Republic of the Philippines

Department of Education
Region V
Schools Division of Sorsogon
District of Bulusan
Name of School
Address of the School

LIST OF TEACHING AND NON-TEACHING PERSONNEL WITH

AND WITHOUT VACCINATION

Name of Personnel Date of Date of Remarks

Vaccine 1st dose 1st dose
Received
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

Prepared by:

_______________________
Name of School Head
Position