PROFILING FORM
Must be completed by a designated official
Profiling Date
/
Month
/
Day
Year
Child Information
Full Name
First Name
Middle Name
Last Name
Gender
Please Select
Female
Male
Current Address
(Descriptive address should include street name, house number and/or significant landmark)
Street Address Line 2
City
State / Province
Postal / Zip Code
Local Govt. Area
State of Origin
Age
Does the child have a birth certificate?
Please Select
Yes
No
Is the Child in School?
Please Select
Yes
No
Has the child ever been enrolled in school?
Please Select
Yes
No
Name of School
Currently enrolled
Name of School last attended
Previously enrolled
Class
Vulnerability Status
Maternal Orphan
Paternal Orphan
Double Orphan
Street Child
Almajiri
Child With Disability
Living in an Orphanage home
Living in a child headed home
Other, please specify below.
Baseline/Initial Child Status Index Assessment
4
Good
3
Fair
2
Bad
1
Poor
Food Security
Nutrition & Growth
Shelter & Care
Abuse & Exploitation
Legal Protection
Health & Wellness
Pschosocial & Emotional Health
Healthcare Service
Social behaviour
Education
Development & Performance
Shoe Size
Uniform SIze
Please Select
Large
Medium
Small
Upload a Passport Photograph
Browse Files
Drag and drop files here
Choose a file
Kindly upload clear picture of the child
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HOUSEHOLD HEAD/ CAREGIVER INFORMATION
Name
First Name
Last Name
Gender
Please Select
Female
Male
Age
Phone Number
Please enter a valid phone number.
Address
(Enter address of nousehold head/caregiver if different from child’s address)
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Relationship to the Child
Parent
Friend of the family
Relative
Neighbour
Other
Number of Vulnerable Children in the household
Number of children in the household (0-17years)
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Data Information
Completed by
Designation
Please Select
Professional Volunteer
Community-based Volunteer
Staff
Partner Volunteer
Organisation
Source of information
Child
Parent
Guardian
Relative
Neighbour
Teacher
Friend
Community member
Worker
Other
Comment
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