School-Based Immunization

To be filled up by the Vaccination Team

RECORDING FORM 1: Masterlist of Grade 1 Students MR
Lot No: ___________________________
Batch No: _________________________
Region: IV-A CALABARZON Name of School: ____________________________ Section: ___________________
Td
Province/City: BATANGAS CITY Division: BATANGAS Lot No: ___________________________
Batch No: _________________________
District/Municipality: MABINI Date: __________________________
To be filled up by the School Nurse/Class Adviser
Date of Previous MCV Sick
Name (1) received Parents’ History of allergies today? Vaccine Given
No. (Surname,First Name,MI) Complete Address (2) Date of Birth Age Sex Response (food,meds,previous (fever,etc Refusal Reasons
MM/DD/YY Slip immunization)
Zero MCV1 MCV2 MCV1 MCV2 Td
dose Y N

ANTONIO M. ILAGAN ____________________________ _______________________________ __________________________

Public Schools District Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 1 Name and Signature of Recorder