____________________________ County Public Health
(revised from a document received from Kandiyohi County)
ID #: ____________________________________
Mom’s Last Name
Mom’s First Name
Mom’s DOB
Home Phone #:
EDC:
Enrolled in EPC:
________________
DOB:
Baby(s) Last Name:
First Identified:
… PN
… Yes
Baby (1)’s First Name:
… PP
gender: … M
Other:
Date
… No
Type*
Stage**
…F
Baby (2)’s First Name:
Baby (3)’s First Name:
gender: … M
gender: … M
…F
Paycode
*Type of contact—ML, TC, UHV, SHV, GROUP, WIC, Other
**Stage—ASS (assessment), ONG (ongoing)
Comment
…F
Intentionally Left Blank