CITY GOVERNMENT OF VALENZUELA

CITY HEALTH OFFICE

SCHOOL BASE
VACCINE INFO.

SCHOOL INFO.
MR Td

NAME OF SCHOOL GRADE SECTION DIVISION LOT NO. BATCH NO. LOT NO.
SCHOOL BASED IMMUNIZATION
TO BE FILLED UP BY THE SCHOOL NUR

Td NAME

BATCH NO. SURNAME FIRST NAME M.I

0
TO BE FILLED UP BY THE SCHOOL NURSE / CLASS ADVISER

DATE OF BIRTH SEX DATE OF PREVIOUS MCV RECEIVED

COMPLETE ADDRESS BARANGAY AGE
(MM/DD/YYYY) (M/F)
ZERO DOSE MCV1
 TO BE FILLED-UP BY THE VACCINATION TEAM
PARENTS SICK TODAY?
MCV RECEIVED RESPONSE SLIP HISTORY OF ALLERGIES (FOOD, (FEVER,ETC.) VACCINE GIVEN (MM/DD/YYYY) REFUSAL (/)
(/) MEDS, PREVIOUS IMMUNIZATION) (/)
MCV2 YES NO YES NO MCV1 MCV2 Td MCV1 MCV2 Td
0 0 0 0 0 0
REASON FOR REFUSAL
CITY GOVERNMENT OF VALENZUELA
CITY HEALTH OFFICE

SCHOOL BASE
VACCINE INFO.

SCHOOL INFO.
MR Td

NAME OF SCHOOL GRADE SECTION DIVISION LOT NO. BATCH NO. LOT NO.
SCHOOL BASED IMMUNIZATION
TO BE FILLED UP BY THE SCHOOL NUR

Td NAME

BATCH NO. SURNAME FIRST NAME M.I

0
TO BE FILLED UP BY THE SCHOOL NURSE / CLASS ADVISER

DATE OF BIRTH SEX DATE OF PREVIOUS MCV RECEIVED

COMPLETE ADDRESS BARANGAY AGE
(MM/DD/YYYY) (M/F)
ZERO DOSE MCV1
 TO BE FILLED-UP BY THE VACCINATION TEAM
PARENTS SICK TODAY?
MCV RECEIVED RESPONSE SLIP HISTORY OF ALLERGIES (FOOD, (FEVER,ETC.) VACCINE GIVEN (MM/DD/YYYY) REFUSAL (/)
(/) MEDS, PREVIOUS IMMUNIZATION) (/)
MCV2 YES NO YES NO MCV1 MCV2 Td MCV1 MCV2 Td
0 0 0 0 0 0
REASON FOR REFUSAL
CITY GOVERNMENT OF VALENZUELA
CITY HEALTH OFFICE

SCHOOL BASE
VACCINE INFO.

SCHOOL INFO.
MR Td

NAME OF SCHOOL GRADE SECTION DIVISION LOT NO. BATCH NO. LOT NO.
SCHOOL BASED IMMUNIZATION
TO BE FILLED UP BY THE SCHOOL NUR

Td NAME

BATCH NO. SURNAME FIRST NAME M.I

0
TO BE FILLED UP BY THE SCHOOL NURSE / CLASS ADVISER

DATE OF BIRTH SEX DATE OF PREVIOUS MCV RECEIVED

COMPLETE ADDRESS BARANGAY AGE
(MM/DD/YYYY) (M/F)
ZERO DOSE MCV1
 TO BE FILLED-UP BY THE VACCINATION TEAM
PARENTS SICK TODAY?
MCV RECEIVED RESPONSE SLIP HISTORY OF ALLERGIES (FOOD, (FEVER,ETC.) VACCINE GIVEN (MM/DD/YYYY) REFUSAL (/)
(/) MEDS, PREVIOUS IMMUNIZATION) (/)
MCV2 YES NO YES NO MCV1 MCV2 Td MCV1 MCV2 Td
0 0 0 0 0 0
REASON FOR REFUSAL
CITY GOVERNMENT OF VALENZUELA
CITY HEALTH OFFICE

SCHOOL BASE
VACCINE INFO.

SCHOOL INFO.
MR Td

NAME OF SCHOOL GRADE SECTION DIVISION LOT NO. BATCH NO. LOT NO.
SCHOOL BASED IMMUNIZATION
TO BE FILLED UP BY THE SCHOOL NUR

Td NAME

BATCH NO. SURNAME FIRST NAME M.I

0
TO BE FILLED UP BY THE SCHOOL NURSE / CLASS ADVISER

DATE OF BIRTH SEX DATE OF PREVIOUS MCV RECEIVED

COMPLETE ADDRESS BARANGAY AGE
(MM/DD/YYYY) (M/F)
ZERO DOSE MCV1
 TO BE FILLED-UP BY THE VACCINATION TEAM
PARENTS SICK TODAY?
MCV RECEIVED RESPONSE SLIP HISTORY OF ALLERGIES (FOOD, (FEVER,ETC.) VACCINE GIVEN (MM/DD/YYYY) REFUSAL (/)
(/) MEDS, PREVIOUS IMMUNIZATION) (/)
MCV2 YES NO YES NO MCV1 MCV2 Td MCV1 MCV2 Td
0 0 0 0 0 0
REASON FOR REFUSAL
CITY GOVERNMENT OF VALENZUELA
CITY HEALTH OFFICE

SCHOOL BASE
VACCINE INFO.

SCHOOL INFO.
MR Td

NAME OF SCHOOL GRADE SECTION DIVISION LOT NO. BATCH NO. LOT NO.
SCHOOL BASED IMMUNIZATION
TO BE FILLED UP BY THE SCHOOL NUR

Td NAME

BATCH NO. SURNAME FIRST NAME M.I

0
TO BE FILLED UP BY THE SCHOOL NURSE / CLASS ADVISER

DATE OF BIRTH SEX DATE OF PREVIOUS MCV RECEIVED

COMPLETE ADDRESS BARANGAY AGE
(MM/DD/YYYY) (M/F)
ZERO DOSE MCV1
 TO BE FILLED-UP BY THE VACCINATION TEAM
PARENTS SICK TODAY?
MCV RECEIVED RESPONSE SLIP HISTORY OF ALLERGIES (FOOD, (FEVER,ETC.) VACCINE GIVEN (MM/DD/YYYY) REFUSAL (/)
(/) MEDS, PREVIOUS IMMUNIZATION) (/)
MCV2 YES NO YES NO MCV1 MCV2 Td MCV1 MCV2 Td
0 0 0 0 0 0
REASON FOR REFUSAL
CITY GOVERNMENT OF VALENZUELA
CITY HEALTH OFFICE

SCHOOL BASE
VACCINE INFO.

SCHOOL INFO.
MR Td

NAME OF SCHOOL GRADE SECTION DIVISION LOT NO. BATCH NO. LOT NO.
SCHOOL BASED IMMUNIZATION
TO BE FILLED UP BY THE SCHOOL NUR

Td NAME

BATCH NO. SURNAME FIRST NAME M.I

0
TO BE FILLED UP BY THE SCHOOL NURSE / CLASS ADVISER

DATE OF BIRTH SEX DATE OF PREVIOUS MCV RECEIVED

COMPLETE ADDRESS BARANGAY AGE
(MM/DD/YYYY) (M/F)
ZERO DOSE MCV1
 TO BE FILLED-UP BY THE VACCINATION TEAM
PARENTS SICK TODAY?
MCV RECEIVED RESPONSE SLIP HISTORY OF ALLERGIES (FOOD, (FEVER,ETC.) VACCINE GIVEN (MM/DD/YYYY) REFUSAL (/)
(/) MEDS, PREVIOUS IMMUNIZATION) (/)
MCV2 YES NO YES NO MCV1 MCV2 Td MCV1 MCV2 Td
0 0 0 0 0 0
REASON FOR REFUSAL
CITY GOVERNMENT OF VALENZUELA
CITY HEALTH OFFICE

SCHOOL BASE
VACCINE INFO.

SCHOOL INFO.
MR Td

NAME OF SCHOOL GRADE SECTION DIVISION LOT NO. BATCH NO. LOT NO.
SCHOOL BASED IMMUNIZATION
TO BE FILLED UP BY THE SCHOOL NUR

Td NAME

BATCH NO. SURNAME FIRST NAME M.I

0
TO BE FILLED UP BY THE SCHOOL NURSE / CLASS ADVISER

DATE OF BIRTH SEX DATE OF PREVIOUS MCV RECEIVED

COMPLETE ADDRESS BARANGAY AGE
(MM/DD/YYYY) (M/F)
ZERO DOSE MCV1
 TO BE FILLED-UP BY THE VACCINATION TEAM
PARENTS SICK TODAY?
MCV RECEIVED RESPONSE SLIP HISTORY OF ALLERGIES (FOOD, (FEVER,ETC.) VACCINE GIVEN (MM/DD/YYYY) REFUSAL (/)
(/) MEDS, PREVIOUS IMMUNIZATION) (/)
MCV2 YES NO YES NO MCV1 MCV2 Td MCV1 MCV2 Td
0 0 0 0 0 0
REASON FOR REFUSAL
CITY GOVERNMENT OF VALENZUELA
CITY HEALTH OFFICE

SCHOOL BAS
VACCINE INFO.

SCHOOL INFO.
HPV

NAME OF SCHOOL GRADE SECTION DIVISION LOT NO. BATCH NO.

 SCHOOL BASED IMMUNIZATION
TO BE FILLED UP BY THE SCHOOL NURSE / CLASS ADVISER

NAME
COMPLETE ADDRESS

SURNAME FIRST NAME M.I

0
R TO BE FILLED-UP BY THE VACCINATION
PARENTS SICK TODAY? DATE OF HPV GIVEN
DATE OF BIRTH SEX RESPONSE SLIP HISTORY OF ALLERGIES (FEVER,ETC.) (MM/DD/YYYY) DEFERRED
BARANGAY AGE (/) (FOOD, MEDS, PREVIOUS (/)
(MM/DD/YYYY) (M/F) IMMUNIZATION) (/)
YES NO YES NO 1ST DOSE 2ND DOSE
0 0 0
ATION TEAM

REFUSAL REASON FOR REFUSAL

(/)
0
CITY GOVERNMENT OF VALENZUELA
CITY HEALTH OFFICE
SCHO
VACCINE INFO.

SCHOOL INFO.
MR Td

NAME OF SCHOOL GRADE SECTION DIVISION LOT NO. BATCH NO. LOT NO.
 SCHOOL BASED IMMUNIZATION
TO BE FILLED UP BY THE SCHOOL NURSE

Td NAME

BATCH NO. SURNAME FIRST NAME M.I

0
TO BE FILLED UP BY THE SCHOOL NURSE / CLASS ADVISER

DATE OF BIRTH SEX DATE OF PREVIOUS MCV RECEIVED

COMPLETE ADDRESS BARANGAY AGE
(MM/DD/YYYY) (M/F)
ZERO DOSE MCV1 MCV2
03/08/2009
Malinta
Malinta
 TO BE FILLED-UP BY THE VACCINATION TEAM
PARENTS SICK TODAY? POTENTIALLY VACCINE GIVEN
RESPONSE HISTORY OF ALLERGIES LAST MENSTRUAL DEFERRED REFUSAL
(FOOD, MEDS, PREVIOUS (FEVER,ETC.) (/) PERIOD PREGNANT (/) (MM/DD/YYYY)
SLIP (/) (/) (/)
IMMUNIZATION) (MM/DD/YYYY)
YES NO YES NO YES NO MR (R ARM) Td (L ARM)
0 0 0 0
REASON FOR REFUSAL
CITY GOVERNMENT OF VALENZUELA
CITY HEALTH OFFICE

Kinder

STUDENT VACCINATED
STUDENT VACCINATED WITH TOTAL OF REF
W/ Td
CITY SCHOOL TOTAL NO. OF
STUDENTS
ENROLLED
MCV1 % MCV2 % NO. % MCV1 %

VALENZUELA CITY 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

 GRADE 1

STUDENT VACCINATED
TOTAL OF REFUSAL STUDENT VACCINATED WITH TOTAL OF REFUSAL
W/ Td
TOTAL NO. OF
STUDENTS
ENROLLED
MCV2 % Td % MCV1 % MCV2 % NO. % MCV1 % MCV2

0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0

 GRADE 2

STUDENT VACCINATED
AL OF REFUSAL STUDENT VACCINATED WITH TOTAL OF REFUSAL
W/ Td
TOTAL NO. OF
STUDENTS
ENROLLED
% Td % MCV1 % MCV2 % NO. % MCV1 % MCV2 %

#DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

 GRADE 3

STUDENT VACCINATED
AL STUDENT VACCINATED WITH TOTAL OF REFUSAL
W/ Td
TOTAL NO. OF
STUDENTS
ENROLLED
Td % MCV1 % MCV2 % NO. % MCV1 % MCV2 % Td

0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0

 GRADE 4

STUDENT VACCINATED
STUDENT VACCINATED WITH TOTAL OF REFUSAL
W/ Td
TOTAL NO. OF
STUDENTS
ENROLLED
% MCV1 % MCV2 % NO. % MCV1 % MCV2 % Td %

#DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

 GRADE 5

STUDENT VACCINATED
STUDENT VACCINATED WITH TOTAL OF REFUSAL
W/ Td
TOTAL NO. OF TOTAL NO. OF
STUDENTS STUDENTS
ENROLLED ENROLLED
MCV1 % MCV2 % NO. % MCV1 % MCV2 % Td %

0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

 GRADE 6 GRAD

STUDENT VACCINATED
STUDENT VACCINATED WITH TOTAL OF REFUSAL NO. OF FEMALE S
W/ Td
TOTAL NO. OF
STUDENTS
ENROLLED
1ST DOSE
MCV1 % MCV2 % NO. % MCV1 % MCV2 % Td % OF HPV

0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0

 GRADE IV FEMALES STUDENTS (9-13 YEARS OLD) GRADE VII

STUDENTS VACCINATED STUDENTS VACCINATED TOTAL OF DEFERRED

O. OF FEMALE STUDENTS VACCINATED TOTAL OF DEFERRED TOTAL OF REFUSAL W/ MR Td
TOTAL NO. OF
STUDENTS
ENROLLED
2ND DOSE
% % HPV % HPV % NO. % NO. % MR/Td %
OF HPV

#DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

TOTAL OF REFUSAL

MR/Td %

0 #DIV/0!