Recording Form 3

School – Based Immunization

Masterlist of Grade 7 Students

Region: National Capital Region Name of School : New Era High School Section: ___________________________
Province/City: Quezon City Division: Quezon City
Municipality: _______________ Date: ______________________

Parent’s Sick today?

Deferred

Refused
Name Complete Address Date of Birth Gender History of allergies Last Menstrual Potentially Vaccine Information Reasons for Deferral/Refusal

(13)

(14)
Age Response Slip (fever, etc.)
(Surname, First Name, MI) (House No. St., City/Municipality) MM/DD/YY (M/F) (food, meds, previous Period ( for pregnant? (12) (15)
No. (6) (8)
immunization, MR/Td FEMALES only) (Y/N)
(7) (9) (10) Lot Batch Expiry
(1) (2) (3) (4) (5) Y N Y N
No. No. Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

_________________________________________ ______________________________________ _______________________________________ _______________________________________

Name and Signature of School Nurse/Class Advisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 1