Annex (Memo 198)

Republic of the Phillipines

Department of Education
Region VI-Western Visayas
Division of Negros Occidental
District of CAUAYAN II
NAME OF SCHOOL

Address of School Address of Priority Current Allergy to With

Current Residence Vaccine
Name of School (City or School Email Address Group Last Name First Name Middle Name Suffix Contact Number
(City/Municipality)
Residence(Ba Components Copmorbidities
Municipality) (Baranggay) (A1-A5) ranggay) (Yes/No)
(Yes/No)

Prepared by: Noted by:

School Clinic Teacher Principal 1

nstructions how to fill up:

1. Fill up legibly
2. Use DepEd Email Address
3. For Priority Group:
a. A1 – For school personnel with PRC License for allied health professions (e.g. Nurse, Physical Therapist, Medtech etc.)
b. A2 – For school personnel age 60 years old and above
c. A3 – For school personnel 59 years old and blow with medical conditions (e.g. chronic respiratory illness, hypertension etc.)
d. A4 – All Education Frontliners; Teaching and Non-Teaching Personnel who are at risk of exposure to Covid 19 due to the nature of their duties and responsibilities
e. A5 – For school personnel who belong to the economically marginalized sectors
4. Please write correct contact number and email address, the LGU might contact you for vaccination schedule using the given contact number and email
5. Allergy to vaccine component means: allergy to components of vaccine (e.g. PEG – Polyethylene Glycol, etc. NOT – Food or Drug Allergies, if you have no documented allergies against vaccine components do not answer YES)
6. Answer YES if you have medical co-morbidites, or NO if you have none.

Note:
School Personnel have a choice of vaccination whether LGU of residence or LGU of address of school or workplace.
Even though this form will be submitted to the LGU by the school head, the individual School Personnel must register personally and individually at their vaccination LGU of choice