Republic of the Philippines

Department of Health
Center for Health Development
Western Visayas

SBI 2019: Masterlisting Form for Kinder to Grade 7 Learners

To be filled-up by the vaccination team
Name of School ________________________________ Division ______________________________ Start Date of Vaccination _______________________ MR/MMR Vaccine Td Vaccine HPV Vaccine
Province/City __________________________________ Grade Level___________________________ End Date of Vaccination________________________ Lot No/Batch: Lot No/Batch: Lot No/Batch:
Municipality/District _____________________________ Section ______________________________
Date of Masterlisting ___________________ Expiry Date Expiry Date Expiry Date

To be filled up by the School Teacher / Adviser / Clinic Teacher / DepEd Health personnel To be filled up by the Vaccination Team
Parent's Response Sick Today? Date Vaccine Given
Slip Date of Previous MCV received (fever, etc) (mm/dd/yyyy)

Name History of
Complete Date of Birth Allergies HPV
No. Age Sex Deferral Refusal Reasons / Remarks
(Surname, First Name, MI) Address (MM/DD/YYYY) (years) (food, medicine, (for Grade 4, Females 9-14 years old
Not MCV 2 or
previous Td ONLY)
Yes
Submitted Zero Dose MCV 1 more
immunization) Y N MCV (for Grade 1 & 7
2nd Dose
ONLY) 1st Dose (given 6 months after
the 1st dose)

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*(1) All Masterling Forms shall be consolidated by the school and shall be given to the LGU. (2) Consents Forms and Vacination Records shall be secured and filed in the schools. This will be used later-on by the vacination teams as validation reference during the vacination sesson.

_________________________________________ _________________________________________ _________________________________________ _________________________________________

Name & Signature of Teacher In-Charge Name & Signature of Health Vaccination Team Supervisor Name & Signature of Vaccinator Name & Signature of Recorder