School-Based Immunization

RECORDING Form 1: Masterlist of Kinder - Grade 6 Students

To be filled up by the Vaccination Team
MR
Region: _______________________________ Name of School: ________________________________ Grade & Section: _______________________ Lot No: _______________________
Batch No: _____________________
Province/City: _________________________ Division: _______________________
Td
District/Municipality: ___________________ Date:__________________________ Lot No: _______________________
Batch No.______________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents'
Date of previous MCV Response History of allergies Sick today? Vaccine Given
LEARNERS REFERENCE received ( fever, etc)
No. NUMBER Name Complete Address Dare of Birth Age Sex Slip (food, meds, previous No. Reasons
(Surname, First Name, MI) MM/DD/YY Refused
(LRN) Zero immunization)
dose MCV 1 MCV2 Y N Y N MCV1 MCV2 Td

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________________________________________________ ________________________________________________
Name and Signature of Teacher In-Charge Name and Signature of Vaccinator

________________________________________________ ________________________________________________
Name and Signature of Principal Name and Signature of Supervisor
 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 7 Students
Region: _______________________________ Name of School: ________________________________________________________ To be filled up by the Vaccination Team
MR
Province/City: _________________________ Division: _______________________ Section: ________________________ Lot No: _______________________
Batch No: _____________________
District/Municipality: ___________________ Date:__________________________ Td
Lot No: _______________________
Batch No.______________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents' Sick today?
Response Slip ( fever) Last Vaccine Given
LEARNERS REFERENCE History of allergies Menstrual Potentially
No. NUMBER Name Complete Address Dare of Birth Age Sex (food, meds, previous Period pregnant Deferred Refusal Reasons for Refusal
(LRN) (Surname, First Name, MI) MM/DD/YY immunization MR/Td) (for (Y / N)
Y N Y N FEMALES MR Td
only) (R arm) (L arm)

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________________________________________________ ________________________________________________
Name and Signature of Vaccinator
Name and Signature of Teacher In-Charge

________________________________________________ ________________________________________________

Name and Signature of Principal Name and Signature of Supervisor