No.

Date of Date of Family SE Status Name of Child Sex Complete Name of Mother Complete Address Child Protected at Birth Newborn (0-28 days old)
Registration Birth Serial 1: NHTS (First Name, Middle Initial, Last Name) (M or (LN, FN, MI) (CPAB) (10)
(mm/dd/yy) (mm/dd/yy) Number 2: Non- F) (9) Length Weight Status Initiated Immunization
NHTS (Place a √)
(counts should be consistent with
at Birth at birth (Birth breast
Maternal TCL Livebirths) (cm) (kg) Weight) feeding
immediately
TT2/Td2 given TT3/Td3 to L: low: after birth BCG Hepa B-
to the mother a TT5/Td5 (or <2,500gms lasting for 90 (date) BD
month prior to TT1/Td1 to N: normal: minutes (date)
delivery TT5/Td5) ≥2,500gms (date)
(for mothers given to the U: unknown
pregnant for mother
(1) (2) (3) (4) (5) (6) (7) (8) the first time anytime prior
(9a) to delivery
1

10

11

12

13

14

15

16

17

18

19

20

* Exclusively Breastfed: No other food (including water) other than breastmilk given. D
**Complementary Feeding: Infants 6 months old who received solid, semi-solid or so
*** Fully Immunized Child (FIC): A child who has received all of the following antigens

Page 1 of 21
 1-3 months old
(Col 11)
Nutritional Status Assessment Low birth weight given Immunization Exclusive Breastfeeding*
Iron (Write the date) During the following immunization visits of the
(Write the date) child at 1 ½, 2 ½ and 3 ½ months old (or at 4-5
mos.), ask the mother if the child continues to be
exclusively breastfed. Write Y if still EBF or N if
Age in Length Weight (kg) Status 1 mo 2 mos 3 mos DPT-HiB-HepB OPV PCV IPV no longer EBF then write the date below when
months (cm) & date S = stunted 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.
& date taken W-MAM = wasted-MAM 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
taken W-SAM = wasted-SAM
O = obese/ overweight
N = normal

an breastmilk given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively breastfed."
olid, semi-solid or soft foods to complement breastfeeding
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 21
 6-11 months old 12 months old CIC
(12) (13) (date)
Nutritional Status Assessment Exclusively Introduction of Vitamin A MNP MMR IPV Nutritional Status Assessment MMR FIC***
Breastfed* up to 5 Complementary Feeding** (date given) (date when 90 Dose 1 at Dose 2 at Dose 2 at 12th (date)
months and 29 at 6 months old sachets given) 9th month 9th month month
days (date given) (Routine) (date given)
Write Y if Yes or N if (date given)
Age in Length Weight Status Y or N 1 - With Age in Length Weight (kg) Status
No then write the date
months (cm) (kg) S = stunted below when the infant continuous months (cm) & date S = stunted
& date & date W-MAM = was assessed.
breastfeeding & date taken W-MAM = wasted-MAM
taken taken wasted-MAM 2 - no longer taken W-SAM = wasted-SAM
W-SAM = breastfeeding or O = obese/ overweight
never breastfed
wasted-SAM N = normal
(14)

* 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 on or 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 21
 0-11 months old Remarks
(15)
MAM SAM without Complication

Admitted in SFP Cured Defaulted Died Admitted in OTC Cured Defaulted Died

(16)

SFP - Supplementary Feeding Program

OTC - Out-patient Therapeutic center

Page 4 of 21
No Date of Date of Family SE Status Name of Child Sex Complete Name of Mother
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)

10

Page 5 of 21
Complete Address

(8)

Page 6 of 21
Length / Weight 12-23 Months Old
Height (kg) (11)
(cm)
Nutritional Status Nutrition Services IPV
Indicate if: Dose 2
Micronutrient
S = stunted
W-MAM = wasted-MAM Supplementation Deworming (Catch-Up)
W-SAM = wasted-SAM (date given)
MNP Services
O = obese/ overweight Vitamin A
N = normal (Date when
180 sachets (Date Given)
given)
1st 2nd 1st 2nd dose Child Given 2
dose dose dose (date doses of
(date given)
given)
deworming
drug
Put a (√) check

(9) (10)

Page 7 of 21
 24-35 Months Old
(12)
Nutritional Status Nutrition Services
Indicate if:
Micronutrient
S = stunted
W-MAM = wasted-MAM Supplementation Deworming
W-SAM = wasted-SAM Services
O = obese/ overweight Vitamin A
N = normal
(Date Given)

1st dose 2nd dose 1st 2nd dose Child Given 2

dose (date doses of
(date given)
given)
deworming
drug
Put a (√) check

Page 8 of 21
 36-47 Months Old 48-59 Months Old
(13) (14)
Nutritional Status Nutrition Services Nutritional Status Nutrition Services
Indicate if: Indicate if:
Micronutrient Micronutrient
S = stunted S = stunted
W-MAM = wasted-MAM Supplementation Deworming W-MAM = wasted-MAM Supplementation
W-SAM = wasted-SAM Services W-SAM = wasted-SAM
O = obese/ overweight Vitamin A O = obese/ overweight Vitamin A
N = normal N = normal
(Date Given) (Date Given)

1st dose 2nd dose 1st 2nd dose Child Given 2 1st dose 2nd dose
dose (date doses of
(date given)
given)
deworming
drug
Put a (√) check

Page 9 of 21
48-59 Months Old 12-59 months old
(14) (15)
MAM SAM without Complication

Deworming
Services Admitted in Cured Defaulted Died Admitted in Cured
SFP OTC

1st 2nd dose Child Given 2

dose (date doses of
(date given)
given)
deworming
drug
Put a (√) check

Page 10 of 21
old Remarks

SAM without Complication

Defaulted Died

(16)

Page 11 of 21
No. Date of Date of Family SE Status Name of Child Sex Complete Name of Mother
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)

10
 Deworming Services
Complete Address (9)
5 Years Old 6 Years Old 7 Years Old
1st 2nd dose Child given 1st 2nd dose Child given 1st 2nd dose Child given
dose (date 2 doses of dose (date 2 doses of dose (date 2 doses of
(date given) deworming (date given) deworming (date given) deworming
given) drug given) drug given) drug
Put a (√) Put a (√) Put a (√)
check check check

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

(10)
No. Date of Date of Family SE Status Name of Adolescent Sex Complete Name of Mother
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)

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

(8)
Deworming Services
(9)
12 Years Old 13 Years Old 14 Years Old 15 Years Old 16 Years Old
Adolescent 1st 2nd dose Adolescent 1st 2nd dose Adolescent 1st 2nd dose Adolescent 1st 2nd dose
given 2 dose (date given 2 dose (date given 2 dose (date given 2 dose (date
doses of (date given) doses of (date given) doses of (date given) doses of (date given)
deworming given) deworming given) deworming given) deworming given)
drug drug drug drug
Put a (√) check Put a (√) check Put a (√) check Put a (√) check
 Deworming Services
(9)
Remarks
16 Years Old 17 Years Old 18 Years Old 19 Years Old
Adolescent 1st 2nd dose Adolescent 1st 2nd dose Adolescent 1st 2nd dose Adolescent
given 2 dose (date given 2 dose (date given 2 dose (date given 2
doses of (date given) doses of (date given) doses of (date given) doses of
deworming given) deworming given) deworming given) deworming
drug drug drug drug
Put a (√) check Put a (√) check Put a (√) check Put a (√) check

(10)
 No. Date of Family Name of Child Date of Sex Complete Name of
Registration Serial (First Name, Middle Initial, Birth (M or F) Mother
(mm/dd/yy) Number Last Name) (mm/dd/yy) (Last Name, First Name,
Middle Initial)

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

10
** Recommended Vitamin A Supplement
Diagnosis Preparation/Capsule
Measles cases 100,000 IU for infants 6-11 months
200,000 IU for children 12-59 mont
Persistent diarrhea 100,000 IU for infants 6-11 months
200,000 IU for children 12-59 month
 Complete Address SE Status Vitamin A Supplementation** Diarrhea Cases Seen and Given
1: NHTS Treatment
2: Non-NHTS
(9) (10)
Put a (√) Diagnosis/ Date Age in Date Given
Findings* Given Months ORS Oral zinc
12-59 (Use Code)
6-11 mos. drops or
mos. syrup
(7) (8)

** Recommended Vitamin A Supplementation Given to High Risk/Sick Children

Preparation/Capsule
100,000 IU for infants 6-11 months old
200,000 IU for children 12-59 months old
100,000 IU for infants 6-11 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)
capsule after 24 hours
Give one capsule upon diagnosis, except when the child was given VAC less than 4 week

200,000 IU for children 12-59 months old

 Pneumonia Cases Seen Remarks
and Given Treatment
(11)
Age in Date Given
Months Treatment

(12)

dule of Administration
se of vitamin A capsule (VAC) was given. Give another
4 hours

was given VAC less than 4 weeks before diagnosis.