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Daily Gram Form—CNICCYP 1700/41 Arrival Information (to be completed by the parent/guardian) Child’s Name (First Last):

Date:

Arrival Time: Arrival Notes: Please tell us anything that will help your child have a good day. (For example, how rested is your child, when was last feeding/meal, is your child teething, etc.)

Daily Health Check Completed by a CYP Professional: ☐ Comments (if needed):

Feedings/Meal Times FOODS TIME type of food served  fruit/veggie  fruit/veggie  fruit/veggie  fruit/veggie  fruit/veggie

 grains  grains  grains  grains  grains

 dairy  dairy  dairy  dairy  dairy

 meat  meat  meat  meat  meat

amount of serving consumed  none  some  all  none  some  all  none  some  all  none  some  all  none  some  all

BREAST MILK/ FORMULA ounces consumed

LIQUIDS ounces consumed

Nap Times FROM

TO

COMMENTS

FROM

1

3

2

4

TO

COMMENTS

Diapering/Toileting W=Wet

D=Dry

BM=Bowel Movement

LBM=Loose Bowel Movement/Diarrhea

TIME Status TIME Status

Additional Notes and Reminders Please bring more:

 Diapers

 Clean clothes

 Other:

 Pull-Ups

 Breast milk

 Formula

 Baby food

 Wipes

A note or an activity from today I want to share with you: Daily Gram Form—CNICCYP 1700/41 (9.17)

FOR OFFICIAL USE ONLY—PRIVACY SENSITIVE

Required for infants, pretoddlers, and 2’s (optional for children 3 and older)