REPUBLIKA ng PILIPINAS

Rehiyon VII

SULAT PAHIBALO

DIVISION: CEBU PROVINCE

SCHOOL:
ADDRESS:
DATE:
STUDENT's NAME:
STUDENT's ADDRESS:
NAME of PARENT / GUARDIAN:

Tinahod namong mga Ginikanan / Guardian ,

Ang Departamento sa Edukasyon inubanan sa Departamento sa Panglawas ug sa Local nga

Pangagamhanan magpasiugda ug dakung kalihokan sa pagpamakuna sa atong kabataan ug kabatan-onan
nga walay bayad batok sa tipdas, tetanus, luas sa kabaw kon Dipthteria.

Kini nga tulungha-an uban sa lokal nga buhatan sa maayong panglawas mohatag ug serbisyo alang sa
pagbakuna sa mga tinun-an nga makita sa mga kahon nga gi-markahan sa ubos;

Grade 1 (MCV, Td)

Grade 4 (HPV 2 doses)
Grade 7 (Td, MR)

Ipahigayon kini sa tibuok bulan sa Agosto niining tuig 2018. Kining sulata gipadala aron sa
pagpahibalo kaninyo mahitungod sa maong kalihokan. Palihug ug marka sa kahon nga makita sa ubos ani nga
sulat alang sa inyong tubag sa pag-uyon o dili sa pagpabakuna.

Alang sa dugang pangutana o impormasyon mahitungod niini, palihog sa pagpakisayod sa Principal sa

tulunghaan o sa Lokal Pangagamhanan sa maayong panglawas.

Daghang salamat.

Kanim matinud-anon, Kanimo matinud-anon,

Ngalan ug Pirma sa School Head / Principal

TUBAG / SANONG SA SULAT O PAGTUGOT

Agi ug pagsanong sa Sulat Pahibalo mahitungod sa pagahimoong Pamakuna sa tunghaan diin nagtung-ha
ang ako anak, ako nakabasa ug nakasabot sa gipahibalo nga pagpamakuna.
 Ako nagatugot nga ang akong anak __________________________________________ mabakunahan.
(Pangalan sa Bata)

Ako dili motugot, tungod kay .

Ngalan ug Pirma sa Magtutudlo Ngalan ug Pirma sa Ginikanan / Guardian

ANNEX A
SCHOOL - BASED IMMUNIZATION
REPRTING FORM (FR MCV / MR, HPV and Td): REGIONAL / PROVINCIAL / CITY CONSOLIDATED ACCOMPLISHMENT FOR

REGION: VII
PROVINCE / CITY:

GRADE 1 GRADE IV
Total No. Total No. Students Students Total No. STUDENTS VACINATED w/ TOTAL No. of DEFERRED TOTAL No. of RE
Province / City / of of of HPV
Vaccinated Vaccinated Total No. of Deferred Total No. of Refusal
Municipality Schools Students w/ MCV w/ Td Students TOTAL TOTAL TOTAL TOTAL TOTAL
Covered Enrolled Enrolled No. of 1st % No. of 2nd % No. of 1st % No. of 2nd % No. of 1st
No. % No. % MCV % Td % MCV % Td % DOSE DOSE DOSE DOSE DOSE

TOTAL

* ALL DEFERRED STUDENTS WHO SUBMITTED FOR VACCINATION SHALL BE RECORDED IN RECORDING FORM 1-3 AND REPORTED U
BASED IMMUNIZATION
/ PROVINCIAL / CITY CONSOLIDATED ACCOMPLISHMENT FORM REPORT

DATE:

GRADE IV GRADE VII

TOTAL No. of REFUSAL Total No. Students Students

of Vaccinated Vaccinated Total No. of Deferred Total No. of Refusal
TOTAL Students w/ MR w/ Td
% No. of 2nd % Enrolled
DOSE No. % No. % MR % Td % MR % Td %

L BE RECORDED IN RECORDING FORM 1-3 AND REPORTED USING REPORTING FORM 1.

 SCHOOL-BASED IMMUNIZATION
RECORDING FORM1: MASTERLIST of GRADE 1 STUDE

REGION: VII NAME of SCHOOL:

PROVINCE / CITY: CEBU DIVISION: CEBU PROVINCE
DISTRICT / MUNICIPALITY: DATE: SECTION:

DATE F PREVIOUS
MCV RECEIVED PARENT's
DATE of BIRTH
No. NAME (1) COMPLETE ADDRESS (2) AGE SEX RESPONSE
ZERO
MCV1 MCV2
MM/DD/YY DOSE Y

10

11

12

13

14

15

NAME and SIGNATURE OFO SUPERVISOR NAME and SIGNATURE of VACCINATOR 1 NAME and SIGNATURE of VAC
L-BASED IMMUNIZATION
MASTERLIST of GRADE 1 STUDENTS
To be filled up by the Vaccination team
MR Td
LOT No.: LOT No.:
BATCH No.: BATCH No.:

PARENT's HISTORY of SICK TODAY?

REFUSAL
ALLERGIES (food, VACCINE GIVEN
RESPONSE REASONS
meds, previous (fever)
immunization, MR, Td)
N Y N MCV1 MCV2 Td

NAME and SIGNATURE of VACCINATOR 2 NAME and SIGNATURE of RECORDER

 SCHOOL - BASED IMMUNIZATION
RECORDING FORM 2: MASTERLIST of GRADE 4 FEMALE STUDENTS ( 9 - 13 yrs

REGION: VII NAME of SCHOOL:

PROVINCE / CITY: CEBU DIVISION: CEBU PROVINCE
DISTRICT / MUNICIPALITY: DATE: SECTION:

To be filled up by the School Nurse / Class Adviser

PARENT's HISTORY o
DATE of BIRTH ALLERGIES (f
No. NAME (1) (SURNAME, FIRST NAME. MI COMPLETE ADDRESS (2) AGE SEX RESPONSE
meds, previou
immunization)
MM/DD/YY Y N
1

10

11

12

13

14

15

Name and Signature of Vaccinator1

Name and Signature of Supervisr Name and Signature oof Recorder

L - BASED IMMUNIZATION
ST of GRADE 4 FEMALE STUDENTS ( 9 - 13 yrs. Old)
To be filled up by the Vaccination team
HPV
LOT No.:
BATCH No.:

To be fiiled up by the Vaccination Team

SICK

DEFERRED
HISTORY of DATE of HPV

REFUSAL
TODAY? REASONS for
ALLERGIES (food, VACCINE GIVEN
meds, previous (fever) REFUSAL
immunization)
Y N 1st dose 2nd dose

Name and Signature of Vaccinator1

Name and Signature oof Recorder

 SCHOOL-BASED IMMUNIZATION
RECORDING FORM3: MASTERLIST of GRADE 7 STUDENTS

REGION: VII NAME of SCHOOL:

PROVINCE / CITY: CEBU DIVISION: CEBU PROVINCE
DISTRICT / MUNICIPALITY: DATE: SECTION:

To be filled up by the School Nurse / Class Adviser

SICK
PARENT's HISTORY of
DATE of BIRTH TODAY?
No. NAME (1) COMPLETE ADDRESS (2) AGE SEX RESPONSE ALLERGIES (food,
meds, previous (fever)
immunization, MR, Td)
MM/DD/YY Y N Y

10

11

12

13

14

15

NAME and SIGNATURE OFO SUPERVISOR NAME and SIGNATURE of VACCINATOR 1 NAME and SIGNATURE of VACCINATOR
BASED IMMUNIZATION
ASTERLIST of GRADE 7 STUDENTS
To be filled up by the Vaccination team
MR Td
LOT No.: LOT No.:
BATCH No.: BATCH No.:

To be fiiled up by the Vaccination Team

SICK LAST

DEFERRED
POTENTIALLY VACCINE GIVEN

REFUSAL
TODAY? MENSTRUAL REASONS for
PREGNANT
(fever) PERIOD MR Td REFUSAL
N (for FEMALES only) Y/N R arm L arm

NAME and SIGNATURE of VACCINATOR 2 NAME and SIGNATURE of RECORDER