School-Based Immu

MASTERLIST OF LEARNER

Regio I Name of School: _____________ TABOC ELEMENTARY SCHOOL

Provi LA UNION Section: I-C

Distr SAN JUAN Date: JULY 26, 2019

To be filled up by the School Nurse/ Class Adviser

Date of previous MCV
Name (1) Dare of Birth received
No. Complete Address (2) Age Sex
(Surname, First Name, MI) MM/DD/YY
Zero
Dose MCV 1

1 BALNEG,ROBYLENE, PABILLONAR TALOGTOG, SAN JUAN, LA UNION 7/30/2012 6 F

2 BUENAVENTE,IRISH, LADIA TALOGTOG, SAN JUAN, LA UNION 08-16-2012 6 F

3 CABANBAN,ARRIANE JOYCE, GANADEN TALOGTOG, SAN JUAN, LA UNION 09-06-2012 6 F

4 CAYETANO,HENIE ROSE, SOLMORO TABOC, SAN JUAN, LA UNION 10-17-2012 6 F

5 CUSIPAG,JESSICA MAE, GALICIA TABOC, SAN JUAN, LA UNION 11-12-2011 7 F

6 DELA CRUZ,SAMANTHA KAYE, - TABOC, SAN JUAN, LA UNION 11-29-2012 6 F

7 FELICIANO,RYONAH ANNE, GUTIERREZ TALOGTOG, SAN JUAN, LA UNION 09-17-2012 6 F

8 GAGTO,ANICA JOY, AGADER TALOGTOG, SAN JUAN, LA UNION 10-18-2012 6 F

9 GARCIA,CHELSEA AUDREY, SARANQUIN TABOC, SAN JUAN, LA UNION 04-04-2013 6 F

10 JUMAWID,PRINCESS JHOREN, PABILLONAR TALOGTOG, SAN JUAN, LA UNION 09-10-2012 6 F

11 NONAN,RUBY ANN, PABILLONAR TALOGTOG, SAN JUAN, LA UNION 03-19-2013 6 F

12 PIMENTEL,JOLINA, ESPINA TALOGTOG, SAN JUAN, LA UNION 10-21-2011 7 F

13 VELASCO,XHEATINA CRISTIN, CACCAM TABOC, SAN JUAN, LA UNION 08-08-2013 5 F

Name and Signature of Supervisor Name and Signature of Vaccinator 1
School-Based Immunization
TERLIST OF LEARNERS GRADE I-C
To be filled up by the Vaccination Team
MR
Lot No: _______________________
Batch No: _____________________
Td
Lot No: _______________________
Batch No.______________________
Total no. of Grade 1 students:_______________
Total no. of MR vaccine given:_______________
Total no. of Td vaccine given:_______________
Total no. of children vaccinated:_____________
Total no. of deferred: ______________________
Total no. of refusal: _______________________

To be filled up by the Vaccination Team

previous MCV Parents' Sick today?
eceived Response Slip History of allergies ( fever, etc) Vaccine Given
(food, meds, previous Refusal
immunization)
Y N Y N MCV1 MCV2 Td
MCV2 (L arm)
 _____________________________
Name of and Signature of Vaccinator 2 Name and Signature of Recorder
Reasons
 School-Based Immunization
MASTERLIST OF LEARNERS GRADE I-C
To be filled up by the Vaccination Team
Regio I Name of School: ______________ TABOC ELEMENTARY SCHOOL MR
Lot No: _______________________ Total no. of Grade 1 students:_______________
Provi LA UNION Section: I-C Batch No: _____________________ Total no. of MR vaccine given:_______________
Total no. of Td vaccine given:_______________
Distr SAN JUAN Date: JULY 26, 2019 Td Total no. of children vaccinated:_____________
Lot No: _______________________ Total no. of deferred: ______________________
Batch No.______________________ Total no. of refusal: _______________________

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?
received Response Slip History of allergies ( fever, etc) Vaccine Given
Name (1) Dare of Birth
No. (Surname, First Name, MI) Complete Address (2) MM/DD/YY Age Sex (food, meds, previous Refusal Reasons
Zero immunization)
Y N Y N MCV1 MCV2 Td
Dose MCV 1 MCV2 (L arm)

1 BANIQUED,RENNIEL, SABADO TABOC, SAN JUAN, LA UNION 2/7/2013 6 M

2 CABADING,JAMES CARL, CABANBAN TALOGTOG, SAN JUAN, LA UNION 8/24/2013 5 M

3 CASUGA,MARLON, DUCLAYAN TALOGTOG, SAN JUAN, LA UNION 9/5/2012 6 M

4 CINCO,JIMUEL, CATINDOY TABOC, SAN JUAN, LA UNION 12/30/2011 7 M

5 COLLADO,FEYL CARLITO, COSTALES TABOC, SAN JUAN, LA UNION 5/19/2013 6 M

6 DAMASCO,ARCHIE, CABADING TABOC, SAN JUAN, LA UNION 10/14/2011 7 M

7 HERNANDEZ,RODHEN, AGADER TALOGTOG, SAN JUAN, LA UNION 3/13/2013 6 M

8 LANA,FREDRICH JOHANNES, PASCUAL TABOC, SAN JUAN, LA UNION 6/11/2012 6 M

9 LIPAR,JORDAN STEPHEN, LAUREA TABOC, SAN JUAN, LA UNION 5/28/2013 6 M

10 MEDINA,MARK ALJHUR, RIMAS TALOGTOG, SAN JUAN, LA UNION 9/13/2012 6 M

11 OPRIDO,IAN MICHAEL, CATBAGAN TALOGTOG, SAN JUAN, LA UNION 11/28/2012 6 M

12 OSANO,CARSON, OPLE TALOGTOG, SAN JUAN, LA UNION 3/25/2013 6 M

13 PUMARES,LANZ IVAN, ABAYA TALOGTOG, SAN JUAN, LA UNION 9/25/2012 6 M

14 SARANQUIN,NORLAN JR, BARO TABOC, SAN JUAN, LA UNION 3/5/2013 6 M

15 SEMIC,REIVEN DYLAN, ABAYA TALOGTOG, SAN JUAN, LA UNION 8/19/2013 5 M

16 TABAT,VIEN ALLEN, CLARO TABOC, SAN JUAN, LA UNION 10/5/2012 6 M

17 YLLERA,DENVER, CARMELO TABOC, SAN JUAN, LA UNION 8/3/2013 5 M

_____________________________
Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name of and Signature of Vaccinator 2 Name and Signature of Recorder
 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: _________________________ Section: _______________________ Lot No: _______________________
Batch No: _____________________
District/Municipality: ___________________ Date:__________________________
Td
Lot No: _______________________
Batch No.______________________
Total no. of Grade 7 students:_______________
Total no. of MR vaccine given:______________
Total no. of Td vaccine given:_______________
Total no. of children vaccinated:_____________
Total no. of deferred: ______________________
Total no. of refusal: _______________________
Total no. of female with
sexual contact in the past 4 wks.: ____________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents' Sick today?
Response History of allergies Vaccine Given
( fever)
Slip (food, meds, Last Menstrual
Dare of Birth Potentially
No. Name (1) Complete Address (2) Age Sex previous Period (for Deferred Refusal Reasons for Refusal
MM/DD/YY
Y N immunization Y N FEMALES only) Pregnant (Y/N)
MR/Td) MR Td
(R arm) (L arm)

10

11

12

13

14

15

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name of and Signature of Vaccinator 2 Name and Signature of Recorder
 RECORD
Region: _______________________________ Name of School: ________________________

Province/City: _________________________ Section: _______________________

District/Municipality: ___________________ Date:__________________________

To be filled up by the School Nurse/ Class Adviser

Name (1) (Surname, First

No. Complete Address (2)
Name, MI)

10
11

12

13

14

15

Name and Signature of Supervisor

 School-Based Immunization
RECORDING Form: Masterlist of Grade 4 FEMALE Students (9-13 yrs. old)
_____________________________________________________ To be filled up by the V
HPV
_____________ Lot No: __________
Batch No: ________
______________

Class Adviser
Parents' Response Sick today?
Date of Birth Slip ( fever)
Age Sex
MM/DD/YY History of allergies (food,
Y N meds, previous immunization) Y
Name and Signature of Vaccinator 1 Name of and Signature of Vaccinator 2
(1st Dose) (2nd Dose)
-13 yrs. old)
To be filled up by the Vaccination Team

Lot No: __________

Batch No: ________

To be filled up by the Vaccination Team

Sick today? Date of HPV Vaccine Given
( fever)

N 1st dose 2nd dose

 Total no. of Grade 4 eligible:___________________
Total no. of 1st dose of HPV vaccine given:_______
Total no. of 2nd dose of HPV vaccine given:______
Total no. of children vaccinated:________________
Total no. of deferred: _________________________
Total no. of refusal: __________________________

y the Vaccination Team

Remarks
Name and Signature of Recorder

Region: _______________________________
Province/City: _________________________
District/Municipality: ___________________
School-Based Immunization
RECORDING Form 2: Masterlist of Grade 4 FEMALE Students (9-13 yrs. old)
Name of School: ________________________________________________________ To be filled up by the Vaccination Team
HPV Total no. of Grade 4 eligible:___________________
Section: _______________________ Lot No: __________ Total no. of 1st dose of HPV vaccine given:_______
Batch No: ________ Total no. of 2nd dose of HPV vaccine given:______
Date:__________________________ Total no. of children vaccinated:________________
Total no. of deferred: _________________________
Total no. of refusal: __________________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents' Response Sick today? Date of HPV Vaccine Given
No. Name (1) (Surname, First Complete Address (2) Date of Birth Age Sex Slip ( fever) Remarks
Name, MI) MM/DD/YY History of allergies (food,
Y N meds, previous immunization) Y N 1st dose 2nd dose

10

11

12

13

14

15

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name of and Signature of Vaccinator 2 Name and Signature of Recorder
(1st Dose) (2nd Dose)