School-Based Immunization

Recording Form 1:Masterlist of Grade 1 Students

Region:

Name of School:

Section:

To be filled up by the Vaccination Tea

Province:

Division:

MR

District/Municipality:

Date:

Lot No.
Batch No.
Td
Lot No.
Batch No.

Date of previous MCV

Parent's

received

Response Slip

To be fiilled up by the School Nurse/Class Adviser

Sick today?
History of

(fever,etc)

Vaccine Given

allergies(food,meds,p
Date of
No.

Name(Surname,First Name, MI)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Complete Adress

Bith(mm/dd/yy)

Zero
Age

Sex

dose

revious
MCV1

MVC2

immunization)

MCV1

Name and Signature of Supervisor

Name and Siganature of Vaccinator 1

Name/Signature of Vaccinator 2

be filled up by the Vaccination Team

Vaccine Given

MCV2 Td

Refusal

Reasons

Name/Signature of Recorder

Region:
Province:
District/Municipality:

Name of School:
Division:
Date:

School-Based Immunization
Recording Form 2:Masterlist of Female Students(9-10 yrs. Old)

Parent's
To be fiilled up by the School Nurse/Class Adviser

Response Slip

Date of
No.

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Name(Surname,First Name, MI)

Name and Signature of Supervisor

Complete Adress

Bith(mm/dd/yy) Age

History of
allergies(food,m

To be filled up by the Vaccination Team

HPV:
Lot No.
Batch No.

Sick today?

Date of HPV

(fever,etc)

Vaccine Given

eds, previous
Sex

immunization)

Name and Siganature of VaccinName/Signature of Vaccinator 2

1st dose

2nd Dose

Name/Signature of Recorder

Vaccination Team

Deffered

Refusal

Name/Signature of Recorder

Reasons

School-Based Immunization
Recording Form 3:Masterlist of Grade 1 Students
Region:

Name of School:

Province:
District/Municipality:

Division:
Date:

To be filled up by the Vaccination Team

MR
Lot No.
Batch No.
Td
Lot No.
Batch No.

Parent's
To be fiilled up by the School Nurse/Class Adviser

Response Slip

Date of
No. Name(Surname,First Name, MI)

Complete Adress

Bith(mm/dd/yy)

History of
allergies(food,meds

Sick today?
(fever,etc)

Vaccine Given

,previous
Age

Sex

immunization)

MR(R arm) Td(L arm)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Name and Signature of Supervisor

Name and Siganature of Vaccinator 1

Name/Signature of Vaccinator 2

Name/Signature of Recorder

Deffered

gnature of Recorder

Refusal

Reasons

Total No.
Province/
of
City/Mun schools
icipality Covered

Students
Vaccinated with
MCV
No.

Grade 1
Students
Vaccinated with Td
No.

Total no. of Deffered

MCV

Td

Total Number of Reffusal

%

MCV

Td

Total
Number
of
Enrolled

Grade IV FEMALE Students(9-13 yrs. Old

No. of Female Students Vaccinated
1st dose
HPV

2nd dose
HPV

Total no. of deffered

2st dose
HPV

2nd dose
HPV

Total No. of Reffusal

%

1st dose
HPV

2nd dose
HPV

Total No.
of
Students
Enrolled

Students
vaccinated with
MR
no.

Grade VII
Students
vaccinated with Td
No.

Total no. of deffered

MR

Td

Total No. of Refusal

%

MR

Td

ANNEX C
Recording Form for HPV Vaccination
Region of RHU:

Province/City:

Municipality:

Name of RHU:
Name of Children(Surname, First Name, MI)

Date Submitted:
Complete Adress

Date of Birth

INSTRUCTION: completely fill-out Form and keep for the next vaccination cshedulschedule
Note: Health workers must ensure that those who received the HPV 1st dose of HPV vaccine after 6 mons.

Age in Years

Date 1st dose given

Date 2nd dose given

Remarks

Reporting Form 1

Consolidated Accomplishment Report for HPV Vaccination

Region: I

Province: La Union

Municipality/RHU: San Gabriel RHU & Birthing Clinic

No. Given 1st
Name of Province/City/RHU/BHS

Bayabas Elementary School

Lon-oy Elementary School
Sisi Elementary School

Prepared by:
Joyce Anne D. Africano, RN
Name and Designation

dose

8
13
14

Date Submitted: 8/25/16

Remarks

No. Given
%

100
100
93.33

2nd dose

Approved by:
Juan Alfonso R. Perez IV, MD-MBA
Name and Designation

1 absent