Healthy Steps – Data Collection (to be submitted after diapers and/or period products are picked up) Staff Name* First Last Work Location County*ColumbiaCumberlandJuniataLebanonMifflinMontourNorthumberlandPerrySnyderSomersetUnionFAMILY FID #* Date Items Received* MM slash DD slash YYYY Military Status* Active Duty Veteran Non-Veteran Relationship to Child:* Child #1 DiaperCHILD PID # Date of Birth MM slash DD slash YYYY Child Weight (lbs)Gender Female Male RaceSelect OneAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or More RacesRace Not ReportedHispanic/Latino Yes No Residence Zip Code ZIP Code First Time Receiving Diapers Yes No Potty Training Yes No Diaper Type Diaper Training Pants Size Quantity Child #2 DiaperCHILD PID # Date of Birth MM slash DD slash YYYY Child Weight (lbs)Gender Female Male RaceSelect OneAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or More RacesRace Not ReportedHispanic/Latino Yes No Residence Zip Code ZIP Code First Time Receiving Diapers Yes No Potty Training Yes No Diaper Type Diaper Training Pants Size Quantity Child #3 DiaperCHILD PID # Date of Birth MM slash DD slash YYYY Child Weight (lbs)Gender Female Male RaceSelect OneAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or More RacesRace Not ReportedHispanic/Latino Yes No Residence Zip Code ZIP Code First Time Receiving Diapers Yes No Potty Training Yes No Diaper Type Diaper Training Pants Size Quantity Period ProductsPID # Date of Birth MM slash DD slash YYYY Military Status Active Duty Veteran Non-Veteran Gender Female Male RaceSelect OneAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or More RacesRace Not ReportedHispanic/Latino Yes No Residence Zip Code ZIP Code First Time Receiving Diapers Yes No Currently Receiving Diapers Yes No Packets Received Pads Only (pink) Pads/Tampons (teal) Postpartum (white) Notes: Δ
