MASS NUTRITION SCREENING AND REFERRAL FORM

County: _________________________ Sub-County: __________________________

Site ______________________ Date_____ /_____/ ______

2nd Stage screening

Reference For children with MUAC
number Age Living between 12.5 - 13.4cm) OR
Bilateral children <6months
Name of child under 5/Pregnant/Lactating (e.g.National (Months with MUAC
No Sex oedema
mother ID, CWC No., OR disability (cm)
(Y/N)
SFP No., OTP Years) ? (Y/N)
Z
No. etc) WT HT
score

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
NB: Children with MUAC ≥11.5 cm and <12.5 cm should be referred to SFP; Children with MUAC <11.5 cm should be referred to SC/OTP;Mothers/caretakers of children at risk MUAC ≥ 12.5 cm and <13.5
2nd stage screening must be done for all children at risk (weight and length measurements)
Person(s) doing screening
Name: __________________________________________ Designation: ________________________ Sign: ______________
Name: __________________________________________ Designation: ________________________ Sign: ______________
RM
__________________

____

Indicate if child been

Action ill in the last two
Already (specify) weeks?
Registered
(0-No illness.
in IMAM
1=diarrhoea.
prog.
to 2=fever. 3=ARI.
(Y/N) tSFP
SC/ 4=Suspected
BSF
OTP Measles. 5=Others)
P
risk MUAC ≥ 12.5 cm and <13.5 cm should be given nutrition education.

Sign: __________________________________
Sign: __________________________________
 ON SITE SUMMARY TOOL : EMERGENCY NUTRITION OUT

COUNTY: _________________________ SUB-COUNTY: __________________________

OUTREACH/SCREENING SITE ______________________ LINKING HEALTH FACILITY: __________________

Section A: Mass screening

Children<5yrs
Children<5yrs with SAM Children<5yrs with MAM AT RISK Children<5yrs NORMAL

By MUAC By WHZ By MUAC

Children < 5years By MUAC By WHZ ( ≥ 11.5 to (-3 to <2 Z- (≥ 12.5 to <13.5 By MUAC By WHZ
Screened (<11.5 cm) (<-3 Z score) 12.5cm) Score ) cm) ( >13.5 cm) (≥ - 2 Z-score)

M F Total M F M F M F M F M F M F M

Section B: Provision of essential health services Section C: Supplies

Service M F Total Commodity

Diagnosis and treatment of common and minor ailments RUTF (Plumpy Nut) - in satchets (For UNDER
Vitamin A supplementation for children 6-11 months RUTF (Plumpy Nut) - in pouches FBP
Vitamin A supplementation for children 12-59 months RUSF (Plumpy Sup) - in satchets
IFAS supplementation for ANC women CSB/Super cereal - in kg/satchets
BCG Oil
POLIO: Polio birth dose:________ Polio 1:_________
Polio 2: _________ Polio 3:_________ First Food - in satchets
PENTAVALENT: Penta 1: ______Penta 2: ______Penta 3: ______ Foundation Plus - in satchets
PCV: PCV 1:_____PCV 2:_____PCV 3:_____ Advantage - in satchets
MEASLES: Measles at 9months:_____Measles at 18months:_____
Vitamin A supps.: 100,000IU_____ 200,000
FULLY IMMUNIZED (FIC)
Dewormers: Albendazole______Mebendazo
Deworming for children 12-59 months
BCG - in vials
RH services : FP POLIO- in vials
RH services- ANC: First visit:_____Second visit:____Third visit:____ PENTAVALENT- in vials
Health messaging. TOPIC:_________________________________ PNEUMOCCOCAL (PCV)- in vials
Provider initiated testing and counselling
MEASLES- in vials
OTHERS: specify:______________________

Summarised by: NAME: ____________________________ DESIGNATION: _________________________ DATE: ____________

NUTRITION OUTREACH

_________ WARD:__________________________________

________________________________ DATE: _____ /_____/ _____

5yrs NORMAL
PLW with
Total MAM
By WHZ Chldren <5 PLW (By MUAC
(≥ - 2 Z-score) yrs ILL No. No. No. No. already screened <21cm)
past 2 referred to referred to referred to registered in
F weeks SC OTP SFP IMAM Number Number

Total Amount No. of clients

Commodity distributed issued
ut) - in satchets (For UNDER 5)

ut) - in pouches FBP

up) - in satchets
al - in kg/satchets

tchets

- in satchets
atchets
s.: 100,000IU_____ 200,000IU______ -in capsules

endazole______Mebendazole_____ - in tablets

in vials
AL (PCV)- in vials

ls
y:___________________________

DATE: _________________________
 NUTRITION MASS SCREENING AND RAPID ASSESSMENTS
ANNEX 1: SUMMARY FORM

COUNTY kajiado
___________________________________________________ DATE 29/01/18

A B C1 C2 C3 C4 D1 D2 D3 D4 D5 E1 E2 E3 E4 E5 F1 F2 F3 F4 F5 G1 G2 H1 H2 H3 H4 J1 J2 J3 J4 J5 J6
PROPORTI
PROPORT TOTAL
ON OF
TOTAL ION OF PROPORT
PROPORTIO PROPORTIO TOTAL CHILDREN PROPORTI PROPORTIO PROPORTI
PROPORTION NUMBER OF CHILDRE ION OF
N OF N OF PROPORTIO UNDER NUMBER OF NUMBER OF ON OF N OF ON OF NUMBER OF TOTAL
TOTAL NUMBER OF OF CHILDREN NUMBER OF NUMBER OF CHILDREN UNDER
CHILDREN UNDER N UNDER CHILDRE CHILDREN UNDER
NUMBER OF
NUMBER OF CHILDREN WHO ARE NUMBER OF NUMBER OF PROPORTIO NUMBER OF
TOTAL NUMBER OF NUMBER OF CHILDREN UNDERFIVE CHILDREN UNDER CHILDREN CHILDREN UNDER CHILDREN N OF FIVE DIAGNOSED FIVE CHILDREN CHILDREN UNDER CHILDREN NUMBER OF CHILDREN MALNOURISHED AND NUMBER OF NUMBER OF NUMBER OF NUMBER OF WOMEN NUMBER OF NUMBER OF PLW WITH NUMBER OF PLW
UNDERFIVE FIVE DIAGNOSED FIVE N FIVE AT RISK CHILDREN UNDER CHILDREN WHO CHILDEN PLW WITH PLW WITH
N OF PLW PLW
CHILDREN UNDER CHILDREN UNDER WHO ARE FIVE DIAGNOSED UNDER FIVE FIVE DIAGNOSED UNDER FIVE CHILDREN WITH MAM DIAGNOSE UNDER FIVE WITH MUAC UNDER WERE ILL IN THE WHO WERE ARE ALREADY CHILDREN CHILDREN CHILDEN
ADMITTED TO
PRGNANT
MUAC <21 CURRENTLY MUAC ≥21
ADMITTED TO
FIVE SCREENED FIVE SCREENED MALNOURISHED WHO ARE WITH SAM WITH SAM 12.5 cm < MUAC ≥
WITH MAM DIAGNOS UNDERFI 12.5 cm ≥ MUAC
≥ 13.5 CM
FIVE WITH WHZ ≥ 2 REGISTERED IN A REFERED TO SC REFERED TO OTP REFERED TO SFP AND MUAC ≥21 CM WITH MUAC CM REFERED BSFP
(MAM AND SAM) DIAGNOSED DIAGNOSED UNDERFIVE D WITH -3 ≥ Z-Score <-2 <13.5 cm FIVE AT FIVE WITH PAST TWO WEEKS ILL IN THE FEEDING BSFP LACTATING CM ON SFP
TO SFP
MALNOURISH MUAC <11.5 < - 3 SD 11.5 cm ED WITH VE <21 CM
WITH SAM WITH SAM DIAGONISE MAM RISK MUAC ≥ PAST TWO PROGRAMME SCREENED
ED (MAM MAM DIAGONIS
MUAC <11.5 < - 3 SD D WITH SAM 12.5 cm < 13.5 CM WEEKS
SUB-COUNTY WARD LOCATION/ SITE AND SAM) -3 ≥ Z- ED WITH
MUAC ≥
Score <-2 MAM
11.5 cm

% BOTH % BY
% BY BOTH % BOTH % BOTH % BY BOTH % BOTH % BOTH % BOTH % BOTH
BOTH MALE AND MALE BOTH BOTH MALE AND
BOTH MALE AND FEMALE BOTH
MALE AND BOTH MALE AND BOTH MALE AND BOTH MALE AND
FEMALE
FEMALE MALE BOTH MUAC AND WHZ MUAC AND FEMALE MALE MALE AND FEMALE MALE MALE AND MUAC AND FEMALE MALE MALE AND FEMALE MALE FEMALE MALE MALE AND FEMALE MALE MALE AND FEMALE MALE
FEMALE MALE AND FEMALE FEMALE FEMALE FEMALE %
AND MUAC
WHZ FEMALE FEMALE WHZ FEMALE FEMALE FEMALE FEMALE
FEMALE AND WHZ

1 kajiado west Loodokilani Torosei 47 17 30 6 13% 0 0 0% 1 2 6% 6% 0 0 0% 1 2 6% 6% 1 2 6% 13 26 83% 2 0 0 0% 5 0 3 3 0 0 0 0 0% 0 0 0

3 Magadi Lengobei 93 45 48 14 15% 0 1 1% 0 0 0% 1% 4 2 6% 3 4 8% 14% 4 5 10% 36 40 82% 0 0 0 0% 9 0 1 13 0 0 0 0 0% 0 0 0

4 Magadi Pakase 159 80 79 51 32% 5 5 6% 0 0 0% 6% 21 20 26% 0 0 0% 26% 3 6 6% 51 43 59% 2 5 0 0% 22 0 10 41 0 0 0 0 0% 0 0 0

5 Magadi Eldonyo Lasho 73 38 35 29 40% 3 0 4% o 1 0% 0% 10 3 18% 3 2 7% 25% 2 5 10% 22 27 67% 0 3 2 3% 4 0 4 25 0 0 0 0 0% 0 0 0

Godfrey Ogembo DESIGNATION: SCN0

SIGNATURE: _______________________________________________________________ DATE: 8/2/2018