Recording Form 1

MASTERLIST FOR PNEUMOCOCCAL VACCINATION (Non-Senior)

Region ____VII_________ Province / City: ____CEBU________ Municipality: ___GINATILAN__________ RHU: ___MAIN HEALTH CENTER___________

Date Other Vaccine Received

Date of Date of Birth Name Complete Address Gender
Pneumococcal Remarks
Registration MM/DD/YY (Surname, First, MI) (House No., Street, Purok/Sitio/Block) M/F Vaccine Date Given
Vaccine Received

Instructions: * During screening for Pneumococcal vaccination, ask each senior citizen the following. If deferred, indicate the corresponding number (code on the appropriate column above
4. Conduct a quick assessment before vaccination
5. For any deferred vaccination, indicate the reason by writing the 11. Currently taking systemic steroids
Appropriate number corresponding to the reason given. 7. Received Pneumococcal Vaccine in the last 5 years 12. Fever
6. Do not leave any blank; indicate NA if not applicable 13. Cough
History of allergy to:
14. Flu-like illness
8. Vaccine Components
* If Refused vaccination, write in the Remarks Column
9. Antibiotics such as Neomycin or Polymyxin
10. Latex Gloves

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Name and Signature of Vaccinator Name and Signature of Encoder