School-Based Immunization

RECORDING Form 2: Masterlist of Grade _______ Students

Region: _____________________________________ Name of School: __________________________ To be filled up by the Vaccination Team

Province/City: _______________________________ Division:_____________ Section: _____________ MR
District/Municipality: ________________________ Date: __________________________ Lot No: __________________
Batch No:________________
Td
Lot No: __________________
Batch No:________________

To be filled up by the School Nurse/Class Adviser

Parents' Sick today? Vaccine Given
Response Slip (fever) Last
History of allergies Menstual
Date of Birth (food, meds, previous Potentially
No. Name (1) Complete Address (2) MM/DD/YY Age Sex immunization Period (for pregant (Y/N) Deferred
FEMALES
(MR/Td) only) MR (R Td (L
Y N Y N arm) arm)

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___________________________ ___________________________ _____________________________ __________________________
Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
To be filled up by the Vaccination Team

Lot No: __________________

Batch No:________________

Lot No: __________________

Batch No:________________

Refusal Reasons for Refusal

__________________________
Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 4 Students (9-13 yrs. Old)

Region: _____________________________________ Name of School: __________________________ To be filled up by the Vaccination Team

Province/City: _______________________________ Division:_____________ Section: _____________ HPV
District/Municipality: ________________________ Date: __________________________ Lot No: __________________
Batch No:________________

To be filled up by the School Nurse/Class Adviser

Parents' Sick today? Date of HPV Vaccine
Response Slip (fever) Given
History of allergies
Date of Birth (food, meds, previous
No. Name (1) (Surname, First Name, MI) Complete Address (2) MM/DD/YY Age Sex immunization Deferred Refusal
(MR/Td)
Y N Y N 1st dose 2nd dose

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___________________________ ___________________________ _____________________________
Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2

___________________________ ______________________________
Name and Signature of Recorder Name and Signature of Recorder
ed up by the Vaccination Team

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:________________

Reasons for Refusal

 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 7 Students

Region: IV-A CALABARZON Name of School: DR. ALCANTARA NATON AL HIGH SCHOOL
Province/City: BATANGAS Division:TANAUAN Section: AGONCILLO
District/Municipality: TANAUAN CITY Date: SEPTEMBER 4, 2019

To be filled up by the School Nurse/Class Adviser

Parents' Sick today?
Response Slip (fever) Last
History of allergies Menstual
Date of Birth (food, meds, previous Potentially
No. Name (1) Complete Address (2)
MM/DD/YY Age Sex immunization
Period (for
pregant (Y/N)
FEMALES
(MR/Td)
Y N Y N only)

1 ALCANTARA,JIAN CLYDE, ULEP MABINI, TANAUAN CITY, BATANGAS 12-21-2006 12 M

2 AZUL,KURT JERIST, TAÑO TINURIK, TANAUAN CITY, BATANGAS 08-25-2007 11 M
3 BARRION,BRADFORD IVAN, RAMOS BOOT, TANAUAN CITY, BATANGAS 07-10-2007 11 M /
4 CABRERA,LLOYD ERVIN, ROBERT MABINI, TANAUAN CITY, BATANGAS 05-27-2007 12 M /
5 CADANO,BENJAMIN, III GARCIA MABINI, TANAUAN CITY, BATANGAS 07-21-2007 11 M /
6 CATAPANG,JHOMAR, BALBA BAGBAG, TANAUAN CITY, BATANGAS 10-28-2007 11 M /
7 CONTRERAS,KYLE KERVIN, CATIMBANG BAGBAG, TANAUAN CITY, BATANGAS 05-18-2007 12 M /
8 ELIC,JHUN ERWIN, TIPONO BAGBAG, TANAUAN CITY, BATANGAS 03-07-2007 12 M
9 FAUNE,ANGELO BENEDICTO, FALCESO MABINI, TANAUAN CITY, BATANGAS 01-03-2007 12 M
10 GALVAN,JOSEPH, BRAZAL MABINI, TANAUAN CITY, BATANGAS 06-12-2005 13 M
11 HAGAD,JULIAN, OBUSA MABINI, TANAUAN CITY, BATANGAS 12-13-2006 12 M /
12 LAXAMANA,EDGIE, RAMIRO MABINI, TANAUAN CITY, BATANGAS 02-11-2007 12 M /
13 LLONADO,ARWIN JOSEPH, LOSA MABINI, TANAUAN CITY, BATANGAS 04-05-2007 12 M
14 MAGTIBAY,JOSH VION, LUCINE MABINI, TANAUAN CITY, BATANGAS 09-04-2007 11 M
15 MANOJO,RB, UMALI MABINI, TANAUAN CITY, BATANGAS 04-21-2006 13 M /
16 MERCADO,MARK KERBIE, SANTELICES MABINI, TANAUAN CITY, BATANGAS 09-27-2007 11 M /
17 MILLAREZ,LLOYD STEVEN, LUSTADO MABINI, TANAUAN CITY, BATANGAS 03-16-2007 12 M /
18 RESURRECCION,NHIEL ABIEL, CUPINO MABINI, TANAUAN CITY, BATANGAS 07-12-2007 11 M /
19 RIVERA,RAYVEN JAY, DEL MUNDO BAGBAG, TANAUAN CITY, BATANGAS 03-22-2007 12 M
20 SILVA,MIKEL SELWYN REX, PIALAGO BAGBAG, TANAUAN CITY, BATANGAS 01-13-2007 12 M /
21 VILLEGAS,STEVEN JOSH, REYES MABINI, TANAUAN CITY, BATANGAS 06-17-2007 11 M
22 YABUT,XEAN YAUN, DELOS REYES MABINI, TANAUAN CITY, BATANGAS 02-20-2007 12 M
23 ADAYO,MARY ROSE, - MABINI, TANAUAN CITY, BATANGAS 12-24-2006 12 F /
24 ALCANTARA,YLONNA, ABBANG MABINI, TANAUAN CITY, BATANGAS 03-27-2007 12 F /
25 BUENAFLOR,ERAH STEFANIE, GUTIERREZ MABINI, TANAUAN CITY, BATANGAS 12-19-2006 12 F /
26 DOLINOG,JINKY, DELAS ALAS BAGBAG, TANAUAN CITY, BATANGAS 04-23-2007 12 F /
27 EVANGELISTA,ANDREA GRACE, TRANCO BAGBAG, TANAUAN CITY, BATANGAS 02-03-2007 12 F /
28 ISAAC,JOSHANE MAE, MANALO MABINI, TANAUAN CITY, BATANGAS 07-09-2007 11 F /
29 JAVIER,SHAYNE, SANTIA MABINI, TANAUAN CITY, BATANGAS 09-27-2007 11 F /
30 MACALINGA,TRISHA MAE, UMALI MABINI, TANAUAN CITY, BATANGAS 08-14-2007 11 F
31 PASCUAL,FAYSAH, ALCANTARA MABINI, TANAUAN CITY, BATANGAS 01-11-2007 12 F /
32 PLAC,KYLE JOY, OLIVA BAGBAG, TANAUAN CITY, BATANGAS 08-30-2007 11 F /
33 SUMINTAC,ANGEL MAE, CALOOY BAGBAG, TANAUAN CITY, BATANGAS 08-13-2007 11 F /
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___________________________ ___________________________ _____________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
 To be filled up by the Vaccination Team
MR
Lot No: __________________
Batch No:________________
Td
Lot No: __________________
Batch No:________________

Vaccine Given

Deferred Refusal Reasons for Refusal

MR (R Td (L
arm) arm)
____________ __________________________
Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 7 Students

Region: IV-A CALABARZON Name of School: DR. ALCANTARA NATON AL HIGH SCHOOL
Province/City: BATANGAS Division:TANAUAN Section: DIOKNO
District/Municipality: TANAUAN CITY Date: SEPTEMBER 4, 2019

To be filled up by the School Nurse/Class Adviser

Parents' Sick today?
Response Slip (fever) Last
History of allergies Menstual
Date of Birth (food, meds, previous Potentially
No. Name (1) Complete Address (2)
MM/DD/YY Age Sex immunization
Period (for
pregant (Y/N)
FEMALES
(MR/Td)
Y N Y N only)

1 ABDON,RENZ GANI, BORJAL POBLACION, CANDELARIA, QUEZON 10-10-2007 11 M /

2 ALCANTARA,ACHILLES SHAWN, PARREÑO MABINI, TANAUAN CITY, BATANGAS 09-14-2007 11 M /
3 ALCANTARA,THOM RANCEL, STA ANA MABINI, TANAUAN CITY, BATANGAS 03-07-2007 12 M
4 BARILLOS,JEMUEL, CATAMORA BAGBAG, TANAUAN CITY, BATANGAS 05-25-2007 12 M /
5 CATAN,REGGIE, LINDO MABINI, TANAUAN CITY, BATANGAS 12-24-2005 13 M
6 COMIA,JOHN PATRICK, MACUHA BAGBAG, TANAUAN CITY, BATANGAS 10-21-2007 11 M
7 EVANGELISTA,NEIL LAWRENCE, DUMALAOG BAGBAG, TANAUAN CITY, BATANGAS 03-21-2007 12 M /
8 GUTIERREZ,ALTHEO NYKKOS, MONCAYO BAGBAG, TANAUAN CITY, BATANGAS 09-02-2007 11 M /
9 HADRAQUE,JERVIE, - MABINI, TANAUAN CITY, BATANGAS 01-02-2007 12 M /
10 HAGAD,RGIE, BORLAZA MABINI, TANAUAN CITY, BATANGAS 08-23-2007 11 M /
11 KATIGBAK,ALJUR, RAMOS MABINI, TANAUAN CITY, BATANGAS 10-31-2007 11 M /
12 LADIP,JULIUS, SAN ANTONIO MABINI, TANAUAN CITY, BATANGAS 10-02-2003 15 M
13 MAGDAMIT,MARK CARLO, KATIGBAC MABINI, TANAUAN CITY, BATANGAS 02-23-2007 12 M /
14 MANABE,CARL-JAY, GONZALES MABINI, TANAUAN CITY, BATANGAS 09-12-2007 11 M
15 MANIMTIM,JOHN LAWRENCE, CONTRERAS BAGBAG, TANAUAN CITY, BATANGAS 09-22-2007 11 M /
16 MENDOZA,ANDRAE JERALD, ALCANTARA MABINI, TANAUAN CITY, BATANGAS 07-19-2007 11 M /
17 MERCADO,CHRISTIAN, BUAYA MABINI, TANAUAN CITY, BATANGAS 09-24-2007 11 M /
18 MOREDO,JEMUEL KYLE, SATAIRAPAN POBLACION, BRGY.1, TANAUAN CITY, BATANGAS 10-09-2007 11 M
19 SILVESTRE,JOHN DRANREB, MERCADO MABINI, TANAUAN CITY, BATANGAS 04-14-2007 12 M
20 SIMAN,CHRISTIAN, BARANGGOT BAGBAG, TANAUAN CITY, BATANGAS 05-02-2007 12 M /
21 TORRES,YANZEI, CAYETANO MABINI, TANAUAN CITY, BATANGAS 03-28-2007 12 M /
22 ALCANTARA,MIA, GEBILAGIN MABINI, TANAUAN CITY, BATANGAS 10-31-2006 12 F /
23 CASTILLO,RHONA MAE, LANZO MABINI, TANAUAN CITY, BATANGAS 01-21-2007 12 F /
24 CRUZ,JOSA, BINETEZ MABINI, TANAUAN CITY, BATANGAS 09-24-2007 11 F /
25 DELA TORRE,AQUEENA ANGEL PEARL, MACATANGAY BAGUMBAYAN, TANAUAN CITY, BATANGAS 01-28-2007 12 F
26 GADIANO,MARY GRACE, SERENO MABINI, TANAUAN CITY, BATANGAS 08-11-2007 11 F /
27 GLINOGO,MARY ANN, RAMENTO BAGBAG, TANAUAN CITY, BATANGAS 08-30-2005 13 F /
28 GONZALES,ANGEL, PORTO TINURIK, TANAUAN CITY, BATANGAS 02-24-2007 12 F /
29 GUTIERREZ,ANNE, MECINA MABINI, TANAUAN CITY, BATANGAS 12-04-2006 12 F /
30 JAVIER,STEPHANIE JANE, CANSING BAGBAG, TANAUAN CITY, BATANGAS 11-25-2006 12 F /
31 LEYNES,ALTHEA, PEREDA MABINI, TANAUAN CITY, BATANGAS 05-10-2007 12 F /
32 PANCHO,NICOLE QUEROBIN, BRIONES BRGY. 743, MALATE, MANILA 04-15-2007 12 F /
33 PEREZ,KIM, VILLANUEVA BAGBAG, TANAUAN CITY, BATANGAS 05-07-2007 12 F /
34 REFORMADO,ERICKA NICOLE, EXCIJA MABINI, TANAUAN CITY, BATANGAS 01-24-2007 12 F /

___________________________ ___________________________ _____________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
 To be filled up by the Vaccination Team
MR
Lot No: __________________
Batch No:________________
Td
Lot No: __________________
Batch No:________________

Vaccine Given

Deferred Refusal Reasons for Refusal

MR (R Td (L
arm) arm)
____________ __________________________
Name and Signature of Recorder