Republic of the Philippines

Department of Education
Region XIII
Division of Surigao del Sur
CORTES I District
FELISBERTO VERANO NATIONAL HIGH SCHOOL

Students’ and Family Members Vaccination Tracking

Name of Student Vaccinated

YES NO
1st Dose/Date of Fully Vaccinated
2nd dose
1. AJOS, JERALD JOHN
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
2. BACSAN, ELEAZAR V.
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
3. CANTIGA, JEMBOY G.
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
 number of vaccinated & unvaccinated relative/s)
Name of Student Vaccinated
YES NO
1 Dose/Date of
st
Fully Vaccinated
2nd dose
3. CARESUGA, KIAN DAVE T.
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
4. CUARTERON, ARIAN
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
5. MATURAN, CHRISTIAN
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)

Name of Student Vaccinated

YES NO
1st Dose/Date of Fully Vaccinated
2nd dose
6. PLAZA, EGIE BOY
 FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
7. BALILI, JOHN MARK L.
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
8. BOLONGAITA, EARL JOHN
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
Name of Student Vaccinated
YES NO
1st Dose/Date of Fully Vaccinated
2nd dose
9. CASANO, KENNETH D.
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
 unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
10. COQUILLA, CENRIC JOHN T.
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
11. BARRETA, ERCYL
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)

Name of Student Vaccinated

YES NO
1st Dose/Date of Fully Vaccinated
2nd dose
12. BENIGA, CHARLYN
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
13. CARESUGA, PRENCESS ALLEONAH
 FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
14. CUARTERON, RHEAN
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
Name of Student Vaccinated
YES NO
1st Dose/Date of Fully Vaccinated
2nd dose
15. PLAZA, RUNALIZA P.
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
16. ROSIT, CHEN CHEN A.
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
17. SABANDAL, KAREN
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)

Name of Student Vaccinated

YES NO
1st Dose/Date of Fully Vaccinated
2nd dose
18. SUAN, RENDEL T.
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
19. AJOS, LEA MAE
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
20. AUGUSTO, WIENDELYN
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
Name of Student Vaccinated
YES NO
1st Dose/Date of Fully Vaccinated
2nd dose
21. CANTAPAY, MA. ESTRELLA Q.
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
22. HISTORIA, MARIAN ROSE
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
23. LEMENTE, GLYZA
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
  Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)

Name of Student Vaccinated

YES NO
1st Dose/Date of Fully Vaccinated
2nd dose
24. ORACION, JELLEN MAE
FAMILY Members:
 Mother

 Father

 Brother/s (indicate the number of vaccinated &

unvaccinated brother/s)
 Sister/s (indicate the number of vaccinated &
unvaccinated sister/s)
 Guardian/s (indicate the number of vaccinated &
unvaccinated guardian/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)
 Relative/s inside your household (indicate the
number of vaccinated & unvaccinated relative/s)

Prepared by: Noted by:

KATHLEEN C. DANDO GENEVIEVE P. DAMARILLO

Class Adviser Principal