BNS FORMS

Page # Forms No. of copies Total

# of
copies
1-2 BNS Contract of service 1 copy each page 2
3 Family Profile 4 copies 4
4 Baseline of Immunization 3 copies 3
5 Barangay Situational Analysis 1 copy 1
6 Master list of PS to be weighed 3 copies 3
7-a Master list of Pregnant 1 copy 1
7-b Master list of Lactating 1 copy 1
8-9 BNS Action Plan 1 copy each 1
10-11 BNS Accomplishment Report 12 copies each (extra 24) 48
12 Quarterly Accomplishment Report 4 copies 4
13 OPT form I 3 copies 3
14 OPT form I A 1 copy 1
15 OPT Result by Purok 1 copy 1
16 OPT form IB- Underweight 2 copy 2
17 OPT form IB-Severely 1 copy 1
18 OPT form IB-Overweight 1 copy 1
19- a Monthly weighing of 0-24 months ( Jan-June) 1 copy 1
19 b Monthly weighing of 0-24 (July-Dec) 1 copy 1
20 a Monthly weighing of Severely (JanJune) 1 copy 1
20 b Monthly weighing of Severely (July-Dec) 1 copy 1
21- a Monthly weighing of Underweight (Jan-June) 2 copy 2
21b Monthly weighing of Underweight (July- Dec) 2 copy 2
22 Quarterly weighing of 25-71 months 2 copy 2
23 Master list of Beneficiaries of Families Severely & 2 copies 2
Underweight Children
23-a Master list of Children (0-71 months) 2 copies 2
23-b Master list of Beneficiaries of Pregnant & Lactating 2 copies 2
24 Diary 15 copies 15
25 Guide Posts 1 copy 1
Table of contents 1 copy 1
Cover 1 copy 1
TOTAL 111
Page # BNS FORMS Schedule
1-2 BNS Contract of service Annual- January
3 Family Profile Annual- January
4 Baseline of Immunization Monthly
5 Barangay Situational Analysis Annual- January
6 Master list of PS to be weighed Annual-January
7-a Master list of Pregnant Annual-January
7-b Master list of Lactating Annual-January
8-9 BNS Action Plan Annual-January
10-11 BNS Accomplishment Report Monthly
12 Quarterly Accomplishment Report Quarterly
13 OPT form I Annual-February
14 OPT form I A Annual-February
15 OPT Result by Purok Annual-February
16 OPT form IB- Underweight Annual-February
17 OPT form IB-Severely Annual-February
18 OPT form IB-Overweight Annual-February
19- a Monthly weighing of 0-24 months ( Jan-June) Monthly
19 b Monthly weighing of 0-24 (July-Dec) Monthly
20 a Monthly weighing of Severely (JanJune) Monthly
20 b Monthly weighing of Severely (July-Dec) Monthly
21- a Monthly weighing of Underweight (Jan-June) Monthly
21b Monthly weighing of Underweight (July- Dec) Monthly
22 Quarterly weighing of 25-71 months Quarterly
23 Master list of Beneficiaries of Families Severely & Underweight Monthly
Children
23-a Master list of Beneficiaries of Severely & Underweight Children (0-71 Monthly
months)
23-b Master list of Beneficiaries of Pregnant & Lactating Monthly
24 Diary Every time render
duties
BNC FORMS
25 Barangay Nutrition Action Plan (BNAP) Annual, 2nd
quarter
26 BNAP Accomplishment Quarterly
27 OPT consolidation (blow up) Annual-March
28 Barangay Profile Annual-March
MNC FORMS
29 Municipal Nutrition Action Plan (MNAP) Annual, 3rd
quarter
30 MNAP Quarterly Accomplishment Quarterly
31 Municipal Profile March
32 MNC monitoring visit checklist (as agreed)
33 BNS Renewal March
34 OPT Municipal consolidation April-May
35 Prevalence of malnutrition ( municipal ) April-May
 Republic of the Philippines
Ministry of Agriculture
NATIONAL NUTRITION COUNCIL
Manila

CONTRACT OF SERVICE

KNOW ALL MEN BY THESE PRESENTS:

This contract entered into by and between the National Nutrition Council, herein presented by
A/Sec Bernardita T. Flores, Executive Director, herein after referred to as COUNCIL and
_______________________________________________, of legal age, Filipino and residence
____________________________________ hereafter referred to as SCHOLAR.

WITNESETH

1. That for and in consideration of the following:

a. Stipend of P100.00 a month from the Provincial Government of Bohol to cover incidental
expenses while performing his/her duties.
b. Additional stipend from local government where he/she is assigned.
c. One (1) year free accident insurance.
d. Allowance of P15.00 from National Nutrition Council for every month of actual services.
which consideration shall be provided by the COUNCIL to the SCHOLAR and for which
consideration the SCHOLAR has agreed to work with the Council of the Philippine Food
and Nutrition Program more in particular under the Barangay Nutrition Scholar Program.
2. That the SCHOLAR shall first undergo, training to be conducted by the Provincial Training Team
before his/her actual service within the designated barangay.
3. That the SCHOLAR will work under the Barangay Nutrition Committee including but not limited
to the performance of the following duties:
a. Conducts / assist in Operation Timbang.
1. Helps the Teacher Coordinator and the unit leader prepares the spot map.
2. Inform people the place, date and time of weighing.
3. Helps transport and maintain the bar scales.
4. Prepares master list of children to be weighed.
5. Conducts mass weighing twice (2x) a year, follow up weighing monthly & quarterly.
b. Refers to the identified malnourished children to proper, authorities.
c. Conducts follow-up of target families.
1. Makes regular home visits to target families at least twice a month.
2. Teaches mothers, particularly those with infants & underweight children on:
a. What and how to feed the child.
b. Proper food selection and preparation, breast-feeding and food production.
d. Assist the Rural Health Unit in Nutrition and Related Health Services within the barangay
such as deworming prenatal care and immunization activities and others of the same nature.
e. Attend meetings of the Barangay Nutrition Committee to explain his/her role as a BNS & to
report his/her activities in the barangay related to nutrition.
f. Attend monthly or quarterly meetings of the BNS conducted by the Municipal Nutrition
Action Officer and the Dist. Nutritionist may call for a meeting as need arises.
g. Assist the Barangay Nutrition Action Officer and act as secretariat of the Barangay Nutrition
Committee.
4. That the SCHOLAR will keep record of his/her activities in the BNS work diary and submit
monthly report to the Municipal Nutrition Officer and District Office.
5. That in case of voluntary resignation or any other cause of termination of services, the Scholar
shall automatically lose insurance benefits, stipends and shall surrender to the MNAO all
nutrition information and education materials and equipments supplied by the Council and
 the same shall given to the next designated SCHOLAR.
6. That this contract of services shall take effect from January 1, 2011 to December 31, 2013.
Renewable on option of the SCHOLAR upon satisfactory performance of service for another
three years period.
7. That the SCHOLAR can only be terminated from his/her duty based on unsatisfactory performance /
rating at the end of the contract.

In Witness hereof, the parties have signed this contract this ________day of ____________, 2013

at barangay ______________ municipality of ___________________ province of Bohol.

___________________________________
Signature of the Barangay Nutrition Scholar

Conform:
By the Municipal Government

___________________________________
Municipal Mayor
Chairman, Municipal Nutrition Committee

Signed in the presence of: Barangay Nutrition Committee:

___________________________________ _______________________________
Municipal Nutrition Action Officer Barangay Captain
Chairman, Barangay Nutrition Committee
 BARANGAY SITUATIONAL ANALYSIS

2013
BNS Form No. 1 A
Food and Nutrition Program

Barangay: ____________ Date Prepared: _______________

Municipality: _____________
Province:_________

ITEM NUMBER

1. Total No. of Households _______________________

2. Total No. of Families _______________________
3. Total No. of Households Surveyed _______________________
4. Total No. of Infants (0-11 months) _______________________
5. Total No. of Women who are:
a) Pregnant ________________________
b) Nursing/Lactating ________________________
6. Total No. of:
a) Preschool Children ________________________
b) School Children ________________________
7. Total No. of Children Weighed :
a) Preschool Children ________________________
b) School Children ________________________
8. Weight Status of Preschool Children:
a) No. Overweight ________________________
b) No. Normal ________________________
c) No. Underweight ________________________
d) No. Severely Underweight ________________________
9. Weight Status of School Children:
a) No. Overweight ________________________
b) No. Normal _________________________
c) No. Severely wasted _________________________
d) No. Wasted _________________________
10. Families/Mothers with Severely underweight PS _________________________
11. Families/Mothers with Underweight PS _________________________
12. Families/Mothers with Severely wasted SC _________________________
13. Families/Mothers with Wasted SC _________________________
14. No. of Preschoolers Immunized:
a) BCG _________________________
b) Penta 1 _________________________
c) Penta 2 _________________________
d) Penta 3 _________________________
e) Polio1 _________________________
f) Polio2 _________________________
g) Polio3 _________________________
h) Measles _________________________
15. No. of Households with:
a) Water Sealed Toilet _________________________
b) Open Pit Toilet _________________________
c) No Toilet _________________________
16. No. of Households Getting Water from:
a) Piped Water system __________________________
b) Well __________________________
c) Spring
d) Rain __________________________
17. No. of Households with:
a) Vegetable Garden _____________ ___________
 b) Livestock /Poultry __________________________
c) Fishpond __________________________
18. No. of Household with:
a) Proper segregation of waste materials __________________________
b) No proper disposal of garbage __________________________
19. No. of Households with:
a) Proper drainage __________________________
b) No proper drainage __________________________
20. Total No. of Sari-sari stores __________________________

Prepared by:

_______________________
Barangay Nutrition Scholar

Attested by :

___________________________
Barangay Captain
Chairman, Barangay Nutrition Committee
 BARANGAY NUTRITION SCHOLAR ACTION PLAN

January 2013 to December 2013

NAME: ___________________ BARANGAY : ________________

INTERVENTION/ TARGET GROUP TARGET COOPE SCHEDULE OF ACTIVITIES

ACTIVITIES NUMBER RATOR J F M A M J J A S O N D

A.IDENTIFYING
& LOCATING
TARGETS * All preschool
children Pop.X BHW
1.Full weighing (0-71 months) 16.2%
2.Monthly * SE underweight
weighing PS BHW
* Underweight PS
* 0-24 months PS 55
3. Quarterly * 25-71 months PS 45 BHW
weighing
BHW/
B.REFERRALS * SE underweight mother
PS leader
1.To Feeding * Underweight PS
Center *Pregnant woman
*Lactating mothers
* Others (specify)
- normal
BHW/
2.To Health mother
Center * Severely PS leader
* Underweight PS
* Pregnant woman
* Lactating mothers
* Un immunized
children
* Others (specify)
-normal
BHW/
3.To Agriculture *Families with SE & mother
for distribution underweight PS leader
2. of seeds/ *Families with SW
3. seedlings & Wasted SC
*Others (specify)
BHW/
4. For attendance *Mothers with SE mother
to Mothers Class & underweight PS leader
or Pabasa sa *Pregnant woman
Nutrisyon or *Lactating mothers
Counseling * Mothers with SW
& wasted SC
* Others (specify)
INTERVENTION/ TARGET GROUP TARGET COOPE SCHEDULE OF ACTIVITIES
ACTIVITIES NUMBER RATOR J F M A M J J A S O N D
C. OTHER
ACTIVITIES
1. Organization/
Reactivation
of the BNC BNC BNAO

2.Attendance to : Number of BNS

- BNS Meetings meetings

-BNC Meetings Number of BNC

meetings

3. Income Number of Income

Generating Generating
Activities Activities

4. Information
Campaigns on : BHW
Un immunized
- Immunization Infants

- Environmental HH w/out toilet

Sanitation BHW
HH w/out proper
Drainage

HH w/out proper
garbage disposal
BALA
- Selective Food HH w/out vegetable
Production Garden
BHW
-Family Planning Families w/ more
than 3 children
or families w/ 2 PS
underweight
BHW
5. Breastfeeding Pregnant women

6. Utilization of HH
fortified foods
BHW
7. Availability of Sari-sari stores
fortified foods
 EXAMPLE BARANGAY NUTRITION SCHOOLAR ACTION PLAN

FROM January TO December 2010

Rosalinda Bertulfo Poblacion I

Barangay Nutrition Scholar Barangay
INTERVENTION/ TARGET GROUP TARGET COOPE SCHEDULE OF ACTIVITIES
ACTIVITIES NUMBER RATOR
J F M A M J J A S O N D
A.IDENTIFYING &
LOCATING
TARGETS
1.Full weighing * All preschoolers. 85 BHW

2.Monthly weighing * Severely 3 BHW

*Underweight PS 4 BHW
* 0-24 months 10 BHW
preschoolers

B.REFERRALS

1. To feeding * Severely PS 3 BHW

Center * Underweight PS 4
*Pregnant woman 5
*Lactating mothers 10
* Others
(specify)

2.To Health * Severely PS 3 BHW

Center * Underweight 4
*Pregnant woman 5
*Lactating mothers 10
* Unimmunized 10
children
* Others
(specify)

4. 3.To AT for *Families with 12 BALA

5. distribution of underweight (PS
6. seeds and & SC)
7. seedlings *Others
(specify)
BHW
4. For attendance *Mothers with 7
to Mothers Class underweight PS
*Pregnant & 15
lactating
mothers
*others (specify)
 BNS MONTHLY ACCOMPLISHMENT REPORT
For the month of _______________, 2013

Province: Municipality: Barangay: Name of BNS:

Target No. reached this month Last This Remarks

Number OLD CASES NEW months months
(As stated (Cases CASES total total
ACTIVITIES
in BNS reached in the (Cases (Write the (Add
Action previous reached entry from columns
Plan) month for the Column 6 4-5)
reached again first time) of last
this month) Months
(1) (2) (3) (4) report)
(5) (6)
A. WEIGHING
1. Full weighing Est. 0 50 35 85 complete
-All Pre-school Children Pop.x16.
( 0-71 months) 2%
2. Monthly Re-weighing
- SE underweight PS 2 2 0 2 2
- Underweight PS 15 10 5 15 18 2 over age
- 0-24 Months PS 75 8 5 20 23 2 over age
3. Quarterly Re-weighing
- 25-71 Months PS april 12 5 15 17 3 over age
B. REFERRALS
1. To Feeding Center :
- SE underweight PS april
- Underweight PS
- Pregnant women 10 - - - - No activity
- Lactating mothers 15
- Others/ (Specify) SC
2. To Health Center :
- SE underweight PS 1 0 1 1 Same child
- Underweight PS
- Pregnant women
- Lactating mothers
- Un Immunized infants
- Others (Specify)
Non acceptor
3. To Agriculture for
distribution of seeds/
seedlings :
-Families with SE &
underweight PS
-Families with SE
wasted & Wasted SC
- Others (Specify)
4.For attendance to
Mothers Class or
Pabasa sa Nutrisyon
or counseling :
- Mothers w/ SE &
Underweight PS
-Mothers with SE
wasted & Wasted SC
- Pregnant women
- Lactating mothers
-Others (specify)
 Target Last This Remarks
Number No. reached this month months months
ACTIVITIES (As OLD CASES NEW total total
stated in (Cases reached CASES (Write the (Add
BNS in the previous (Cases entry from columns
Action month reached reached C 6 of last 4-5)
Plan) again this for the Months
month first time) report)
(1) (2) (3) (4)
(5) (6)
C. OTHER
ACTIVITIES
1. Organization /
Reactivation of the BNC
2. Attendance to:
-BNC Meetings
- BNS Meetings
3. Income Generating
Activities
4. Information
Campaigns on :
- Immunization
- Environmental
Sanitation
-Selective Food
Production
-Family Planning
-Breastfeeding
-Utilization of Fortified
Foods
-Availability of
Fortified Foods
5.Others (specify)

D. RESULTS OF FOLLOW - UP MONTHLY WEIGHING

0-24 Months Severely Underweight
No. Weighed 75 2 18
No. Normal 60 1 0
No. Severely 1 0 0
No. Underweight 4 1 18
No. Overweight 10 0 0
No. Not weighed 0 0
No. Over age 0 2
No. Moved out 0
No. Died 0

Prepared by:

______________________
Name of Barangay Nutrition Scholar
Attested by :

_______________________________
Barangay Captain/Chairman,Bargy. Nut. Committee

Noted by :

____________________________
Municipal Mayor
Chairman, Municipal Nutrition Council
 BNS QUARTERLY ACCOMPLISHMENT REPORT
________ QUARTER, 2013

Province: Municipality: Barangay: Name of BNS:

Target No. reached this month Last months This

Number OLD CASES NEW total quarters
ACTIVITIES (As (Cases CASES (Write the total
stated in reached in the (Cases entry from (Add
BNS previous month reached for Column 6 of columns
Action reached again the first last Months 4-5)
Plan) this month time) report)
(1) (2) (3) (4) (5) (6)
A. WEIGHING
1. Full weighing: All 0-71 months PS
2. Monthly Re-weighing
- SE underweight PS
- Underweight PS
- 0-24 Months PS
3. Quarterly Re-weighing:
- 25-71 Months PS
B. REFERRALS
1. To Feeding Center :
- SE underweight PS
- Underweight PS
- Pregnant women
- Lactating mothers
-Others (pls specify)
2. To Health Center :
- Severely underweight PS
- Underweight PS
- Pregnant women
- Lactating mothers
- Un Immunized infants
-Others (pls specify)
3. To Agriculture for distribution of
seeds/seedlings :
-Families with SE & underweight PS
-Families with SE wasted & Wasted
SC
4. For attendance to Mothers Class or
Pabasa sa Nutrisyon or counseling:
- Mothers w/ SE & Underweight PS
-Mothers w/ SE wasted & Wasted SC
- Pregnant women
- Lactating mothers
C. OTHER ACTIVITIES
1. Organization / Reactivation of the
BNC
2. Attendance to:
-BNC Meetings
- BNS Meetings
3. Income Generating Activities
4. Information Campaigns on :
- Immunization
- Environmental Sanitation
-Selective Food Production
-Family Planning
-Breastfeeding
-Utilization of Fortified Foods
-Availability of Fortified Foods

Prepared & submitted by : _________________________________

Barangay Nutrition Scholar
 MASTERLIST OF PRESCHOOL CHILDREN TO BE WEIGHED
0-71 MONTHS OLD
PUROK ______1_________
Barangay :__________________ Province: __________
Municipality: _______________ Year : 2013____
HH Number Name of Father or Mother Name of Child Sex Date of Age in
Birth Months
(Y-M-D)

Prepared by: ___________________________ Date: __________________

BHW
OPT Form 1B. List of Priority Preschoolers 0-71 Months old - WEIGHT FOR AGE STATUS

Barangay ______________________ Province _________

Municipality ___________________ Year 2013
Purok Name of Father or Mother Name of Child Sex Date of Age in
Birth months
(Y-M-D)
Underweight
(1) (2) (3) (4) (5) (6)

Prepared by ___________________________ Date: __________________

Barangay Nutrition Scholar

Approved by: __________________________________ Date: __________________

Chairperson, Barangay Nutrition Committee
OPT Form 1B. List of Priority Preschoolers 0-71 Months old- WEIGHT FOR AGE STATUS

Barangay :_____________________ Province: ________________

Municipality ___________________ Year 2013
Purok Name of Father or Mother Name of Child Sex Date of Age in
Birth months
(Y-M-D)
Severely Underweight

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

Prepared by ___________________________ Date: __________________

Barangay Nutrition Scholar

Approved by: __________________________________ Date: __________________

Chairperson, Barangay Nutrition Committee
OPT Form 1B. List of Priority Preschoolers 0-71 Months old WEIGHT FOR AGE STATUS

Barangay :_____________________ Province: _____________

Municipality ___________________ Year: 2013____________

Purok Name of Father or Name of Preschool Sex Date of Age in

Mother children Birth months
(Y-M-D)
Overweight
(1) (2) (3) (4) (5) (6)

Prepared by ___________________________ Date: __________________

Barangay Nutrition Scholar

Approved by: __________________________________ Date: __________________

Chairperson, Barangay Nutrition Committee
 LENGTH OR HEIGHT FOR AGE STATUS

Purok Full name of Father Name of Sex Date of Age in Height Status
or Mother Preschooler Birth months
( Y-M-D)

N-Normal St- Stunted/Short SSt Severely Stunted T -Tall

 WEIGHT FOR LENGTH STATUS = ( 0-23 MONTHS )
WEIGHT FOR HEIGHT STATUS = ( 24-60 MONTHS)

Purok Full name of Father Name of Sex Date of Age in Height Status
or Mother Preschooler Birth months
( Y-M-D)
 PRESCHOOL CHILDREN WEIGHED AND NUTRTIONAL STATUS

Purok Full name of Father Name of Sex Date of Date of Age in Weight Status
or Mother Preschooler Birth Weighing months
( Y-M-D) ( Y-M-D)

N - Normal W - Wasted SW Severely Wasted OW - Overweight Ob - Obese

 MASTER LIST OF PREGNANT WOMEN

Expected No. of No. of

Purok Name Age date of children Under
delivery (living) weight
(M-D-Y) Children
1 Maria Cruz 35 5-15-13 8 2
 MASTER LIST OF LACTATING MOTHERS

Date started No. of Remarks/

Purok Name Age exclusive months (Reasons
breastfeeding breastfed why stop
( Month & the child breastfeeding)
Year only )
January 2013 4 Working
 BNS DIARY
January to December 2013

Date Activity Undertaken

EXAMPLE
BARANGAY SITUATIONAL ANLYSIS

REGION: VII DATE PREPARED: January 10, 2010

PROVINCE: BOHOL
MUNICIPALITY: SAGBAYAN

ITEM NUMBER
1. Total No. of Households ____________100___________
2. Total No. of Households Surveyed ____________100__________
3. Total No. of Infants _____________8____________
4. Total No. of Women who are:
a) Pregnant _____________5_____________
b) Nursing _____________10____________
5. Total No. of Preschoolers ____________85_____________
6. Total No. of Preschoolers Weighed _____________80_____________
7. Weight Status of Preschoolers
a) No. Overweight _____________8___________
b) No. Normal ____________70__________
d) No. Underweight _____________4___________
e) No. Severely Underweight _____________3___________
8. No. of Preschoolers Immunized:
a) BCG _____________8____________
b) DPT1 _____________8____________
c) DPT2 _____________8_____________
d) DPT3 _____________8____________
e) Polio1 __________________________
f) Polio2 __________________________
g) Polio3 __________________________
h) Measles __________________________
9. No. of Households with:
a) Water sealed Toilets ______________90__________
b) Open Pit Toilet ______________4___________
c) No Toilet ______________6___________
d) Others __________________________
10. No. of Households Getting Water from:
a) Piped Water system ______________95___________
b) Well _______________5___________
c) Spring _______________0___________
11. No. 0f Households with:
a) Vegetable Garden _____________ 95___________
b) Livestock Poultry ______________50____________
c) Fishpond ______________5_____________

Prepared by:
ROSALINDA BERTULFO
Barangay Nutrition Scholar
Attested by :
______________________________
Chairman, Barangay Nutrition Committee