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bOPV SIA Recording Form Final

The document is a form for recording information about supplemental immunization activities for bOPV vaccination. It collects information such as name, birthdate, address, and vaccination details for children aged 0-59 months. Reasons for deferral or refusal are also coded.

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aldricharquiza0128
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18 views

bOPV SIA Recording Form Final

The document is a form for recording information about supplemental immunization activities for bOPV vaccination. It collects information such as name, birthdate, address, and vaccination details for children aged 0-59 months. Reasons for deferral or refusal are also coded.

Uploaded by

aldricharquiza0128
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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2024 bOPV Supplemental Immunization Activity Recording Form

Information:
Last Name: __________________ First Name: __________________ Middle Name: _____________ Suffix: ____
Birthdate (mm/dd/yyyy): ________________ Date of Vaccination (mm/dd/yyyy): ______________
Sex (Male/Female): __________________
Address:
________________________________________________________________________________,
Contact Person: _______________________________________ Contact No.
__________________________

Place of Vaccination:
Region: Province: __________________
Municipality________________Barangay:_________________
Child Deferral (/): ___ Refusal (/): __ If Check, please indicate the reasons: _____________________
Schedule of Next Visit (mm/dd/yyyy): ________
Name of Vaccinator: _______________________________________

Services:
Aged Group Tick (/) if given If no, schedule of next visit

0-11 months old

12-23 months old

24-59 months old

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

2024 bOPV Supplemental Immunization Activity Recording Form

Information:
Last Name: __________________ First Name: __________________ Middle Name: _____________ Suffix: ____
Birthdate (mm/dd/yyyy): ________________ Date of Vaccination (mm/dd/yyyy): ______________
Sex (Male/Female): __________________
Address:
________________________________________________________________________________,
Contact Person: _______________________________________ Contact No.
__________________________

Place of Vaccination:
Region: Province: __________________
Municipality________________Barangay:_________________
Child Deferral (/): ___ Refusal (/): __ If Check, please indicate the reasons: _____________________
Schedule of Next Visit (mm/dd/yyyy): ________
Name of Vaccinator: _______________________________________

Services:
Aged Group Tick (/) if given If no, schedule of next visit

0-11 months old

12-23 months old

24-59 months old


Reasons for being Unvaccinated
Code Deferred Code Refusal
1. Parent/caregiver was absent/ away from home.
caregiver refused.
1. Child was acutely sick/ Child has chronic. 2. Fear of vaccine side effects
problem or not feeling well; caregiver deferred. 3. Vaccine safety issues (past adverse experience.)
Vaccination 4. Child already has complete routine vaccination,
2. Child is sick with moderate to severe illness. extra vaccine dose not necessary
fever (≥37.6℃) (indicate illness in the remarks) 5. Fear of COVID-19 transmission
3. Child is immunocompromised. 6. Vaccine perceived to be not effective, of low-
(see Quick Health Assessment Form) quality or on near expiry.
4. Child was absent/ away from home. 7. Client is a newborn and parents believed that their
(indicate place in the remarks) child is too young to get vaccinated.
5. Parent/caregiver was absent/ away from home. 8. Child was already vaccinated by private MD,
caregiver cannot decide or give consent. against advised by private MDs
6. Child is sleeping. 9. Personal beliefs or misconceptions of the parents
7. Vaccines are not available on-site. or caregiver on vaccination; against religious beliefs
10. Lack of trust in the vaccinator
11. Child just recovered from illness or just discharged
from the hospital, the parent/ caregiver refused.
12. Child has chronic problem; parents refused.
13. Unaware of the campaign or has not heard
about these vaccine, Outright refusal
14 . Parent/caregiver believes child is not at risk to
getting infected with polio.

Reasons for being Unvaccinated

Code Deferred Code Refusal


12. Parent/caregiver was absent/ away from home.
caregiver refused.
1. Child was acutely sick/ Child has chronic. 13. Fear of vaccine side effects
problem or not feeling well; caregiver deferred. 14. Vaccine safety issues (past adverse experience.)
Vaccination 15. Child already has complete routine vaccination,
2. Child is sick with moderate to severe illness. extra vaccine dose not necessary
fever (≥37.6℃) (indicate illness in the remarks) 16. Fear of COVID-19 transmission
3. Child is immunocompromised. 17. Vaccine perceived to be not effective, of low-
(see Quick Health Assessment Form) quality or on near expiry.
4. Child was absent/ away from home. 18. Client is a newborn and parents believed that
(indicate place in the remarks) their child is too young to get vaccinated.
5. Parent/caregiver was absent/ away from home. 19. Child was already vaccinated by private MD,
caregiver cannot decide or give consent. against advised by private MDs
6. Child is sleeping. 20. Personal beliefs or misconceptions of the parents
7. Vaccines are not available on-site. or caregiver on vaccination; against religious
beliefs
21. Lack of trust in the vaccinator
22. Child just recovered from illness or just
discharged from the hospital, the parent/
caregiver refused.
12. Child has chronic problem; parents refused.
13. Unaware of the campaign or has not heard
about these vaccine, Outright refusal
14. Parent/caregiver believes child is not at risk to
getting infected with polio.

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