School­Based Immunization

Recording Form 1:Masterlist of Grade 1 Students
Region: Name of School: Section: To be filled up by the Vaccination Team
Province: Division: MR
District/Municipality: Date: Lot No.
Batch No.
Td
Lot No.
Batch No.

Parent's  Sick 
Date of previous  Response  today?
To be fiilled up by the School Nurse/Class Adviser MCV received Slip (fever,etc) Vaccine Given
History of 
Date of  allergies(food,m
Bith(mm/dd/ Zero  MVC eds,previous  MCV MCV
No. Name(Surname,First Name, MI) Complete Adress yy) Age Sex dose MCV1 2 Y N immunization) Y N 1 2 Td Refusal Reasons
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
 School­Based Immunization
Recording Form 2:Masterlist of Female Students(9­10 yrs. Old)
Region: Name of School: To be filled up by the Vaccination Team
Province: Division: HPV:
District/Municipality: Date: Lot No.
Batch No.

Parent's  History of 
Response  allergies(foo Sick today? Date of HPV 
To be fiilled up by the School Nurse/Class Adviser Slip d,meds,  (fever,etc) Vaccine Given
Date of  previous 
Name(Surname,First Name,  Bith(mm/dd immunizatio 1st  2nd 
No. MI) Complete Adress /yy) Age Sex Y N n) Y N dose Dose Deffered Refusal Reasons
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Name and Signature of Supervisor Name and Siganature ofName/Signature of Vaccinator 2 Name/Signature of Recorder

 School­Based Immunization
Recording Form 3:Masterlist of Grade 1 Students
Region: Name of School: To be filled up by the Vaccination Team
Province: Division: MR
District/Municipality: Date: Lot No.
Batch No.
Td
Lot No.
Batch No.

Parent's  Sick 
Response  today?
To be fiilled up by the School Nurse/Class Adviser Slip History of  (fever,etc) Vaccine Given
Date of  allergies(food,
Name(Surname,First Name,  Bith(mm/dd/ meds,previous  MR(R  Td(L 
No. MI) Complete Adress yy) Age Sex Y N immunization) Y N arm) arm) Deffered Refusal Reasons
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

 Grade 1 Grade IV FEMALE

Students Vaccinated Students Vaccinated

Total No. with MCV with Td Total no. of Deffered Total Number of Reffusal Total No. of Female Students Vaccinated
Province/ of Number
City/Mun schools of 1st dose 2nd dose
icipality Covered No. % No. % MCV % Td % MCV % Td % Enrolled HPV % HPV %
Grade IV FEMALE Students(9-13 yrs. Old Grade VII

Students Students vaccinated

Total no. of deffered Total No. of Reffusal Total No. vaccinated with MR with Td Total no. of deffered Total No. of Refusal
of
2st dose 2nd dose 1st dose 2nd dose Students
HPV % HPV % HPV % HPV % Enrolled no. % No. % MR % Td % MR %
Total No. of Refusal

Td %
ANNEX C

Recording Form for HPV Vaccination

Region of RHU: Province/City: Municipality:

Name of RHU: Date Submitted:
Name of Children(Surname, First Name,  Date 1st dose  Date 2nd dose 
MI) Complete Adress Date of Birth Age in Years given given Remarks

INSTRUCTION: completely fill­out Form and keep for the next v schedule
Note: Health workers must ensure that those who received the HPV 1st dose of HPV vaccine after 6 mons.
Reporting Form 1
Consolidated Accomplishment Report for HPV Vaccination

Region:  I  Province: La Union

Municipality/RHU: San Gabriel RHU & Birthing 
Clinic Date Submitted: 8/25/16

Remarks
Name of  No. Given  No. Given 
Province/City/RHU/BHS 1st dose % 2nd dose %
Bayabas Elementary School 8 100
Lon­oy Elementary School 13 100
Sisi Elementary School 14 93.33 1 absent

Prepared by: Approved by:

Joyce Anne D. Africano, RN Juan Alfonso R. Perez IV, MD­MBA
Name and Designation Name and Designation