TARGET CLIENT LIST FOR CHILDREN 0-11 MONTHS AND 12 MONTHS OLD (page 1/4)
Child Protected at Birth (CPAB)
(9)
(Place a P
(counts should be consistent with Maternal TCL
Livebirths)
TT2/Td2 given to the
TT3/Td3 to TT5/Td5 (or
mother a month prior to
TT1/Td1 to TT5/Td5)
delivery (for mothers
No. DATE OF DATE OF FAMILY SE STATUS NAME OF CHILD SEX COMPLETE NAME OF MOTHER COMPLETE ADDRESS given to mother anytime
pregnant for the first
prior to delivery
time)
REGISTRATION BIRTH SERIAL 1: NHTS (First Name, Middle Initial, Last Name) (M or F) (First Name, Middle Initial, Last Name)
(mm/dd/yy) (mm/dd/yy) NUMBER 2: Non-NHTS
(1) (2) (3) (4) (5) (6) (7) (8) (9a) (9b)
10
11
12
** Exclusively Braestfed: 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 6-8 months who received solid, semi-solid or soft foods to complement breastfeeding
* Fully Immunized Child: A child who has received all of the following antigen before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses DPT-HiB-HepB, 3 doses of OPV, 1 dose of MMR vaccine at 9 months, and 1 dose of MMR at 12 months.