Rev. 02. 18.

09 Profile ID (to be filled up by the encoder)

Republic of the Philippines

Department of Social Welfare and Development

Early Childhood Care and Development
Child Information Sheet
I. Identifying Information Note: Filleds with * asterisk are required fields

1 Facility
Location
Region Province City / Municipality Barangay No. & Street Address
2 Name
of Facility 3. Service Provider

4a. Name 4b. Nickname

Last Name* First Name* Middle Name* Ext. (Jr. Sr.)

5 Sex* Male Female 6a. Birth Order* 6b. No. of siblings* 7a. Date of Birth*
YYYY MM - DD

8 Birth Place 7b. Birth Registered?*

YYYY MM - DD

9 Home
Address
Region Province City / Municipality Barangay No. & Street Address

9 Religion 11. Ethnicity

II. Nutrition and Services

12. The child underwent the following: (check all applicable and fill details) 13. The child has the following disabilities / impairments:
b. Cause
a. Disability / Impairment (e.g. hearing, speech, visual) (e.g. inborn,illness)
Breastfeeding - breastfed for 1
Kind of breastfeeding 2
Exclusive Mixed 3

4
months
5
Supplemental Feeding - Supplemented for

120 days
Child have Disability/Impairment 14. The child has the following past ECCD experiences:
Has the child been reffered for assistance/ a. Service Type* b. Service* c. From (Start Date) d. To (End Date)
assessment or other services in connection with (e.g. Center, Community) (e.g. Child Minding,Day Care Mother) (YYYY-MM-DD)* (YYYY-MM-DD)*
his/her disability/Impairment
____________________________________________
____________________________________________

Listahan Identified

Pantawid Beneficiary
Household ID

15a Participation Fee / 17. Schedule*

Paid amount of Morning Session
/
Afternoon Session

15.b Parents' Counterpart* 17. Attendance*

Accomplished By:*
Cash Continuing
In Kind Dropped Out
None If drop out, reason:
Illness Name and Signature of ECCD Service Provider*
Transfer of Residence
2021-2022
16 School Year Others (Specify)
_____________________

Date Accomplished*
YYYY MM - DD
Encoder ID
Rev. 02. 18. 09 Profile ID (to be filled up by the encoder)
Republic of the Philippines
Department of Social Welfare and Development
Early Childhood Care and Development
Child Information Sheet
III. Health Services Have the Health Service Provider sign beside each entry (use additional sheets as necessary)
19a. Health Service b.Date YYYY - MM - DD- 19a. Health Service* b. Date YYYY - MM - DD-

1. Newborn Screening
25

2. BCG Vaccination (at birth)

26

3. DPT Vaccination (6, 20, & 14 weeks old)

27

4. OPV Vaccination (6, 20, & 14 weeks old)

28

5. Hepatitis B Vaccination (^, @), & 14 weeks old)

29

6. Measles Vaccination (9 months)

30

7. Vitamin A ( starting from 6 months)

31

8. Deworming
32

9. Dental Checkup
33

10. Physical Checkup

34

11. Micronutrient Supplement

35
12 36
13 37
14 38
15 39
16 40
17 41
18 42
19 43
20 44
21 45
22 46
23 47
24 48
IV. Nutritional Status (use additional sheet as necessary) V. Developmental Status (Using the ECCD Checklist)
Nutritional Log Date YYYY - MM-DD Age Height Weight d.Nutritional 19. Evaluation* 1st Evaluation 2nd Evaluation 2nd Evaluation
(cm) (Kg) Status*
1 Evaluation Date*
2 (YYYY-MM-DD)
3 Domains Raw Score Scaled Score Raw Score Scaled Score Raw Score Scaled Score
4 a. Fine Motor Dev't
5 b. Gross Motor
6 c. Self-Help
7 d. Receptive Language
8 e. Expressive Language
9 f. Cognitive
10 g. Socio-Emotional
11
Overall Interpretation
12
13 Nutritional Status Developmental Status Interpretation Raw Score 1 - 150
14 Weight-for-Age Scale Score 1 - 190
15 1 Highly Advanced
Reference

16 1 <2SD Underweight 2 Slightly Advanced

17 2 -2SD to +2SD Normal 3 Average Development
18 3 >+2SD Overweight 4 Development to be monitored after 6 months
19 5 Development to be monitored after 3 months
20 Reviewed By:
21
22 Name and Signature of ECCD Service Provider*

23
24 Date Accomplished*
YYYY MM DD

Nutritional Status (e.g. Overweight, underweight, normal, malnourished) Encoder ID