Name of School: GABI NATIONAL HIGH SCHOOL

District: Compostela West

Grade and Section: _11 - Athena_
Coverage Date: Ex. December 20 - 24, 2021
Name of Student
Complete Address
Age Vaccinated with First Vaccinated with
Parents' / Guardian's
Vaccinated with Vaccinated with
Type of vaccine / dose? Second dose? AEFI or Side First dose? Second dose?
No. and brand of vaccine effects
Sex Name
Date Date YES NO YES NO
(Family Name, First Name (indicate Purok #)
Middle Initial) Marites Dela Cruz / x
Ex. Juan Dela Cruz 16/M Pfizer 11/8/2021 12/3/2021 None P15, Poblacion, New Bataan
John Michael Dela Cruz x x

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Prepared by:

MARICEL T. PICCIO Noted by:

Class Adviser
RONALD A. DERANO
Assistant School Principal II
AEFI or Side
effects