School-Based Immunization

RECORDING Form 1: Masterlist of Students

Masterlist of Kinder 1 to Grade 7 (Except Grade 4)
Region: ____________________________ Name of School: ________________________________________________________ To be filled up by the Vaccination Team
MR
Province/City: _______________________ Division: _______________________
Section: ___________________ Lot No: _______________________
Batch No: _____________________
City/Municipality: ___________________ Date:__________________________ Td
Lot No: _______________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team

Date of previous MCV Parents' Sick today? Date Vaccine Given

received Response Slip ( fever) Last Menstrual
Date of Birth History of allergies Period Potentially Reasons for
No. Name (1) Complete Address (2) Age Sex (food, meds, previous pregnant Deferred Refusal
MM/DD/YY immunization MCV/Td) (for FEMALES (Y / N) Refusal
Zero only) Td
dose MCV 1 MCV 2 Y N Y N MCV 1 MCV 2 (for Grade 1
and 7 only)

10

11

12

13

14

15

________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
*MCV - Measles Containing Vaccine (Anti-measles Vaccine [AMV], Measles-Rubella [MR], Measles, Mumps, Rubella [MMR])
*Td - Tetanus-diptheria
 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 4 Students
Region: _______________________ Name of School: ________________________________________________________ To be filled up by the Vaccination Team
MR
Province/City: _________________ Division: ______________________
Grade: ___________________
Section: ___________________ Lot No: _______________________
Batch No: _____________________
District/Municipality: ___________ Date:__________________________ Td
Lot No:No.______________________
Batch _______________________
To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Date of previous MCV Parents' Sick today? Date Vaccine Given
received Response Slip ( fever)
History of allergies Last Menstrual Potentially HPV
Date of Birth
No. Name (1) Complete Address (2) MM/DD/YY Age Sex (food, meds, previous Period (for pregnant (for female 9 - 14 Deferred Refusal Reasons for Refusal
Zero immunization MCV/Td) FEMALES only) (Y / N) years old)
MCV 1 MCV 2 Y N Y N MCV 1 MCV 2
dose
1st 2nd
dose dose

10

11

12

13

14

15

________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
*MCV - Measles Containing Vaccine (Anti-measles Vaccine [AMV], Measles-Rubella [MR], Measles, Mumps, Rubella [MMR])
* HPV - Human Papillomavirus Vaccine
Annex A
School-Based Immunization
REPORTING Form 1 (FOR MCV ONLY):Municipality/City Consolidated Accomplishment Form Report
(for Kinder 1-2, Grades II ,III ,V and VI)
Region: ____________________________ Date Covered: ____________________________

City/Municipality: _________________________

Kinder 1 Kinder 2 GRADE II GRADE III GRADE V GRADE VI

Students Total no. Total no. Students Total no. Total no. Students Total no. Total no. Students Total no. Total no. Students Total no. Total no. Students Total no. Total no.
vaccinated w/ of of vaccinated w/ of of vaccinated w/ of of vaccinated w/ of of vaccinated w/ of of vaccinated w/ of of
NAME OF BARANGAY NAME OF SCHOOL Total no. MCV deferred refusal Total no. MCV deferred refusal Total no. MCV deferred refusal Total no. MCV deferred refusal Total no. MCV deferred refusal Total no. MCV deferred refusal
of of of of of of
students students students students students students
enrolled enrolled enrolled enrolled enrolled enrolled
No. % MCV MCV No. % MCV MCV No. % MCV MCV No. % MCV MCV No. % MCV MCV No. % MCV MCV
 Total

*MCV - Measles Containing Vaccine (Anti-measles Vaccine [AMV], Measles-Rubella [MR], Measles, Mumps, Rubella [MMR])
Annex B
School-Based Immunization
REPORTING Form 2 (FOR MCV, HPV and Td): Regional/Provincial/City Consolidated Accomplishment Form Report
(for Grades I, IV and VII)
Region: ____________________________
Date: ______________________________
Municipality/City: _________________________

Grade I Grade IV Grade VII

Students Students Students Total no. Students Students

vaccinated w/ vaccinated w/ Total no. of Total no. of vaccinated w/ of Total no. Students vaccinated w/ HPV Total no. of deferred Total no. of refusal vaccinated w/ vaccinated w/ Total no. of Total no. of
deferred refusal of refusal deferred refusal
Name of Barangay Name of Total no. MCV Td MCV deferred Total no. Total no. MCV Td
School of Total no. of of Female of
students
students enrolled students Total Total Total Total Total Total students
enrolled enrolled no. of no. of no. of no. of no. of no. of enrolled
No. % No. % MCV Td MCV Td No. % MCV MCV % % % % % % No. % No. % MR Td MR Td
1st 2nd 1st 2nd 1st 2nd
dose dose dose dose dose dose

Total

Prepared by: Noted by:

__________________________________________ ___________________________________________________
*MCV - Measles Containing Vaccine (Anti-measles Vaccine [AMV], Measles-Rubella [MR], Measles, Mumps, Rubella [MMR])
*Td - Tetanus-diptheria
* HPV - Human Papillomavirus Vaccine