DEMOGRAPHIC INFORMATION

Indigenous Member LAST_NAME FIRST_NAME MIDDLE_NAME

NO CRUZ JUAN NILLARES

Choose from the

selection if an Encode the Encode the Encode the
individual is part Last/Family complete first COMPLETE
of an indegenous Name of the name of the middle name
group Vaccinee vaccinee of the
vaccinee. For
individuals
without
middle name
indicate "No
Data"
RMATION Data sets under the Demographic information are the basis
of the system for deduplication

SUFFIX BIRTHDATE SEX PERMANENT ADDRESS (HOUSE NUMBER,

(MM/DD/YYYY) BLK NO., LOT NO., STREET NAME)

N/A 08/04/2000 MALE 95 ILANG ILANG ST.

Select from Indicate the Select the sex Encode vaccinee's House
the birthdate of of the lot number, street name
dropdown the vaccinee vaccinee from
choices the using the the drop-
suffix of the prescribed down list
vaccinee. format
Select "N/A" (mm/dd/yyyy)
If the
individual "Select the 1st
does not have day of the
suffix. year of the
estimated
year of birth
for indigenous
members
that does not
know their
birthday. ex:
(01/01/2008)
(01/01/2001)
 PERMANENT ADDRESS
PERMANENT ADDRESS REGION
Select the Region of the
vaccinee's permanent address
Data sets under the Permanent Address are used to measure the actual
vaccination coverage per region, province, city, and barangay
PERMANENT ADDRESS PERMANENT ADDRESS
PROVINCE CITY
Select the Province of the Select the
vaccinee's permanent Municipaliy/City of
address. (The choices in the vaccinee's
this column is dependent permanent address
on the Region column) (The choices in this
column is dependent
on the Province
column)
nder the Permanent Address are used to measure the actual
coverage per region, province, city, and barangay
PERMANENT ADDRESS
BARANGAY
Select the Barangay of the
vaccinee's permanent
address (The choices in
this column is dependent
on the City column)
PLACE OF VACCINATION
PLACE OF VACCINATION PLACE OF VACCINATION
REGION PROVINCE
Ilocos_Region_0100000000 ILOCOS_SUR_0102900000
Select the Region of the Select the Province of the
place where the vaccinee place where the vaccinee
was vaccinated was vaccinated (The choices
in this column is dependent
on the Region column)
Select the
Municipality/City of t
place where the vacci
was vaccinated (The
choices in this column
dependent on the
Province column)
LACE OF VACCINATION Data sets under the Place of Vaccinator are used to measure the actual
vaccination accomplishment per region, province, city, and barangay

PLACE OF VACCINATION PLACE OF VACCINATION ADMINISTERED VACCINE OR

MUNI_CITY BARANGAY SUPPLEMENT

ALILEM_0102901000 AMILONGAN_0102901002 Measles Rubella Vaccine

(MR)_07

Select the Select the Barangay of the Select the vaccine /

Municipality/City of the
place where the vaccinee
was vaccinated (The
choices in this column is
dependent on the
Province column)
place where the vaccinee was supplement administered
vaccinated (The choices in this
column is dependent on the
Municipality/City column)
 VACCINATION INFORMATION

ACTION TAKEN VACCINATION/REFUSAL/

DEFERRAL_DATE
(MM/DD/YYYY)

DEFER 09/02/2023

Select the Indicate the date of the

action vaccination/ deferral/
provided by refusal using the
the health prescribed format
care worker (mm/dd/yyyy)

"The date indicated

here should reflect the
date selected for the
"Action Taken" column
(01/01/2001)
 VACCINATION INFORMATION

REASON_FOR_REFUSAL/DEFERRAL

Child was absent/ away from home (indicate place in the remarks)_06

*Only populate this column if the vaccinee refused or was deferred. The
choices are dependent from the "Action Taken"
(01/01/2001)
DEFERRAL_DATE_OF_NEXT_ VACCINATOR_N DOSE_NUMBER
VISIT (MM/DD/YYYY) AME

03/01/2023

*Only populate this Indicate the Indicate the

column if the vaccinee vaccinator's Dose
was deferred. Indicate name Number
the date of deferral.
(01/01/2001)
 DEMOGRAPHIC INFORMATION

Indigenous LAST_NAME FIRST_NAME MIDDLE_NAME SUFFIX

Member

NO Mario Luigi No data N/A

NO Peach Luigi No data N/A
YES Yoshi Mario No data N/A
YES Bowser Peach No data N/A
YES Bowser Mario No data II
 BIRTHDATE SEX PERMANENT ADDRESS (HOUSE NUMBER,
(MM/DD/YYYY) BLK NO., LOT NO., STREET NAME)

08/04/2021 MALE 1st Street

08/04/2021 MALE 2nd Street
09/09/2009 FEMALE 3rd Street
09/09/2009 FEMALE 4th Street
09/09/2009 FEMALE 5th Street
 PERMANENT ADDRESS

PERMANENT ADDRESS REGION

National_Capital_Region_1300000000
CALABARZON_0400000000
CALABARZON_0400000000
Central_Visayas_0700000000
 PERMANENT ADDRESS

PERMANENT ADDRESS PROVINCE

CITY_OF_TAGUIG_1381500000
CAVITE_0402100000
CAVITE_0402100000
CITY_OF_LAPU_LAPU_0731100000
 PERMANENT ADDRESS CITY PERMANENT ADDRESS
BARANGAY

CITY_OF_TAGUIG_Not_a_Province_1381500000 Post_Proper_Northside_13815
CITY_OF_BACOOR_0402103000 00034
P_F_Espiritu_4_0402103085
CITY_OF_CARMONA_0402104000 BARANGAY_8_0402104019
CITY_OF_LAPU_LAPU_Not_a_Province_0731100000 BUAYA_0731100006
 PLACE OF VACCINATION

PLACE OF VACCINATION PLACE OF VACCINATION PLACE OF VACCINATION

REGION PROVINCE MUNI_CITY

Central_Visayas_0700000000 CEBU_0702200000 ALCOY_0702202000

National_Capital_Region_130000 CITY_OF_TAGUIG_1381500000 CITY_OF_TAGUIG_Not_a_Prov
0000 ince_1381500000
Ilocos_Region_0100000000 ILOCOS_SUR_0102900000 BURGOS_0102904000
 PLACE OF ADMINISTERED VACCINE OR SUPPLEMENT ACTION TAKEN
VACCINATION
BARANGAY

Vitamin A_12 DEFER

Bivalent Oral Polio Vaccine (bOPV)_03 VACCINATE
Vitamin A_12 REFUSE
Measles Rubella Vaccine (MR)_07 VACCINATE
Measles Rubella Vaccine (MR)_07 VACCINATE

NUG_AS_0702202
004
TANYAG_1381500
001
BANGBANGAR_01
02904003
 VACCINATION INFORMATION

VACCINATION/
REFUSAL/
DEFERRAL_DATE
(MM/DD/YYYY)

03/31/2023
03/31/2023
03/16/2023
03/22/2023
03/17/2023
 VACCINATION INFORMATION

REASON_FOR_REFUSAL/DEFERRAL

Fear of vaccine side effects_02

Child is sick with moderate to severe illness; fever (≥37.6 ℃) (indicate illness in the remarks)_02
DEFERRAL_DATE_OF_NEXT_ VACCINATOR_NAM DOSE_NUMBER
VISIT (MM/DD/YYYY) E

SAMPLE JONATHAN 1
SAMPLE JONATHAN 2
SAMPLE 4
SAMPLE 1
03/24/2023 SAMPLE 1