Name of School: GABI NATIONAL HIGH SCHOOL

District: Compostela West

Grade and Section: _11 - Zeus_
Coverage Date: Ex. December 20 - 24, 2021
Name of Student
Complete Address
Age Vaccinated with First Vaccinated with Second
Parents' / Guardian's
Vaccinated with Vaccinated with
Type of vaccine / dose? 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 (indicate Purok #)
Name 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
Richard L. Batoy / x
1 Batoy, Eric John N. 16/M Pfizer 11/30/2021 None P-3 Magading, Nab., DDO

Miralona A. Bongawos / /
2 Bongawos, Stephanie A. 17/F Pfizer 11/15/2021 6/12/2021 Fever; cough P-16 Poblacion, Nab., DDO

Purok Marfori, New Alegria, Comp., Victor Piator / /

3 Lastimoso, Juvy P. 23/F Pfizer 11/18/2021 9/12/2021 Headache
DDO Rosalie Lastimoso / /
Purok Valencia 2, New Alegria, Jeffrey Lendio / /
4 Lendio, Gemmalyn B. 49/F Sinovac 1/12/2021 None
Comp., DDO
Joma Alicaway x x
5 Ondagan, Lucelyn 27/F Pfizer 09/17/2021 8/10/2021 None P-15 Gabi, Comp., DDO

Jerry Serato / /
6 Serato, Arlene 28/F Sinovac 08/31/2021 09/28/2021 None P-5 Panag, New Bataan, DDO

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Prepared by:

JEANILYN CUPAT-MIRANDA Noted by:

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