TARGET CLIENT LIST FOR

NUTRITION AND EXPANDED

PROGRAM FOR IMMUNIZATION

NAME OF BARANGAY/RHU:

MUNICIPALITY OF:

PROVINCE/CITY:

REGION:
 TARGET CLIENT LIST FOR NUTRITION AND EPI PROGRAM PART I
DATE COMPLEMENTARY
DATE IMMUNIZATION RECEIVED PNEUMOCOCCAL CHILD WAS EXCLUSIVELY BREASTFED****
FULLY ROTA VIRUS FEEDING*****
CONJUGATE VACCINES
(13) IMMUNIZED VACCINE (PCV) (15) (16)
HEPA B1 PENTAVALENT OPV MCV CHILD Put a (√) check Put a Put a (√) check
BCG w/in More than MCV1 MCV2 (FIC) *** 1st 2nd 3rd 4th 5th Date for 6th 7th 8th
1 2 3 1 2 3 1 2 1 2 3
24 hrs. 24 hrs. (AMV) (MMR) (14) MO MO MO MO MO 6th mo. MO MO MO

*** FULLY IMMUNIZED CHILD = is a child who has received all of the following antigens before reaching one year old: **** Exclusively breastfed - means no other food (including water) other
a) One (1) dose of BCG at birth or anytime, than breastmilk. Drops of vitamins and prescribed medication
b) Three (3) doses of OPV, three (3) doses of Pentavalent vaccines; and given while breastfeeding is still "exclusively breastfed."
c) One (1) dose of Measles-containing vaccine (MCV1). *****Complementary Feeding = infants 6-8 months who received solid,
semi-solid or soft foods to compliment breastfeeding.

*****Complementary Feeding = complementary foods & foods given

starting at 6 months to compliment breastfeeding.
Numerator: Infants 6-8 months who received solid, semi-solid or soft foods during the previous day

35
REMARKS

(17)

36
 FHSIS v. 2012

TCL- 1
TARGET CLIENT LIST FOR NUTRITION AND EPI PROGRAM PART II
DATE OF MICRONUTRIENT SUPPLEMENTATION

LENGTH/HEIGHT
REGISTRATIO SEX (10) Dewor-

WEIGHT
N DATE OF FAMILY
COMPLETE VITAMIN A IRON MNP ming
BIRTH SERIAL NAME OF CHILD COMPLETE NAME OF MOTHER ADDRESS
REMARKS
(mm\dd\yy) NUMBER
6-11 12-59 mos. 6-11 12-59 6-11 12-23 12-59
(mm/dd/yy) (M/F)
(1) (2) (3) (4) (5) (6) (7) (8) (9) MOS. Dose 1 Dose 2 MOS. MOS. MOS. MOS. MOS. (12)

36
 TARGET CLIENT LIST FOR NUTRITION AND EPI PROGRAM

LENGTH/HEIGHT
DATE OF

WEIGHT
DATE OF FAMILY MICRONUTRIENT SUPPLEMENTATIO
REGISTRATIO SEX COMPLETE
N BIRTH SERIAL NAME OF CHILD COMPLETE NAME OF MOTHER ADDRESS
(10)
(mm\dd\yy) NUMBER VITAMIN A IRON
(mm/dd/yy) (M/F) 6-11 12-59 mos. 6-11 12-59
(1) (2) (3) (4) (5) (6) (7) (8) (9) MOS. Dose 1 Dose 2 MOS. MOS.
 TARGET CLIENT LIST FOR NUTRITION AND EPI PROGRAM
DATE
DATE IMMUNIZATION RECEIVED PNEUMOCOCCAL CHILD WAS E
PPLEMENTATION FULLY ROTA VIRUS
CONJUGATE VACCINES
Dewor- REMARKS (13) IMMUNIZED VACCINE (PCV)
MNP ming HEPA B1 PENTAVALENT OPV MCV CHILD Put
6-11 12-23 12-59 BCG w/in More than MCV1 MCV2 (FIC) *** 1st
1 2 3 1 2 3 1 2 1 2 3
MOS. MOS. MOS. (12) 24 hrs. 24 hrs. (AMV) (MMR) (14) MO
 TARGET CLIENT LIST FOR NUTRITION AND EPI PROGRAM
COMPLEMENTARY
CHILD WAS EXCLUSIVELY BREASTFED**** FEEDING*****
(15) (16) REMARKS
Put a (√) check Put a Put a (√) check
2nd 3rd 4th 5th Date for 6th 7th 8th
MO MO MO MO 6th mo. MO MO MO (17)