School-Based Immunization

MASTERLIST OF LEARNERS GRADE ______

To be filled up by the Vaccination Team
RegioI Name of School: _____SUGCONG ELEMENTARY SCHOOL___________________________MR
Lot No: _______________________ Total no. of Student 40
Provi PANGASINAN Section: _______________________ Batch No: _____________________ Total no. of MR vaccine given:_______________
Total no. of Td vaccine given:_______________
Distr POZORRUBIO II/ POZORRUBIO Date:_______________AUGUST 8, 2019___________ Td Total no. of children vaccinated:_____________
Lot No: _______________________ Total no. of deferred: ______________________
Batch No.______________________ Total no. of refusal: _______________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Date of previous MCV Parents' Sick today?
History of allergies Vaccine Given
Name (1) Dare of Birth received Response Slip ( fever, etc)
No. (Surname, First Name, MI) Complete Address (2) MM/DD/YY Age Sex (food, meds, previous Refusal Reasons
Zero immunization)
Y N Y N MCV1 MCV2 Td
Dose MCV 1 MCV2 (L arm)
SUGCONG, POZORRUBIO,
ARELLANO,CHRISTIAN, ARAGON 02-02-2008 11 M
PANGASINAN
1

SUGCONG, POZORRUBIO,
CASTILLO,LANDER JADE, BADUA 12-07-2007 11 M
PANGASINAN
2

SUGCONG, POZORRUBIO,
CASTILLO,MARK LESTER, MORGADO 11-09-2007 11 M
PANGASINAN
3

CUARESMA,JEFFREY, ARELLANO PALDIT, SISON, PANGASINAN 06-13-2008 10 M

4

SUGCONG, POZORRUBIO,
GULENG,BRIX DICKSEN, PASAG 07-13-2007 11 M
PANGASINAN
5

SUGCONG, POZORRUBIO,
GULENG,JAYSON, MABANA 07-11-2007 11 M
PANGASINAN
6

SUGCONG, POZORRUBIO,
GULENG,RYAN SMITH, LASGETTI 03-28-2008 11 M
PANGASINAN
7

SUGCONG, POZORRUBIO,
JUGUILON,LENDON, BAYACSAN 07-17-2008 10 M
PANGASINAN
8

SUGCONG, POZORRUBIO,
MENDOZA,DAN NATHANIEL, VILLARIN 02-03-2008 11 M
PANGASINAN
9

SUGCONG, POZORRUBIO,
MENDOZA,RANDOLF, DAPNISAN 02-13-2008 11 M
PANGASINAN
10

SUGCONG, POZORRUBIO,
MOYANO,RAMIR, SIBUG 10-17-2007 11 M
PANGASINAN
11

SUGCONG, POZORRUBIO,
NANALI,BERNARD ANDREI, ROSIMO 04-26-2008 11 M
PANGASINAN
12

ANONAS, URDANETA CITY,

OBILLE,ULYSSIS, VALENCIANO 12-15-2007 11 M
PANGASINAN
13

SUGCONG, POZORRUBIO,
ORDOÑA,ROD ZANDREI, GULENG 07-03-2008 10 M
PANGASINAN
14

QUIMPO,EDSEL, QUINIONES PALDIT, SISON, PANGASINAN 01-15-2008 11 M

15

_____________________________
Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name of and Signature of Vaccinator 2 Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 7 Students

Region: _______________________________ Name of School: ________________________________________________________ To be filled up by the Vaccination Team

MR Total no. of Grade 7 students:_______________
Province/City: _________________________ Section: _______________________ Lot No: _______________________ Total no. of MR vaccine given:______________
Batch No: _____________________ Total no. of Td vaccine given:_______________
District/Municipality: ___________________ Date:__________________________ Total no. of children vaccinated:_____________
Td Total no. of deferred: ______________________
Lot No: _______________________ Total no. of refusal: _______________________
Batch No.______________________ Total no. of female with
sexual contact in the past 4 wks.: ____________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents' Sick today?
Response History of allergies Vaccine Given
( fever)
Slip (food, meds, Last Menstrual
Dare of Birth Potentially
No. Name (1) Complete Address (2) Age Sex previous Period (for Deferred Refusal Reasons for Refusal
MM/DD/YY
Y N immunization Y N FEMALES only) Pregnant (Y/N)
MR/Td) MR Td
(R arm) (L arm)

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Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name of and Signature of Vaccinator 2 Name and Signature of Recorder
 RECORD
Region: _______________________________ Name of School: ________________________

Province/City: _________________________ Section: _______________________

District/Municipality: ___________________ Date:__________________________

To be filled up by the School Nurse/ Class Adviser

Name (1) (Surname, First

No. Complete Address (2)
Name, MI)

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Name and Signature of Supervisor

 School-Based Immunization
RECORDING Form: Masterlist of Grade 4 FEMALE Students (9-13 yrs. old)
_____________________________________________________

_____________

______________

Class Adviser
Parents' Response
Date of Birth Slip
Age Sex
MM/DD/YY History of allergies (food,
Y N meds, previous immunization)
Name and Signature of Vaccinator 1 Name of and Signature of Vaccinator 2
(1st Dose) (2nd Dose)
ents (9-13 yrs. old)
To be filled up by the Vaccination Team
HPV
Lot No: __________
Batch No: ________

To be filled up by the Vaccination Team

Sick today? Date of HPV Vaccine Given
( fever)

Y N 1st dose 2nd dose

Vaccinator 2
se)
 Total no. of Grade 4 eligible:___________________
Total no. of 1st dose of HPV vaccine given:_______
Total no. of 2nd dose of HPV vaccine given:______
Total no. of children vaccinated:________________
Total no. of deferred: _________________________
Total no. of refusal: __________________________

y the Vaccination Team

Remarks
Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 4 FEMALE Students (9-13 yrs. old)
Region: _______________________________ Name of School: ________________________________________________________ To be filled up by the Vaccination Team
HPV Total no. of Grade 4 eligible:___________________
Province/City: _________________________ Section: _______________________ Lot No: __________ Total no. of 1st dose of HPV vaccine given:_______
Batch No: ________ Total no. of 2nd dose of HPV vaccine given:______
District/Municipality: ___________________ Date:__________________________ Total no. of children vaccinated:________________
Total no. of deferred: _________________________
Total no. of refusal: __________________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents' Response Sick today? Date of HPV Vaccine Given
No. Name (1) (Surname, First Complete Address (2) Date of Birth Age Sex Slip ( fever) Remarks
Name, MI) MM/DD/YY History of allergies (food,
Y N meds, previous immunization) Y N 1st dose 2nd dose

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Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name of and Signature of Vaccinator 2 Name and Signature of Recorder
(1st Dose) (2nd Dose)