ANNEX A.

Reporting Forms for 2021 Community-based MR-Td Immunization

Community-based Immunization Activity
RECORDING Form 1: MR-Td (6-7 Years Old)

Region: _______________________________

Province/City: _________________________

District/Municipality: ___________________

To be filled up by the DepEd Personnel To be filled up by the Vaccination Team

Sick today? MR Td
( fever)
History of allergies
Name (1) Date of Birth Grade (food, meds, Contact Number of Vaccinated Vaccinated
No. Complete Home Address (2) Complete Name of School MM/DD/YY Age Sex Date of Deferred Remarks
(Surname, First Name, MI) Level previous Parents/Guardian Deferral (VD)/ Reason for Date of Deferred (D)/ Deferral (VD)/ Reason for
immunization) Y N Vaccine (D) / Refused Vaccinated Deferral / Vaccine Refused (R) Vaccinated Deferral /
Given (R ) Refusal (VR) Refusal Given Refusal (VR) Refusal

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

ANNEX A. Reporting Forms for 2021 Community-based MR-Td Immunization
Community-based Immunization Activity
RECORDING Form 2: MR-Td (12-13 Years Old)

Region: _______________________________

Province/City: _________________________

District/Municipality: ___________________

To be filled up by the DepEd Personnel To be filled up by the Vaccination Team

Sick today? MR Td
( fever)
History of allergies
Name (1) Date of Birth Grade (food, meds, Contact Number of Vaccinated Vaccinated
No. Complete Home Address (2) Complete Name of School MM/DD/YY Age Sex Date of Deferred Remarks
(Surname, First Name, MI) Level previous Parents/Guardian Deferral (VD)/ Reason for Date of Deferred (D)/ Deferral (VD)/ Reason for
immunization) Y N Vaccine (D) / Refused Vaccinated Deferral / Vaccine Refused (R) Vaccinated Deferral /
Given (R ) Refusal (VR) Refusal Given Refusal (VR) Refusal

GURAY,JUSTINE, ORAIN MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 7/17/2009 12 M 5 NONE 9294753772
1
MABBORANG,LAURENCE, ROSCAIN MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 5/3/2008 13 M 5 NONE 9193651234
2
ROTAZO,RANNIE, BELMONTE MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 9/13/2009 12 M 5 NONE 9287531004
3
SANCHEZ,KYLE YUAN, SULIT MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 6/21/2009 12 M 5 NONE 9171234005
4
DIAZ,ASHLEY, BARTOLOME MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 9/9/2009 12 F 5 NONE 9257866255
5
TATLONGMARIA,RAYSHA MAE,MARCE MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 11/2/2008 13 F 5 NONE 9701380251
6

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

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

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

To be filled up by DepEd Personnel To be filled up by the Vaccination Team

Sick today? HPV1 HPV2
( fever)
History of allergies
No. Name (1) Complete Address (2) Complete Name of School Date of Birth Age Grade Contact Number of Vaccinated Vaccinated Reason for Remarks
(Surname, First Name, MI) MM/DD/YY Level (food, meds, previous Parents/Guardian Date of Deferred Deferral (VD)/ Reason for Deferred Deferral (VD)/
immunization) Y N Vaccine (D) / Refused Vaccinated Deferral / Date of Vaccine Given (D)/ Refused Vaccinated Deferral /
Given (R ) Refusal (VR) Refusal (R) Refusal (VR) Refusal

1 ALOMIA,CASSANDRA COLEEN, FRANCISCO MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 11/6/2010 10 5 NONE 9070158442

2 ALOMIA,LEAN PEARL, NICERIO MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 10/19/2010 11 5 NONE 9285081833

3 ASILO,KHENNY LYN, SULTAN MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 5/29/2011 10 5 NONE 9171234569

4 CABRERA,SHASTELHA, BACURIN MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 11/1/2010 10 5 NONE 9251348972

5 CARABALLO,LADY IZABEL, CORONEL MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 10/21/2010 11 5 NONE 9091212455

6 DIAZ,ASHLEY, BARTOLOME MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 9/9/2009 12 5 NONE 9257866255

7 DUEÑAS,SAMANTHA JANE, BAGACINA MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 11/20/2010 10 5 NONE 9107593123

8 LAZARETO,SHELANIE, BARTOLOME MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 12/8/2010 10 5 NONE 9408197450

9 MALOMA,RYZA, CABAEL MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 9/19/2010 11 5 NONE 9614957024

10 OLAGUER,KEITH MYKA, MIRABONA MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 9/4/2010 11 5 NONE 9602910417

11 PABALAN,PRECIOUS COLYN, PORLAJE MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 11/24/2010 10 5 NONE 9086534098

12 RECUYO,RYNE ASHLEE, CALAYAG MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 6/30/2011 10 5 NONE 9682679127

13 SAYAGO,SHIERLY, PELAEZ MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 3/2/2011 10 5 NONE 9480471341

14 SWANWICK,PRINCESS ERICH, LIBADIA MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 10/14/2011 10 5 NONE 9607682398

15 TARUC,ROMINA, GERISANO MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 9/15/2010 11 5 NONE 9204567631

16 TATLONGMARIA,RAYSHA MAE,MARCE MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 11/2/2008 13 5 NONE 9701380251

17 VENTURA,ANNE MARIE, PALMA MALABAN, CITY OF BIÑAN, LAGUNA MALABAN ELEMENTARY SCHOOL 4/23/2011 10 5 NONE 9124645034

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