Department of Health

REGION OFFICE VI
Expanded Program on Immunization

SCHOOL-BASED IMMUNIZATION MONITORING TOOL

Name of School: ______________________________ Municipality: ____________________

Division: _____________________________________ Province: _____________________
Distict: ______________________________________
Vaccination Team Members :
Target No. of Students: __________ No. of Supervisor : _____________
No. (%) of Students Vaccinated : ____________ No. of vaccinators : ____________
No. of Screener : ______________

OBSERVED OR
No. Items VERIFIED COMMENTS
YES NO
1 SOCIAL MOBILIZATION ACTIVITIES
1.a Are there IEC materials for School-Based Immunization ?
1.b Were preparatory activities such as orientation during PTA meetings
and faculty meeting, etc. implemented as planned ?
1.c Were the consent forms provided to the students at least 1 week
prior to the immunization schedule?

2 PREPAREDNESS AND SET UP AT VACCINATION SITE

2.a Are there adequate /appropriate signages directing to vaccination
site/room?
2.b Does the vaccination room/area have adeqaute space to
accommodate the students and the vaccination team?
2.c Are there adequate vaccination and injection supplies (syringes,
cotton balls, soap) for vaccination session ?
2.d Are there safety collector boxes and disposal bag/box for other waste
e.g. cotton balls ?
2.e Are there adequate recording forms and cards?
2.f Does the vaccination team knows where to refer patients with
Adverse event following immunization ?
2.g Is there an available epinephrine kit?

3 VACCINATION SESSION
3.a Is the vaccination flow systematic and well organized ?

3.b
Was the SBI Form ____ - Masterlist completely and properly filled up?
3.c Were all students for vaccination have signed consent ?
3.d
Were all students been properly screened prior to vaccination ?
3.e Observation during Vaccination

3.e.1 1. Did the Heath Worker (HW) check for the signed consent prior to
vaccination?
3.e.2 2. Did the Health Worker (HW) use an insulated carrier with
conditioned icepacks to keep vaccines in the correct temperature?
3.e.3 3. Did the HW use one sterile reconstituting syringe with needle per
vial or ampule?
3.e.4 4. Did the HW use Auto Disabled (AD) syringe?
3.e.5 5. Was aseptic technique on the injection site observed prior to
vaccination?
3.e.6 6. Were the vaccines (MR/Td) given in the correct route of
administration?
3.e.7 7. Was there recapping of needle?
3.e.8 8. Were there pre-filled syringes ?

Department of Health
REGION OFFICE VI
Expanded Program on Immunization

SCHOOL-BASED IMMUNIZATION MONITORING TOOL

Name of School: ______________________________ Municipality: ____________________

Division: _____________________________________ Province: _____________________
Distict: ______________________________________

3.e.9 9. Were the needles and syringes disposed of into the

recommended disposal unit?
3.e.10 Were
10. Were the vaccines
the students submerged
observed in water?for possible adverse
after vaccination
3.f reaction?
3.g Were the vaccination card properly filled up and given to the
students?
3.h
Were the vaccination recording and reporting forms poperly filled up?
3.i Identify reasons for not vaccinated :

4 POST-VACCINATION
4.a Were all opened and unopened vaccines left after vaccination
properly stored and accounted for?
4.b.
Was there an identified area to dipose used needles and syringes?

5 AEFI
5.a Was there any Adverse Event Following Immunization (AEFI)
encountered by the Vaccination Team- _
5.b Was this reported to the City/Rural Health Center (Yes/No) ?
5.c Was this AEFI investigated ?
5.d What was the outcome of the AEFI case ( e.g. died, hospitalized,
improved, etc. )
 Remarks: ______________________________________________________________________________
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Name and Signature of Monitor: ________________________________________

ing : ______________________
2 PRE-VACCINATION
Ask about timely receipt of adequate supply of vaccines,
2.1 supplies, safety bozes, recording forms at district and
health center
2.2 Record date of vaccine receipt at municipal health center Record Date of vaccine receipt: ____/

2.3 Refrigerator /cold box temperature charts at health center

show storage between 2-80C and temprecorded 2x per day
2.4 Vaccine expiration date documented MR: __/__/__
Appropriate preparation and transport of vaccine to
2.5 vaccination site (prep of cold box using ice packs, checking
of temperature
2.6 How many health workers helped to prepare the vaccines? No. of Health workers: _____
ate of vaccine receipt: ____/____/____

Td: __/__/__ HPV: __/__/__

alth workers: _____