Facility ID:
*Location Code:
*Month:
*Year:
Birth Weight Categories
Date
<750 gm
751-1000 gm
1001-1500 gm
1501-2500 gm
>2500 gm
*Pts
**U/C
**CL
**VNT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
*Total
Pts=number of infants U/C=number of infants with umbilical catheter CL=number of infants with 1 or more central linesVNT=number of infants on a ventilator *If infant has both a U/C and CL, count as U/C infant only for the day
Label
__________
Data