Community-Based Immunization

RECORDING FORM 1: Masterlist of Grade 8 Students- MR-Td Immunization

To be filled up by the Vaccination Team
PUNTOD NATIONAL HIGH SCHOOL MR
8-COMPASSION
Region: __X___ Name of School: _____________________________ Grade/Section: ______________ Lot No. _________________
Batch No.: ______________
Province/City: _Cagayan de Oro City___ Division: _Cagayan de Oro City_ Td
Lot No.: ________________
District/Municipality: _Misamis Oriental_ Batch No.: ______________

To be filled up by the Class Adviser To be filled up by the Vaccination Team

Name (1) Date of Age Gen- Parent’s History of allergies Sick Date of Deferred/ Vaccinated Remarks
(Surname, First Name, MI) Complete Address (2) Birth der Consent (food, meds, Today? Vaccine Given Refused Deferral/
No. previous (fever, Vaccinated
Immunization) etc.) Refusal
MR Td
MM/DD/ Y N Y N (RA) (LA)
YY
1. ABREA,CHRISTIAN DAVE, ROSARIO 07-15-2005 16 MALE
ESCOBIDO ST. PUNTOD CDO

2. ACLAN,GIAN CARLO, MANAHAN 03-25-2008 13 MALE

PUNTOD CDO
3. ALEONAR,REYNALD, BENITEZ BLK 2 PUNTOD CDO 04-17-2005 16 MALE

4. ANDUJAR,KIM ELVIS, - BLK 4 SAN ROQUE PUNTOD 01-26-2008 13 MALE

5. AQUINO,FREDERICK JHON, SAMSON BLK 4 PUNTOD CDO 02-09-2008 13 MALE

6. ARAPOC,DARYL, NOLASCO Blk.4, Puntod Cagayan De 12-27-2008 12 MALE

Oro City

7. ARRIESGADO,ARNOLD JAY R, OPIASA BLK 3 PUNTOD CDO 12-08-2007 13 MALE

8. BACOR,REY, SALUDES DISTRICT 7 BLK 4 PUNTOD 08-21-2006 15 MALE

CDO
9. CABALLERO,JAN ANDREW, BARTOLOME PUNTOD CDO 10-22-2005 16 MALE

10. CERIÑO,CHARLES JOSHUA, GARCIA CILRAI PUNTOD CDO 10-28-2008 13 MALE

11. JAMODIONG,JAMES HAROLD, ELECSION PUNTOD CDO 01-31-2008 13 MALE

12. LAGMAN,JHUN ANDRE, NACALABAN BARRA MACABALAN CDO 12-31-2007 13 MALE

13. LENIS,MARK DAVE, PATOC ESCOBIDO ST. PUNTOD 03-10-2007 14 MALE

 CDO
14. LUMENDAS,JIMBOY, CELVANO CILRAI PUNTOD CDO 11-13-2007 13 MALE

15. MEJIAS,BON MILES, PERALTA MACABALAN CDO 07-27-2008 13 MALE

16. ROMULO,ARIEL REY, MAGLASANG DISTRICT 7 BLK 4 PUNTOD 04-11-2008 13 MALE

17. ROXAS,JERECHO, TUZON PUNTOD CDO 03-23-2006 15 MALE

18. SALON,JOHN KEVIN, CERVANTES BLK 2 PUNTOD CDO 05-15-2008 13 MALE

19. SEVILLA,DON BENEDICT, BRIONES ESCOBIDO ST. PUNTOD 02-16-2007 14 MALE

20. TEMARIO,JAMES CHARLES, REMENTIZO ST JOHN PUNTOD CDO 02-05-2008 13 MALE

21 TOMITA,HIRO, JABAGAT PUNTOD CDO 09-16-2005 16 MALE

22 YAMIT,RELUN, PACANA MULMAC MACABALAN 01-28-2008 13 MALE

To be filled up by the Class Adviser To be filled up by the Vaccination Team

Name (1) Date of Age Gen- Parent’s History of Sick Vaccine Given Deferred/ Vaccinated Remarks
(Surname, First Name, MI) Complete Address (2) Birth der Consent allergies (food, Today? Refused Deferral/
No. meds, previous (fever, Vaccinated
Immunization) etc.) Refusal
MR Td
MM/DD/YY Y N Y N (RA) (LA)
1 ABERO,KISSA SHANE, MIOLE PUNTOD CDO 05-04-2008 13 FEMALE

2. ANDUHAN,IREN, LUMAYAO ST JOHN PUNTOD CDO 12-22-2006 14 FEMALE

3. ATILLO,APRIL JOY, MACADANGDANG PUNTOD CDO 04-10-2008 13 FEMALE

4. BACULIO,JENNICA FAYE, MANGUBAT BLK 4 PUNTOD CDO 01-17-2008 13 FEMALE

5. BOLO,SAMANTHA, ELIM CILRAI PUNTOD CDO 05-21-2008 13 FEMALE

6. CAMPANER,CLOE JANE, OTUZA DISTRICT 7 BLK 4 PUNTOD 07-27-2007 14 FEMALE

7. CANILLO,JESSA, MASICAMPO BLK 4 PUNTOD CDO 11-22-2007 13 FEMALE

8. CUBILLAN,KRYSSIA MAE, - ESCOBIDO ST PUNTOD 07-07-2008 13 FEMALE

9. DAAYATA,MARJE, JAMIS CILRAI PUNTOD CDO 05-26-2004 17 FEMALE

 10. DUMAIL,BEVERLY, MANGAON BLK 1 PUNTOD CDO 08-29-2008 13 FEMALE

11. ELACO,NICOLE KIMBERLY, DAVID BLK 3 PUN TOD CDO 10-23-2008 13 FEMALE

12. FELISILDA,PRINCESS ANN MAE, OSMEŇA EXT. BRGY 22 05-05-2008 13 FEMALE

VERSAGA

13. PADUA,ARIELLE MARI, ESTEBAN DISTRICT 3 CORRALES EXT. 11-23-2007 13 FEMALE

SAN NICOLAS
14. PATEÑO,ATEA PHIL, PIAPE DENR COMPOUND 04-15-2008 13 FEMALE
MACABALAN CDO
15 VILLORIA,QUEEN MONICA, SORIANO BLK 4 PUNTOD CDO 08-27-2008 13 FEMALE

ENGELYN T. ANDAJAO
__________________________
Name of Class Adviser

ELISA B. BANLUTA
_________________________________ ___________________________ ____________________________ ____________________________ _________________________
Name School Principal/Head Name & Signature of Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2 Name & Signature of Recorder