REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF HEALTH
NATIONAL NUTRITION COUNCIL

OPT Plus Form 1. List of 0-59 months old Preschoolers with Weight, Length/Height and MUAC Measurements and Identified Nutritional Status
Barangay: Poblacion Municipality: Sominot Province: Zamboanga del Sur Region: IX Year: 2021

Seq. Purok House Name of Mother Name of Preschooler IP 4Ps Sex Date of Date of Age in Measurements Bilater Nutritional Status
Curr hold (Surname, First Name & (Surname, First Name & Middle Birth Measure mont Weight Lengt MUA al Pittin
ent Numb Middle Initial) Initial) (Y/ (Y/ (M/F) ment hs (Kg) h/ C (Y/N)
MUAC Weight Length Weight
OPT er N) N) (mm/ (mm/ Heigh (cm) for /Height for
dd/yyyy) dd/yyyy) t
Status Age for Age Length
/Height
(18)
(15) (17) (19)
(16)
(1) (3) (9) (10)
(4) (5) (6) (7) (8) (11) (12) (14)
(2)
13)

Prepared by: Checked & verified: Attested: Noted:

______________________________ AILEEN FAYE ARELLANO DANILO L. DAMAS GRACE A. PODIOTAN

BNS NDP Punong Barangay MNAO
Date: ____________ Date: ____________ Date: ____________ Date: ____________