Region: ________________________________

Province/City : __________________________
Municipality:____________________________
Name of Facility:_________________________
Date: _________________________________

Grade I

Students Students
vaccinated vaccinated Total no. of deferred Total no. of refusal
w/ MCV w/ Td
No. of
School Total no. of
students
enrolled
No. % No. % MCV % Td % MCV % Td %
Total
 School-Based Immunization
REPORTING Form 5: Municipal/ City Consolidated Accomp

Grade IV FEMALE Students (9-13 yrs. old)

No. of female students vaccinated Total no. of deferred

Total no. of
female students
enrolled
1st dose of 2nd dose 1st dose of 2nd dose
% % % %
HPV of HPV HPV of HPV
n
ccomplishment Form

Grade VII

Students Students
Total no. of refusal vaccinated w/ vaccinated Total no. of
w/ Td
MR
Total no. of
students
enrolled
1st dose of 2nd dose
% % No. % No. % MR
HPV of HPV
Grade VII

Total no. of deferred Total no. of refusal

% Td % MR % Td %
Region: ___________________________
Province: __________________________
Date: ____________________________

Grade I

Total no. of Students Students

Municipality/ City schools vaccinated w/ vaccinated w/ Total no. of d
Total no. of MCV Td
covered students
enrolled
No. % No. % MCV
Total
 School-Based Immunizatio
REPORTING Form 6: Provincial Consolidated A

Grade I Grade IV

Total no. of deferred Total no. of refusal No. of female students vaccinated
Total no.
of female
enrolled
1st dose 2nd dose
% Td % MCV % Td % % %
of HPV of HPV
unization
dated Accomplishment Form

Grade IV FEMALE Students (9-13 yrs. old)

Students
Total no. of deferred Total no. of refusal vaccinated w/
Total no. of MR
students
enrolled
1st dose 2nd dose 1st dose 2nd dose
% % % % No.
of HPV of HPV of HPV of HPV
 Grade VII

Students Students
accinated w/ vaccinated w/ Total no. of deferred Total no. of refusal
MR Td

% No. % MR % Td % MR % Td %
Region: ____________________________

Province/City: _________________________

Grade I

Students Students Total no. o

Total no. vaccinated vaccinated
Total no. w/ MCV deferred
of w/ Td
Province/ City
schools of
covered students
enrolled

No. % No. % MC
V %
 Total

* All deferred students who submitted for vaccination shall be recorded in Recording Form1-3
 School-Based Immunization
REPORTING Form: Regional/Provincial/City Consolidated Accom

Grade IV FEMALE Students (9

al no. of Total no. of No. of female students

Total no. of d
ferred refusal vaccinated
Total no.
of
enrolled
1st 2nd 1st
Td % MC
V % Td % dose % dose % dose %
of HPV of HPV of HPV
Form1-3 and reported using Reporting Form
ccomplishment Form Report

nts (9-13 yrs. old) Gra

Students Students
of deferred Total no. of refusal vaccinate vaccinate
Total no. d w/ MR d w/ Td
of
students
enrolled
2nd 1st 2nd
dose % dose % dose % No. % No. %
of HPV of HPV of HPV
 Date: ______________________________

Grade VII

Total no. of
Total no. of refusal
deferred

MR % Td % MR % Td %