Region: III Name of School: Section: GRADE 1-
Barangay: District/Municipality:
City/Province: TARLAC Date: ___________________
To be filled out by Local Health Center / Vaccination Team
Date of Consent Slip
Name Birth
Complete Address Age Sex
(Surname, First Name, MI) MM/DD/
Y
YYYY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
______________________ _____________________________________ _____________________
Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signa
MR: Td:
Number of Vaccine Received (in vials):_______ Number of Vaccine Received (in vials):______
Number of Vaccine Used (in vials):_______ Number of Vaccine Used (in vials):_______
Number of Vaccine Unused (in vials):_______ Number of Vaccine Unused (in vials):_______
History Sick today?
Consent Slip Vaccine Given
of (Fever, etc) Deferra
Refusal
Allergie Lot/Batch Lot/Batch l
N Y N MR No. Td No.
s
_________________________________________
Name & Signature of Vaccinator 2
e Received (in vials):_______
e Used (in vials):_______
e Unused (in vials):_______
Reason
s
Region: _____________________Name of School: ____________Section: ___________
Barangay: __________________District/Municipalit
City/Province: ______________ Date: _____________
To be filled out by Local Health Center / Vaccination Team To be filled out by Vaccination Team
Date of Date of HPV Received
Name Birth
Complete Address Age Sex
(Surname, First Name, MI) MM/DD/ HPV 1 HPV 2
YYYY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
___________________________________________________________
Name & Signature __________________________________
Name & Signature
of Supervisor of Vaccinator 1 Name & Signature of Vaccinator 2
HPV:
Number of Vaccine Received (in vials):_______
Number of Vaccine Used (in vials):_______
Number of Vaccine Unused (in vials):_______
ed out by Vaccination Team
Consent Slip Sick today? (Fever, etc) Vaccine Given
History of
Lot/Batch Lot/Batch Deferral
Y N Allergies Y N HPV 1 HPV 2
No. No.
____________________________ _________________________________
& Signature of Vaccinator 2 Name & Signature of Recorder
Refusal Reasons
Region: _____________________Name of School: ____________Section: ___________
Barangay: __________________District/Municipalit
City/Province: ______________ Date: _____________
To be filled out by Local Health Center / Vaccination Team
Name Birth Consent Slip
Complete
(Surname, First Name, MM/ Age Sex
Address Y N
MI) DD/
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
___________________ _____________________________ ____________________________________
Name & Signature
of Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccina
MR: Td:
Number of Vaccine Received (in vials):_______ Number of Vaccine Received (in vials):_______
Number of Vaccine Used (in vials):_______ Number of Vaccine Used (in vials):_______
Number of Vaccine Unused (in vials):_______ Number of Vaccine Unused (in vials):_______
History Sick today?
of Vaccine Given Deferra Reason
(Fever, etc) Refusal
Lot/Batch Lot/Batch
Allergie Y N MR No. Td No.
l s
s
_________________________________
ame & Signature of Vaccinator 2
d (in vials):_______
vials):_______
(in vials):_______
