Nevada Department of Agriculture

09/27/2017 vlg

IndividualInfant MealRecord Child andAdultCareFoodProgram

InfantFormulaType:Child’sName:___

BreastmilkYesNoFormulaForm on FileYesNoAge(Months) Date of birth______

Allergies according to medicalstatement:Center/Provider:

Plantoserve thecomponent(s)and amount(s)appropriatefortheageofeach infant. Place“P”byeachitem the parent brings

Food Components / 0-5 mo. / 6-11mo. / Date: / Date: / Date: / Date: / Date:
Breakfast / IronFortifiedFormulaor Breastmilk / 4-6 fluidoz. / 6-8 fluidoz.
InfantCereal
ormeat,or fish,orpoultry, orwholeeggorcookeddrybeansorcookeddry peasor cheese
orcottagecheeseoryogurt
or combinationofabove / 0-4tbsp.
0-4tbsp.
0-4tbsp.0-2oz
0-4oz
½cup
Fruitorvegetableorboth / 0-2tbsp.
Lunch / IronFortifiedFormulaorBreastmilk / 4-6 fluidoz. / 6-8 fluidoz.
InfantCereal
ormeat,or fish,orpoultry, orwholeeggorcookeddrybeansorcookeddry peasor cheese
orcottagecheeseoryogurt
or combinationofabove / 0-4tbsp.
0-4tbsp.
0-4tbsp.0-2oz
0-4oz
½cup
Fruitorvegetableorboth / 0-2tbsp.
Supper / IronFortifiedFormulaorBreastmilk / 4-6 fluidoz. / 6-8 fluidoz.
InfantCereal
ormeat,or fish,orpoultry, orwholeeggorcookeddrybeansorcookeddry peasor cheese
orcottagecheeseoryogurt
or combinationofabove / 0-4tbsp.
0-4tbsp.
0-4tbsp.0-2oz
0-4oz
½cup
Fruitorvegetableorboth / 0-2tbsp.
Snack / IronFortifiedFormulaorBreastmilk / 4-6 fluidoz. / 2-4 fluidoz.
Grain
sliceofbreadcrackers
Infantcerealor
readytoeatbreakfastcereal / 1-1/2slicebread
1-2crackers
0-4tbsp.0-4tbsp
Fruitorvegetableorboth / 0-2tbsp.

*Parent may only supply one meal item (per meal service) for a reimbursable meal to be claimed

NDA is an equal opportunity provider