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    Child Information Sheet

    Uploaded by

    Haidi Meana
    1. This document contains a child information sheet for an Early Childhood Care and Development (ECCD) program. 2. It collects identifying information about the child like name, birthdate, home address, as well as family information. 3. Health services received by the child like vaccinations and checkups are documented. The child's nutritional status over time and developmental status using an ECCD checklist are also recorded.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Child Information Sheet

    Uploaded by

    Haidi Meana
    443 views3 pages
    1. This document contains a child information sheet for an Early Childhood Care and Development (ECCD) program. 2. It collects identifying information about the child like name, birthdate, home address, as well as family information. 3. Health services received by the child like vaccinations and checkups are documented. The child's nutritional status over time and developmental status using an ECCD checklist are also recorded.

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    1. This document contains a child information sheet for an Early Childhood Care and Development (ECCD) program. 2. It collects identifying information about the child like name, birthdate, home address, as well as family information. 3. Health services received by the child like vaccinations and checkups are documented. The child's nutritional status over time and developmental status using an ECCD checklist are also recorded.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    443 views3 pages

    Child Information Sheet

    Uploaded by

    Haidi Meana
    1. This document contains a child information sheet for an Early Childhood Care and Development (ECCD) program. 2. It collects identifying information about the child like name, birthdate, home address, as well as family information. 3. Health services received by the child like vaccinations and checkups are documented. The child's nutritional status over time and developmental status using an ECCD checklist are also recorded.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    1

    Rev. 02.10.09 Profile ID (to be filled up by the encoder

    Republic of the Philippines


    Department of Social Welfare and Development Child Information Sheet
    Early Childhood Care and Development

    I. Identifying Information NOTE: Fields with (*) asterisk are required fields

    1. Facility
    DAY CHILD DEVELOP[MENT CENTER GUERRERO BAUANG LA UNION I
    Location
    Name of Facility* Barangay* Municipality* Province* Region*

    2a. Name
    Last Name* First Name* Middle Name* Ext.(Jr./Sr.)
    2.b Nickname

    3. Sex* Male Female 4a. Birth Order* 4b. No, of Siblings* 5a. Date of Birth*
    / / YYYY - MM - DD
    5b. Birth Registered?* Yes No
    6. Birthplace
    Barangay City/Municipality Province Region

    7. Home BAUANG LA UNION I


    Address
    No. & Street Address Barangay* City/Municipality* Province* Region*

    RELIGION: ROMAN CATHOLIC 9. ETHNICITY:

    II. Family Information (use additional sheets as necessary)


    11a. Full Name* b. Birthday* c. Relationship* d. Sex* e. C.S* f. Highest Education* g. Occupation* h. Income/Mo,

    III. Nutrition and Services


    12. The child underwent the following: 13. The child has the following disabilities / impairments:
    (check all applicable and fill details) a..Disability/Impairment b..Causes
    Breastfeeding – breast fed for 1
    months 2
    3
    Supplemental Feeding – supplemented for
    4
    days 5
    Food for School (Rice Distribution)-weekly allotment of 14. The child has the following past ECCD experiences:
    Kgs.
    a. Service Type* b. Service c. From d. To
    Assessment or Assistance for a Disability from: (e.g. Center, (e.g. Child (Start Date) (End Date)
    Government Hospital/Clinic/Health Unit Community Minding Day (yyyy-mm-dd) (yyyy-mm-dd)
    Care Mother)
    Private Hospital/Clinic/Medical Personnel
    Others:
    15a. Participation Fee 16. Schedule*
    Morning Session
    Paid amount of Afternoon Session
    PhP Accomplished by:*
    17. Attendance*
    Continuing Date Accomplished*
    Dropped Out
    15b. Parents’ Counterpart*
    YYYY - MM - DD
    If drop out, reason:
    Cash Illness HAIDI R. MEANA Encoder ID
    Transfer of Residence
    In Kind Name & Signature of ECCD Service Provider*
    Others: (specify)
    None _____________________
    Rev. 01.18.09 Republic of the Philippines Profile ID (to be filled up by the encoder

    CHILD INFORMATION SHEET


    Department of Social Welfare and Development
    Early Childhood Care and Development

    V. Health Services Have the Health Service Provider sign beside each entry (use additional sheets as necessary)

    b. Date b. Date
    17a. Health Services* a. Health Services*
    YYYY - MM - DD YYYY - MM - DD
    1. Newborn Screening
    2.BCG Vaccination (at birth)
    3.DPT Vaccination
     6 weeks old
     14 weeks old
     20 weeks old
    4. OPV Vaccination
     6 weeks old
     14 weeks old
     20 weeks old
    5. Hepatitis B Vaccination
     6 weeks old
     14 weeks old
     20 weeks old
    6.Measles Vaccination (9 months)
    7.Vitamin A (starting from 6 months)
    8.Deworming
    9.Dental Check up
    10.Physical Check up
    11.Micronutrient Supplement

    VI. Nutritional Status VII. Developmental1stStatus (Using the ECCD Checklist)rd


    (use additional sheets as necessary) 19. Evaluation* Evaluation 2nd Evaluation 3 Evaluation
    18a.Date* b. c. d.
    YYYY - MM - DD Age* Weight kg* Nutritional Status* Evaluation Date*

    Domains Raw Scaled Raw Scaled Raw Scaled


    Score Score Score Score Score Score

    a. Fine Motor
    Development

    b. Gross Motor

    c. Self-Help

    d. Receptive
    Language

    e. Expressive
    Language

    f. Cognitive

    g. Socio-Emotional

    Overall
    Interpretation
    R Nutritional Status Developmental Status Interpretation
    e 1 +2SD Underweight 1 Highly Advanced
    f 2 -2SD to +2SD Normal 2 Slightly Advanced
    e 3 +-2SD Overweight 3 Average Development
    r
    4 Development to be monitored
    e
    n Raw Score 1-150 after 6 months
    c Scaled Score 1-19 5 Development to be monitored
    e after 3 months

    Accomplished by:* Date Accomplished*

    YYYY - MM - DD
    Encoder ID
    Name & Signature of ECCD Service Provider*
    HAIDI R. MEANA

    Nutritional Status
    (e.g. overweight, underweight, normal, malnourished

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