School-Based Immunization

RECORDING Form 3: Masterlist of Grade 7 Students

Region: VII Name of School: Abellana National School To be filled up by the Vaccination Team
Province: Cebu Division: Cebu City MR
District: North Date: Lot No:
Section: 7-Azalea Batch No:
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 Vaccine

Response History of Today? Given

Deferred

Refusal
Date of Birth Slip Allergies (Fever) Last Menstrual Potentially
No. Name (1) Complete Address (2) Age Sex Period (for pregnant
(foods,meds,pre FEMALES only) (Y/N) MR Td
vious
(MM/DD/YY) Y N immunization Y N (R) (L)
MR/Td) arm arm

1 Bigno , Jake Gyrenduke Pluto St. Felina Village Tisa Cebu City 11/21/2006 12 M
2 Cadusale , Rainier 121 W.T Padilla St. T.Padilla Cebu City 08/03/2006 13 M
3 Comision , Lyle Shallum Sitio Lokana Kalunasan Cebu City 11/03/2006 12 M
4 Dela Calzada , Shian Ivan 29-U Mc-Arthur Blvd Tinago Cebu City 01/15/2007 12 M
#59 CSC, Happy Homes,
5 Famulagan , Jason Habitat Housing
Lawaan 3 Cebu City 05/17/2006 13 M
6 Frakes , Lewis Adrian Sitio San Miguel Lorega Cebu City 12/06/2005 13 M
7 Garcia , Joshua Sitio Panpanan Buhisan11 Cebu City 12/20/2006 12 M
Lapu-Lapu
8 Licanda , Deither Soong 1 Bankal Road Mactan
City
01/24/2007 12 M
9 Lobiano , Kent 155-O T. Padilla St. T.Padilla Cebu City 11/10/2007 11 M
10 Mailed , Hanz Christian Sitio Camparville Buhisan Cebu City 02/16/2007 12 M
11 Manalili , Kevin Breith 490-Natalio Bacalso Avenue Labangon Cebu City 10/21/2006 12 M
844-C T.Vila St. M.J. Cuenco
12 Mancao , Kirk Dustine Avenue
T.Padilla Cebu City 02/13/2007 12 M
13 Nacorda , Reyvien Adrian Nazareth Buhisan Buhisan Cebu City 02/24/2007 12 M
14 Orque , Stephen John 682, D Jakosalem St. Kamagayan Cebu City 07/16/2007 12 M
1085, M.J. Cuenco, Sitio
15 Patrocinio , Nathan Sambag
Tejero Cebu City 05/04/2007 12 M

16 Quezon , Nikki Justin Purok 4 Lower Camputhaw Camputhaw Cebu City 01/20/2006 13 M
 #18 CSC Happy Homes,
17 Rizon , Kelvin Christian Habitual Housing
Lawaan 3 Cebu City 10/29/2006 12 M

18 Rosell , DJ 1109 FMJ Cuenco Avenue Carreta Cebu City 01/11/2007 12 M

19 Sarigumba , Ezekiel Kawit, Ermita Ermita Cebu City 03/17/2007 12 M
20 Sedicol , Danilo Jr Ermita Proper Ermita Cebu City 08/19/2007 12 M
21 Tantay , Clark Arellano Blvd San Roque Cebu City 02/20/2007 12 M
22 Antalan Aimee Mohon,Sapangdaku Guadalupe Cebu City 12/06/2006 12 F
23 Bueno Alesson Rholf 88-C, Tangkongan Sambag 1 Cebu City 10/20/2006 12 F
24 Daguinotas Cherey Mae Tres De Abril,Victor Village Labangon Cebu City 11/23/2006 12 F
25 Derecho Kisha Mae 968 G.V. Rama Avenue Guadalupe Cebu City 04/15/2007 12 F
26 Dolotallas Venice 100 B. Aranas Ext. Duljo Fatima Cebu City 09/12/2007 11 F
27 Gajudo Sheen Xochil 35-B Ermita Proper Ermita Cebu City 06/03/2007 12 F
28 Gascal Casophia Unit 1 Kalunasan Kalunasan Cebu City 01/31/2007 12 F
29 Guererro Rica Jane Don Pedro Rodriguez Capitol Site Cebu City 11/06/2006 12 F
30 Henabio Jobieca Unit 4 Oprra Kawnasan Cebu City 12/09/2006 12 F
31 Iwayan Ishi Pfeiffer Ermita Ermita Cebu City 01/13/2007 12 F
32 Jayo Jasmine Gil Tudtud St.,Lahing Lahing Mabolo Cebu City 03/28/2007 11 F
33 Kasayan Venice Jane Jakosalem St. Cogon,Ramos Cebu City 10/11/2007 12 F
34 Labrador Lordalyn Kawit, Ermita Ermita Cebu City 06/11/2007 12 F
35 Niez Irish 31-C Urgello St. Urgello Cebu City 09/30/2006 12 F
36 Ramos Lyndzy Claydie 2237 Sitio Ipil-Ipil Capitol Site Cebu City 05/03/2007 11 F
37 Sayson Precious Cindy Filter Site Tisa Cebu City 10/31/2007 12 F
434 L-P, Natalio Bacalso
38 Suarez Rhica Jane Avenue
Sambag Cebu City 12/26/2006 12 F
39 Tabil Princess Leizel Greenbelt Drive Quiot, Pardo Cebu City 07/17/2007 12 F
40 Yap Ma. Caroline 615 D.R P.del Rosario Ext. Sambag 2 Cebu City 08/08/2007 12 F
41 Ybarita Naomi Shean Upper Kalunasan Iaya Kalunasan Cebu City 06/08/2007 12 F
42 Ylaya Camille Joy 639-D.C.Padilla St. Mambaling Cebu City 07/12/2006 13 F
216 V.Rama Ave.Sitio Lower
43 Zamora Charity Anne San Roque
Calamba Cebu City 11/08/2006 12 F

Name & Signature of Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2 Name & Signature of Recorder
accination Team

Reasons for
Refusal