| Laboratory form | ||||||||
| 20-Jan-08 | ||||||||
| CHSUNO | Child survey number | CHSUNO | ||||||
| Chsno | Child serial number (if mother, add 10,000 to her child's chsno) | Chsno | ||||||
| BF3_1 | Date | BF3_1 | ||||||
| BF3_2 | Time of last meal (khana) (If not today enter 8888) | BF3_3 | ||||||
| BF3_3 | Time of last snack (kaja) (If not today enter 8888) | BF3_4 | ||||||
| BF3_4 | Time of last tea (If not today enter 8888) | BF3_5 | ||||||
| BF3_5 | Time of last breast feed (If not today or mother enter 8888) | BF3_6 | ||||||
| BF3_6 | Time of blood taken | BF3_7 | ||||||
| BF3_7 | Time of serum separation | BF3_8 | ||||||
| BF3_8 | Amount of blood (ml) | BF3_8 | . | |||||
| BF3_9 | Number of vials | BF3_9 | . | |||||
| BF3_10 | Hemoglobin level | BF3_10 | ||||||
| BF3_11 | CRP level | BF3_11 | ||||||
| BF3_12 | Blood group | BF3_12 | ||||||
| BF3_14 | Remarks | |||||||
| SUPERVISOR'S SIGNATURE | ||||||||
| DATA ENTRY 1 | ||||||||
| DATA ENTRY 2 | ||||||||