TARGET CLIENT LIST FOR NEWBORNS AND INFANTS

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, Last Name) (M or F) (LN, FN, MI)
(mm/dd/yy) (mm/dd/yy) Number 2: Non-NHTS

(1) (2) (3) (4) (5) (6) (7)

10

Page 1 of 28
 TARGET CLIENT LIST FOR NEWBORNS AND INFANTS

Complete Address Child Protected at Birth (CPAB) Newborn (0-28 days old)
(9) (10)
(Place a √)
(counts should be consistent with Maternal TCL
Length Weight Status Initiated Immunization Nutritional Status Assessment
Livebirths) at Birth at birth (Birth breast
(cm) (kg) Weight) feeding
immediately
after birth
TT2/Td2 TT3/Td3 to Total L: low: lasting for 90 BCG Hepa Age in Length Weight
given to the TT5/Td5 (or (9a + 9b) <2,500gms (date) B-BD months (cm) (kg)
minutes
mother a TT1/Td1 to N: normal: (date) & date & date
(date)
month prior TT5/Td5) ≥2,500gms taken taken
to delivery given to the U: unknown
mother
anytime prior
to delivery
(9a) (9b)
(8)

* Exclusively Breastfed: No other food (including water) other than breastmilk given. Drops of vitamins and prescribed medication give
**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 before reaching one year old: 1 dose of BCG at

Page 2 of 28
 TARGET CLIENT LIST FOR NEWBORNS AND INFANTS

1-3 months old

(Col 11)
Nutritional Status Assessment Low birth weight Immunization Exclusive Breastfeeding*
given Iron (Write the date) Place a check (√)
(Write the date) During the following immunization visits of the
child at 1 ½, 2 ½ and 3 ½ months old (or at 4-
mos.), ask the mother if the child continues to b
Status 1 mo 2 mos 3 mos DPT-HiB-HepB OPV PCV IPV exclusively breastfed. Place a check (√) on eac
column
UW = underweight
S = stunted
W = wasted
O = obese/ 1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 1st dose 2nd dose 3rd dose 3 1/2 mos 1 ½ mos. 2 ½ mos.
overweight 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
N = normal

given. Drops of vitamins and prescribed medication given while breastfeeding is still "exclusively breastfed."
d or soft foods to complement breastfeeding
ntigens 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 28
 TARGET CLIENT LIST FOR NEWBORNS AND INFANTS

6-11 months old 12 mon

(12) (1
Exclusive Breastfeeding* Nutritional Status Assessment Exclusively Introduction of Vitamin A MNP MMR Nutritional Status Assessm
Place a check (√) Breastfed* Complementary Feeding** (date given) (date when Dose 1 at
uring the following immunization visits of the up to 6 at 6 months old 90 sachets 9th month
ld at 1 ½, 2 ½ and 3 ½ months old (or at 4-5 months given) (date given)
s.), ask the mother if the child continues to be (Y or N)
lusively breastfed. Place a check (√) on each
Age in Length Weight Status Y or N 1 - With Age in
column
months (cm) (kg) UW = underweight continuous months
& date & date S = stunted breastfeeding
taken taken W = wasted 2 - no longer
O = obese/ breastfeeding or
3 ½ mos. 4-5 mos. never breastfed
overweight
N = normal

* 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 before reaching one year old: 1 dose of BCG at birth or anytime, 3 doses of DPT-HiB-HepB, 3 doses of

Page 4 of 28
 TARGET CLIENT LIST FOR NEWBORNS AND INFANTS

12 months old CIC Remarks

(13) (date)
Nutritional Status Assessment MMR FIC***
Dose 2 at (date)
12th
month
(date given)
Length Weight Status
(cm) (kg) UW = underweight
& date & date S = stunted
taken taken W = wasted
O = obese/
overweight
N = normal

(14) (15)

while breastfeeding is still "exclusively breastfed."

th 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 5 of 28
 TARGET CLIENT LIST FOR CHILDREN AGE 12-59 MONTHS OLD

No Date of Date of Family SE Status Name of Child Sex

Registration Birth Serial 1: NHTS (First Name, Middle Initial, (M or F)
(mm/dd/yy) (mm/dd/yy) Number 2: Non-NHTS Last Name)

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

10

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 TARGET CLIENT LIST FOR CHILDREN AGE 12-59 MONTHS OLD

Complete Name of Mother Complete Address

(Last Name, First Name, Middle
Initial)

(7) (8)

Page 12 of 28
 TARGET CLIENT LIST FOR CHILDREN AGE 12-59 MONTHS OLD

Length / Weight 12-23 Months Old 24-35 M

Height (kg) (11) (
(cm)
Nutritional Nutrition Services Nutritional
Status Micronutrient Status
Indicate if: Supplementation Indicate if:
UW = Deworming UW =
underweight MNP Services underweight
S = stunted (Date when Vitamin A S = stunted
W = wasted (Date Given) W = wasted
O = obese/
180 sachets O = obese/
overweight given) overweight
N = normal
1st 2nd 1st 2nd Child Given 2 N = normal
dose dose dose dose doses of
(date (date
given) given)
deworming
drug
Put a (√) check

(9) (10)

Page 13 of 28
 TARGET CLIENT LIST FOR CHILDREN AGE 12-59 MONTHS OLD

24-35 Months Old

(12)
Nutrition Services
Micronutrient
Supplementation Deworming
Services
Vitamin A
(Date Given)

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

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

Page 14 of 28
 TARGET CLIENT LIST FOR CHILDREN AGE 12-59 MONTHS OLD

36-47 Months Old 48-59 Months Old

(13) (14)
Nutritional Nutrition Services Nutritional Nutrition Services
Status Micronutrient Status Micronutrient
Indicate if: Supplementation Indicate if: Supplementation
UW = Deworming UW = Deworming
underweight Services underweight Services
S = stunted Vitamin A S = stunted Vitamin A
W = wasted (Date Given) W = wasted (Date Given)
O = obese/ O = obese/
overweight overweight
N = normal
1st dose 2nd dose 1st 2nd Child Given 2 N = normal
1st dose 2nd dose 1st
dose dose doses of dose
(date (date (date
given) given)
deworming given)
drug
Put a (√) check

Page 15 of 28
 TARGET CLIENT LIST FOR CHILDREN AGE 12-59 MONTHS OLD

8-59 Months Old Remarks

(14)

Deworming
Services

2nd Child Given 2

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

(15)

Page 16 of 28
 TARGET CLIENT LIST FOR CHILDREN AGE 5-9 YEARS OLD

No. Date of Date of Family SE Status Name of Child Sex

Registration Birth Serial 1: NHTS (First Name, Middle Initial, (M or F)
(mm/dd/yy) (mm/dd/yy) Number 2: Non-NHTS Last Name)

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

10

Page 17 of 28
 TARGET CLIENT LIST FOR CHILDREN AGE 5-9 YEARS OLD

Complete Name of Mother Complete Address Deworm

(Last Name, First Name, Middle
Initial)
5 Years Old 6 Years Old
1st 2nd Child given 1st 2nd
dose dose 2 doses of dose dose
(date (date deworming (date (date
given) given) drug given) given)
Put a (√)
check

(7) (8)

Page 18 of 28
 TARGET CLIENT LIST FOR CHILDREN AGE 5-9 YEARS OLD

Deworming Services Remarks

(9)
6 Years Old 7 Years Old 8 Years Old 9 Years Old
Child given 1st 2nd Child given 1st 2nd Child given 1st 2nd Child given
2 doses of dose dose 2 doses of dose dose 2 doses of dose dose 2 doses of
deworming (date (date deworming (date (date deworming (date (date deworming
drug given) given) drug given) given) drug given) given) drug
Put a (√) Put a (√) Put a (√) Put a (√)
check check check check

(10)

Page 19 of 28
 TARGET CLIENT LIST FOR ADOLESCENTS AGE 10-19 YEARS OLD

No. Date of Date of Family SE Status Name of Adolescent Sex

Registration Birth Serial 1: NHTS (First Name, Middle Initial, (M or F)
(mm/dd/yy) (mm/dd/yy) Number 2: Non-NHTS Last Name)

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

10

Page 20 of 28
 TARGET CLIENT LIST FOR ADOLESCENTS AGE 10-19 YEARS OLD

Complete Name of Mother Complete Address

(Last Name, First Name, Middle
Initial)

(7) (8)

Page 21 of 28
 TARGET CLIENT LIST FOR ADOLESCENTS AGE 10-19 YEARS OLD

Deworming Services
(9)
10 Years Old 11 Years Old 12 Years Old 13 Years Old
1st 2nd Adolescent 1st 2nd Adolescent 1st 2nd Adolescent 1st 2nd
dose dose given 2 dose dose given 2 dose dose given 2 dose dose
(date (date doses of (date (date doses of (date (date doses of (date (date
given) given) deworming given) given) deworming given) given) deworming given) given)
drug drug drug
Put a (√) check Put a (√) check Put a (√) check

Page 22 of 28
 TARGET CLIENT LIST FOR ADOLESCENTS AGE 10-19 YEARS OLD

13 Years Old 14 Years Old

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

Page 23 of 28
 TARGET CLIENT LIST FOR ADOLESCENTS AGE 10-19 YEARS OLD

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

Page 24 of 28
 TARGET CLIENT LIST FOR ADOLESCENTS AGE 10-19 YEARS OLD

Remarks

18 Years Old 19 Years Old

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

(10)

Page 25 of 28
 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
** Re
* Diagnosis/Findings:
A = Measles Diagnosis
B = Severe Pneumonia
C = Persistent Diarrhea Measles cases
D = Severely Underweight
E = Xerophthalmia
F = Night Blindness Severe pneumonia, persistent diarrhea and severely underweight
G = Bitot's spots
H = Corneal Xerosis
I = Corneal Ulcerations Cases with Xerophthalmia, including night blindness, Bitot's spots, corneal xerosis,
J = Keratomalacia corneal ulcerations and keratomalacia
K = Corneal Scar
 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
(Use Code)
ORS
12-59
6-11 mos.
mos.
(7) (8)

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

gnosis Preparation/Capsule
100,000 IU for infants 6-11 months old
200,000 IU for children 12-59 months old
and severely underweight 100,000 IU for infants 6-11 months old
200,000 IU for children 12-59 months old
ht blindness, Bitot's spots, corneal xerosis, 100,000 IU for infants 6-11 months old
200,000 IU for children 12-59 months old
Vitamin A Dosage and Schedule of A
Give one capsule upon diagnosis regardless of wh
capsule (VAC) was given. Give another cap
Give one capsule upon diagnosis, except when the ch
weeks before diagnosis
Give one capsule immediately upon diagnosis. Give
1 capsule 2 weeks after
Cases Seen and Given Pneumonia Cases Seen Remarks
Treatment and Given Treatment
(10) (11)
Date Given Age in Date Given
Months Treatment
Oral zinc
drops or
syrup (12)

Vitamin A Dosage and Schedule of Administration

capsule upon diagnosis regardless of when the last dose of vitamin A
psule (VAC) was given. Give another capsule after 24 hours

apsule upon diagnosis, except when the child was given VAC less than 4
weeks before diagnosis.

apsule immediately upon diagnosis. Give one capsule the next day, and
1 capsule 2 weeks after.