Author: Toshiba

Mother’s name:_____________________
Name of baby _______________________
Name of kebele ________Gote:_________
Name of HDAs ______________________
Date of birth: ______/____/_________ E.c
Place of birth: _______________________
Birth weight:_________________________
Baby weight at discharge ______________
Vaccine given:_______________________
Number of days stayed at KMC hospital: __________
Date of Discharge: ______/____/____ E.c
Name of hospital: ___________________

Date of visits:

Visit 1:______/______/_______) _______gm
Visit 2: ______/_______/ ______) _______gm
Visit 3 : _____/_______/ _______) _______gm
Visit 4: ______/ ______/ ________) ______gm

Baby weight

Remarks to HEWs:
1. Please visit and follow this baby twice per week and assist the mother and her family in continuing KMC at home
2. Refer the baby back if any danger signs has encountered
3. This card should be kept by the mother and HEWs should fill each date of visit

Contacts in case of Emergency:
HEW’s Phone Number : ___________________________
Hospital Phone Number :__________________________

KMC Notification Card to Health Extension Workers