(mm/dd/yy) (mm/dd/yy) Number 2: Non-NHTS

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

10
Complete Name of Mother Complete Address Child Protected at Birth Newborn (0-28 days old
(LN, FN, MI) (CPAB) (10)
(9) Length Weight
(Place a √)
(counts should be consistent with
at Birth at birth
Maternal TCL Livebirths) (cm) (kg)

TT2/Td2 given to TT3/Td3 to

the mother a TT5/Td5 (or
month prior to TT1/Td1 to
delivery TT5/Td5) given
(for mothers to the mother
pregnant for the anytime prior to
first time delivery
(9a) (9b)

(7) (8)

* Exclusively Breastfed: No other food (includin

**Complementary Feeding: Infants 6 months ol
*** Fully Immunized Child (FIC): A child who ha
 Newborn (0-28 days old)
(10)
Status Initiated Immunization Nutritional Status Assessment Low birth weight
(Birth breast given Iron
Weight) feeding (Write the date)
immediately
after birth
L: low: lasting for 90 BCG Hepa Age in Length Weight Status 1 mo 2 mos 3 mos
<2,500gms minutes (date) B-BD months (cm) (kg) S = stunted
N: normal: (date) (date) & date & date W-MAM = wasted-MAM
≥2,500gms taken taken W-SAM = wasted-SAM
U: unknown O = obese/ overweight
N = normal

usively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively brea
mplementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeeding
lly Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB,
 1-3 months old
(Col 11)
Immunization Exclusive Breastfeedi
(Write the date) During the following immunization vis
at 1 ½, 2 ½ and 3 ½ months old (or
ask the mother if the child contin
exclusively breastfed. Write Y if still E
DPT-HiB-HepB OPV PCV IPV longer EBF then write the date bel
infant was assessed.

1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 1 ½ mos.
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 3 ½ mos

breastfeeding is still "exclusively breastfed."

anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR at 12 months.
 6-11 months old
(12)
Exclusive Breastfeeding* Nutritional Status Assessment Exclusively Introduction of
During the following immunization visits of the child Breastfed* Complementary Feeding**
at 1 ½, 2 ½ and 3 ½ months old (or at 4-5 mos.), up to 6 at 6 months old
ask the mother if the child continues to be months
exclusively breastfed. Write Y if still EBF or N if no Write Y if Yes
longer EBF then write the date below when the
Age in Length Weight Status or N if No then Y or N
infant was assessed. write the date
months (cm) (kg) S = stunted
& date & date W-MAM = wasted-MAM below when the
taken taken W-SAM = wasted-SAM infant was
assessed.
2 ½ mos. 3 ½ mos. 4-5 mos. O = obese/ overweight
N = normal

* Exclusively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed
**Complementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeed
*** Fully Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1
1 months old 12 months old
(12) (13)
Introduction of Vitamin A MNP MMR IPV Nutritional Status Assessment
Complementary Feeding** (date given) (date when Dose 1 at Dose 2 at
at 6 months old 90 sachets 9th month 9th month
given) (date given) (date given)

1 - With Age in Length Weight Status

continuous months (cm) (kg) S = stunted
breastfeeding & date & date W-MAM = wasted-MAM
2 - no longer taken taken W-SAM = wasted-SAM
breastfeeding or O = obese/ overweight
never breastfed
N = normal

given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively breastfed."
id or soft foods to complement breastfeeding
antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR
old CIC Remarks
(date)
MMR FIC***
Dose 2 at (date)
12th month
(date given)

(14) (15)

at 9 months, and 1 dose of MMR at 12 months.

No. Date of Date of Family SE Status Name of Child Sex
Registration Birth Serial 1: NHTS (First Name, Middle Initial, Last Name) (M or F)
(mm/dd/yy) (mm/dd/yy) Number 2: Non-NHTS

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

10
Complete Name of Mother Complete Address Child Protected at Birth Newborn (0-28 days old
(LN, FN, MI) (CPAB) (10)
(9) Length Weight
(Place a √)
(counts should be consistent with
at Birth at birth
Maternal TCL Livebirths) (cm) (kg)

TT2/Td2 given to TT3/Td3 to

the mother a TT5/Td5 (or
month prior to TT1/Td1 to
delivery TT5/Td5) given
(for mothers to the mother
pregnant for the anytime prior to
first time delivery
(9a) (9b)

(7) (8)

* Exclusively Breastfed: No other food (includin

**Complementary Feeding: Infants 6 months ol
*** Fully Immunized Child (FIC): A child who ha
 Newborn (0-28 days old)
(10)
Status Initiated Immunization Nutritional Status Assessment Low birth weight
(Birth breast given Iron
Weight) feeding (Write the date)
immediately
after birth
L: low: lasting for 90 BCG Hepa Age in Length Weight Status 1 mo 2 mos 3 mos
<2,500gms minutes (date) B-BD months (cm) (kg) S = stunted
N: normal: (date) (date) & date & date W-MAM = wasted-MAM
≥2,500gms taken taken W-SAM = wasted-SAM
U: unknown O = obese/ overweight
N = normal

usively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively brea
mplementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeeding
lly Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB,
 1-3 months old
(Col 11)
Immunization Exclusive Breastfeedi
(Write the date) During the following immunization vis
at 1 ½, 2 ½ and 3 ½ months old (or
ask the mother if the child contin
exclusively breastfed. Write Y if still E
DPT-HiB-HepB OPV PCV IPV longer EBF then write the date bel
infant was assessed.

1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 1 ½ mos.
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 3 ½ mos

breastfeeding is still "exclusively breastfed."

anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR at 12 months.
 6-11 months old
(12)
Exclusive Breastfeeding* Nutritional Status Assessment Exclusively Introduction of
During the following immunization visits of the child Breastfed* Complementary Feeding**
at 1 ½, 2 ½ and 3 ½ months old (or at 4-5 mos.), up to 6 at 6 months old
ask the mother if the child continues to be months
exclusively breastfed. Write Y if still EBF or N if no Write Y if Yes
longer EBF then write the date below when the
Age in Length Weight Status or N if No then Y or N
infant was assessed. write the date
months (cm) (kg) S = stunted
& date & date W-MAM = wasted-MAM below when the
taken taken W-SAM = wasted-SAM infant was
assessed.
2 ½ mos. 3 ½ mos. 4-5 mos. O = obese/ overweight
N = normal

* Exclusively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed
**Complementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeed
*** Fully Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1
1 months old 12 months old
(12) (13)
Introduction of Vitamin A MNP MMR IPV Nutritional Status Assessment
Complementary Feeding** (date given) (date when Dose 1 at Dose 2 at
at 6 months old 90 sachets 9th month 9th month
given) (date given) (date given)

1 - With Age in Length Weight Status

continuous months (cm) (kg) S = stunted
breastfeeding & date & date W-MAM = wasted-MAM
2 - no longer taken taken W-SAM = wasted-SAM
breastfeeding or O = obese/ overweight
never breastfed
N = normal

given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively breastfed."
id or soft foods to complement breastfeeding
antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR
old CIC Remarks
(date)
MMR FIC***
Dose 2 at (date)
12th month
(date given)

(14) (15)

at 9 months, and 1 dose of MMR at 12 months.

No. Date of Date of Family SE Status Name of Child Sex
Registration Birth Serial 1: NHTS (First Name, Middle Initial, Last Name) (M or F)
(mm/dd/yy) (mm/dd/yy) Number 2: Non-NHTS

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

10
Complete Name of Mother Complete Address Child Protected at Birth Newborn (0-28 days old
(LN, FN, MI) (CPAB) (10)
(9) Length Weight
(Place a √)
(counts should be consistent with
at Birth at birth
Maternal TCL Livebirths) (cm) (kg)

TT2/Td2 given to TT3/Td3 to

the mother a TT5/Td5 (or
month prior to TT1/Td1 to
delivery TT5/Td5) given
(for mothers to the mother
pregnant for the anytime prior to
first time delivery
(9a) (9b)

(7) (8)

* Exclusively Breastfed: No other food (includin

**Complementary Feeding: Infants 6 months ol
*** Fully Immunized Child (FIC): A child who ha
 Newborn (0-28 days old)
(10)
Status Initiated Immunization Nutritional Status Assessment Low birth weight
(Birth breast given Iron
Weight) feeding (Write the date)
immediately
after birth
L: low: lasting for 90 BCG Hepa Age in Length Weight Status 1 mo 2 mos 3 mos
<2,500gms minutes (date) B-BD months (cm) (kg) S = stunted
N: normal: (date) (date) & date & date W-MAM = wasted-MAM
≥2,500gms taken taken W-SAM = wasted-SAM
U: unknown O = obese/ overweight
N = normal

usively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively brea
mplementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeeding
lly Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB,
 1-3 months old
(Col 11)
Immunization Exclusive Breastfeedi
(Write the date) During the following immunization vis
at 1 ½, 2 ½ and 3 ½ months old (or
ask the mother if the child contin
exclusively breastfed. Write Y if still E
DPT-HiB-HepB OPV PCV IPV longer EBF then write the date bel
infant was assessed.

1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 1 ½ mos.
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 3 ½ mos

breastfeeding is still "exclusively breastfed."

anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR at 12 months.
 6-11 months old
(12)
Exclusive Breastfeeding* Nutritional Status Assessment Exclusively Introduction of
During the following immunization visits of the child Breastfed* Complementary Feeding**
at 1 ½, 2 ½ and 3 ½ months old (or at 4-5 mos.), up to 6 at 6 months old
ask the mother if the child continues to be months
exclusively breastfed. Write Y if still EBF or N if no Write Y if Yes
longer EBF then write the date below when the
Age in Length Weight Status or N if No then Y or N
infant was assessed. write the date
months (cm) (kg) S = stunted
& date & date W-MAM = wasted-MAM below when the
taken taken W-SAM = wasted-SAM infant was
assessed.
2 ½ mos. 3 ½ mos. 4-5 mos. O = obese/ overweight
N = normal

* Exclusively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed
**Complementary Feeding: Infants 6 months old who received solid, semi-solid or soft foods to complement breastfeed
*** Fully Immunized Child (FIC): A child who has received all of the following antigens before reaching one year old: 1
1 months old 12 months old
(12) (13)
Introduction of Vitamin A MNP MMR IPV Nutritional Status Assessment
Complementary Feeding** (date given) (date when Dose 1 at Dose 2 at
at 6 months old 90 sachets 9th month 9th month
given) (date given) (date given)

1 - With Age in Length Weight Status

continuous months (cm) (kg) S = stunted
breastfeeding & date & date W-MAM = wasted-MAM
2 - no longer taken taken W-SAM = wasted-SAM
breastfeeding or O = obese/ overweight
never breastfed
N = normal

given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively breastfed."
id or soft foods to complement breastfeeding
antigens before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR
old CIC Remarks
(date)
MMR FIC***
Dose 2 at (date)
12th month
(date given)

(14) (15)

at 9 months, and 1 dose of MMR at 12 months.