Republic of the Philippines

Department of Health

NATIONAL NUTRITION COUNCIL

OPT Plus Form 1B. List of Malnourished/Nutritionally -At-Risk Preschoolers 0-59 Months Old

Barangay: Province: Period of Measurment coverd

City/Municipality: Region:

Seq. Purok Household Name of Mother Name of preschooler Sex Indigenous Age in Nutritional status
No. Numbers (Surname, First name and (Surname, First name and (M,F) (IP)/Ethnic Group Months WFA L/HFA WFL/H MUAC Status
middle initial) middle initial)
(1) (2) (3) (4) (5) (6) (7) (8) UW SUW St SSt W SW OW Ob SAM MAM Edam
(9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)

TOTAL
Prepared by: Checked and Verified: Attested: Noted:

Name and signature of Barangay Nutrition Scholar Name and signature of Public Health Midwife Name and signature of BNC/ Barangay Chairman Name and signature of City/Mun. Action officer

Date: Date: Date: Date: