Enter number of children in each category for columns a to k
Finger mark and immunization are only method for verification of vaccination. MR Vaccination status bOPV Vaccination status
# of children who If unvaccinated, Source of Information
# of children # of children # of children # of children who DID Method of verification DID NOT receive Method of verification enter reason on Polio 0-8 MOs 9-11 MOs 12-59 MOs NOT receive vaccine HH # vaccine (record code Immunization (record present in present in present in number from list code number from house house house Left little Immunization Immunization below) the list below) 9 - 11 12-59 Left index (pinky Card (if no Card (if no 0 - 11 MOs 12-59 Mos MOs Mos finger Finger) finger mark) finger mark)
a b c d e f g h i j k l m
10
TOTAL
Mop-up Needed: YES NO
Note: Any Purok/Zone with 2 or more "Missed" children shall conduct a mop-up
REASONS FOR BEING UNVACCINATED
SOURCE OF INFORMATION: (Select all that apply for the HH) Code Reasons Code Source Code Reasons 10 Parent/caregiver was absent/ away from home; caregiver refused 1 Radio 1 Child was acutely sick/ Child has chronic 11 Fear of vaccine side effects 2 TV problem or not feeling well; caregiver deferred 12 Vaccine safety issues (past adverse experience, etc.) 3 Streamer/ Tarpaulin vaccination 13 Child already has complete routine vaccination, 4 Health Workers 2 Child is sick with moderate to severe illness; extra vaccine dose not necessary 5 Flyers fever (≥37.6℃) (indicate illness in the remarks) 14 Fear of COVID-19 transmission 6 Social Media (FB, Twitter, etc.) 3 Child received MCV/BCG Vaccine within the last 15 Vaccine perceived to be not effective, of low- 7 Barangay officials 4 weeks quality or on near-expiry 8 Relatives/ neighbors 4 Child is immunocompromised (see Quick Health 16 Client is a newborn and parents believed that 9 Others (specify) Assessment Form) their child is too young to get vaccinated 5 Child have severe allergy to Measles Containing 17 Child was already vaccinated by private MD, Vaccine and any component of the vaccine (e.g. against advised by private MDs neomycin or gelatin) 18 Personal beliefs or misconceptions of the parents 6 Child was absent/ away from home (indicate place or caregiver on vaccination; against religious in the remarks) beliefs 7 Parent/caregiver was absent/ away from home; 19 Lack of trust in the vaccinator caregiver cannot decide or give consent 20 Child just recovered from illness or just discharged 8 Child is sleeping from the hospital, the parent/ caregiver refused 9 Vaccines are not available on-site 21 Child has chronic problem; parents refused 22 Unaware of the campaign or has not heard about these vaccines 23 Outright refusal 24. Parent/caregiver believes child is not at risk to getting infected with (measles, rubella, mumps, polio, etc.)
