School-Based Immunization

RECORDING Form 1: Masterlist of Grade 1 Students

Region: _______________________________
Province/City: _________________________
District/Municipality: ___________________
To be filled up by the Vaccination Team
MR
Name of School: ________________________________ Section: _______________________ Lot No: _______________________
Batch No: _____________________
Division: _______________________
Td
Date:__________________________ Lot No: _______________________
Batch No.______________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team

Date of previous MCV Parents' Sick today?

received Response History of allergies ( fever, etc) Vaccine Given
No. Name Complete Address Date of Birth Age Sex Slip No. Reasons
(Surname, First Name, MI) MM/DD/YY (food, meds, previous Refused
Zero immunization)
dose MCV 1 MCV2 Y N Y N MCV1 MCV2 Td

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
 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 4 FEMALE Students (9-13 yrs. old)

To be filled up by the Vaccination Team

Region: IX Name of School: HPV
Lot No: ___________
Province/City: ZAMBOANGA DEL SUR / PAGADIAN CITY Division: PAGADIAN CITY Batch No: _________

District/Municipality:PAGADIAN CITY Date:

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents' Sick today? Date of HPV Vaccine
Date of Birth Age Response Slip History of allergies ( fever) Given
No. Name (1) (Surname, First Name, MI) Complete Address (2) Sex Deferred Refusal Reason for Refusal
MM/DD/YY (food, meds,
Y N Y N 1st dose 2nd dose
previous immunization)

1 / /

2 / /

3 / /

4 / /

5 / /

6 / /

7 / /

8 / /

10

11

12

13

14

15
 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 7 Students
Region: _______________________________ Name of School: ________________________________________________________ To be filled up by the Vaccination Team
MR
Province/City: _________________________ Division: _______________________ Section: ___________________ Lot No: _______________________
Batch No: _____________________
District/Municipality: ___________________ Date:__________________________ Td
Lot No: _______________________
Batch No.______________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team

Parents' Sick today?

Response Slip ( fever) Vaccine Given
Last
History of allergies Menstrual Potentially
No. Name Complete Address Date of Birth Age Sex (food, meds, previous Period pregnant Deferred Refusal Reasons for Refusal
MM/DD/YY immunization MR/Td) (for FEMALES (Y / N) MR Td
Y N Y N only) (R arm) (L arm)

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