Community-based

RECORDING Immunization
Form 3: HPV Masterlist Activity
of FEMALE 9-14 years old

Region: _______________________________
Province/City: _________________________
District/Municipality: ___________________

To be filled up by the Vaccination Team

Sick today? Date of HPV Vaccine
History of allergies ( fever) Given Vaccinated
Date of Birth Age Deferred Deferral (VD)/
No. Name (1) (Surname, First Name, MI) Complete Address (2) (D)/ Remarks
MM/DD/YY (food, meds, previous Vaccinated
immunization) Y N 1st dose 2nd dose Refused (R) Refusal (VR)

10

11

12

13

14

15

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2

Name and Signature of Recorder Name and Signature of Recorder