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    Child Profile Form Final - 030722

    Uploaded by

    mark san andres
    The document outlines a partnership program between Ceelin-Unilab Foundation and Caritas Philippines to provide Ceelin supplements to children in order to boost their immunity. It includes a child profile form to collect medical history and monitor the health impacts of receiving the supplements over 8 weeks. Parents must consent to having their child's data collected and used to evaluate the program's outcomes.

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

    Child Profile Form Final - 030722

    Uploaded by

    mark san andres
    20 views3 pages
    The document outlines a partnership program between Ceelin-Unilab Foundation and Caritas Philippines to provide Ceelin supplements to children in order to boost their immunity. It includes a child profile form to collect medical history and monitor the health impacts of receiving the supplements over 8 weeks. Parents must consent to having their child's data collected and used to evaluate the program's outcomes.

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    Child-Profile-Form-final-_030722

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    The document outlines a partnership program between Ceelin-Unilab Foundation and Caritas Philippines to provide Ceelin supplements to children in order to boost their immunity. It includes a child profile form to collect medical history and monitor the health impacts of receiving the supplements over 8 weeks. Parents must consent to having their child's data collected and used to evaluate the program's outcomes.

    Copyright:

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

    Child Profile Form Final - 030722

    Uploaded by

    mark san andres
    The document outlines a partnership program between Ceelin-Unilab Foundation and Caritas Philippines to provide Ceelin supplements to children in order to boost their immunity. It includes a child profile form to collect medical history and monitor the health impacts of receiving the supplements over 8 weeks. Parents must consent to having their child's data collected and used to evaluate the program's outcomes.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    CARITAS-CACERES (NAGA), INC.

    ARCHDIOCESE OF CACERES
    in partnership with
    CBCP-NASSA/Caritas Philippines

    Ceelin-Unilab Foundation Partnership


    Pangakong Proteksyon:
    IMMUNITY for all Kids

    Ceelin Pangakong Proteksyon: Immunity for all Kids

    CEELIN KID PROFILE FORM


    Diocese/Province: CAMARINES SUR
    Parish/Town ____________________
    Chapel/Barangay ____________________

    I. General Information

    Date Supplement Started: ________________ Date Supplement Ended:________________


    Height (cm, if possible): _____ Weight (kg): _____ Height (cm, if possible): _____ Weight (kg): _____
    Child’s Name: _______________________________ Age: _____ Birthday: ________________________
    Grade: ___________ Gender: ( ) Male ( ) Female
    Home Address: _______________________________________________
    Religion: _________________________ Contact Numbers: ________________
    Birth History: if known

    Full term

    Preterm

    Medical History:

    Previous hospitalization/ surgery

    Known medical illness


    Variable Day 0 (Baseline) Week 4 (intermediate) Week 8 (after 2 months)
    Weight As above To be provided if possible To be provided as outcome
    +/- of Cough or colds How many times before How many times the past 4 How many times the past 4
    the start of weeks, if present? weeks, if present?
    supplementation
    Other forms of illness Please indicate baseline
    or infection requiring
    medicines or
    hospitalization

    Other observation Please indicate


    Passage of worms
    Lack of appetite
    Anemia
    Gross malnutrition
    Presence of mental
    handicap

    Family Status:

    No. of family members living in household:_______________

    No. of family members studying_____________

    No. of family members working_____________

    Daily food intake per family member:

    Please encircle applicable answer and indicate usual food intake

    Breakfast (YES) (NO) __________

    Lunch (YES) (NO) _________

    Dinner (YES) (NO)_____________


    Child Snapshot: Please paste a child picture in the box below (optional)

    We,__________________________ (RELATIONSHIP TO THE CHILD), expressly give our consent to CARITAS-


    CACERES (NAGA), INC. obtain information about out child/children which will be used in monitoring the
    receipt and consumption of Ceelin products, which is part of the Immunity For All-Alay Kapwa joint program
    of Caritas Philippines and Ceelin. We were made aware of our rights as a Data Subject under the Data
    Privacy Act.

    The data that will be gathered from the project will only be used as the basis for the number of bottles that
    were received and consumed and to monitor the possible health improvements of the participating
    child/children within the duration of the activity. The child/children will not be promoted as brand
    endorsers of Ceelin.

    We are also aware that the program will be communicated to the public through various medium such as
    traditional and social media.

    The process on the selection of participants for this project was also explained to us by Caritas Philippines
    through its Social Action Network.

    _______________________________ _______________________________
    Name & Signature of the Father Name & Signature of the Mother

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