BREASTFEEDING CORNER MONITORING FORM

Community:______________________ Date of Assessment:___________________

Name of FH Staff:___________________________

Kindly indicate if the following criteria are being followed:

Compliance
Criteria Remarks/Observations
Compliant Non-Compl
iant

1. Physical State of Established Breastfeeding Corner

1.1 Corner area with provision for privacy ( i.e.,

curtain)

1.2 Have a table, comfortable seat, and electronic

outlet for a possible electronic breast pump.

1.3 Have a lavatory with soap and water for

hand-washing. The station may be near a lavatory
but not in a toilet.

1.4 The breastfeeding corner is well-maintained,

clean, well-ventilated, well-lighted, and free from
contaminants and hazardous substances

1.5 The established breastfeeding corner is located

at an accessible place.

1.6 There is a refrigerator provided. Exclusively used

for storage of breastmilk.

2. IEC Materials and Key Messages: Does the breastfeeding corner have the ffg:

2. 1 IEC Material on the “Ten Steps to Successful

Breastfeeding”

2.2 The importance of exclusive breastfeeding for

at least 6 months

2.3 Benefits of breastfeeding to the baby, mother,

and community as well

2.4. NO Posters on Artificial Milk promotion seen

 3. Utilization and Usage of the Breastfeeding Corner

3.1 A log book or other recording tool is being

maintained to document the visits in the
breastfeeding corner.

4. Functionality of Equipment provided by FH: (Note: Check only if provided by FH. If not, kindly disregard)

For furniture/equipment, please indicate if it is Functional Dilapidated Remarks/Observations

functional or dilapidated: (needs repair
or damaged)

Privacy Curtains

Comfortable Breastfeeding armchair/sofa

Breast pump

Logbook

Electric fan

Others: _______________________

5. Monitoring Data 6. Facility Utilization

Monthly/ Daily Attendance Log: 6.1 Identify peak hours of usage:__________ (time)

● Number of Mothers visited: _______

Reasons for peak hours (if available)_____________________________
● Total Attendance: ___________
● Average daily attendance: ______
________________________________________________________________
● Others:

6.2 Identify off-peak hours of usage:__________ (time)

Reasons for off-peak hours (if available) ________________________

_______________________________________________________________
7. Issues/Improvements:
● Any reported issues or suggestions for improvement:

8. Feedback and Testimonials