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School-Based Immunization Record Form

This document is a recording form used by a vaccination team to document the immunization of grade 1 students at a school. It collects students' names, addresses, dates of birth, ages, sexes, dates of previous vaccinations, parental consent, medical histories, and whether vaccines for measles, mumps, and rubella (MCV1 and MCV2) and tetanus (Td) were given or refused on the date of the school-based immunization program. The form is signed by the vaccinators and recorder to validate the immunization records.

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Jenevieve Odtojan Bajan
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4K views1 page

School-Based Immunization Record Form

This document is a recording form used by a vaccination team to document the immunization of grade 1 students at a school. It collects students' names, addresses, dates of birth, ages, sexes, dates of previous vaccinations, parental consent, medical histories, and whether vaccines for measles, mumps, and rubella (MCV1 and MCV2) and tetanus (Td) were given or refused on the date of the school-based immunization program. The form is signed by the vaccinators and recorder to validate the immunization records.

Uploaded by

Jenevieve Odtojan Bajan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

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

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