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FLOW AND SUBMISSION OF REPORTS

To be
Levels of Schedule of
Type of report Responsible Person Submitted
Implementation Report
Recording Form 1: Masterlist to
of Grade 1 Form
Recording Students
2: Masterlist Local Health Center /
School RHU Daily
of Grade 4 Form
Recording Students
3: Masterlist Vaccination Team
of Grade 4 Students
Consolidated
RHU Accomplishment report by RHU Midwife PHO/CHO Weekly
Schools per Municipalities
Regional NIP
RHO Bulletin report of Prov/City CO-NIP Weekly
Coordinator
Analysis report of Provincial / City NIP
PHO/CHO RHO Weekly
Municipalities Coordinator
CO Bulletin report of CHDs DPCB NIP PHSC U Weekly
for those requesting a copy of this file, please download excel version. Access to this files are limited
SCHOOL-BASED IMMUNIZATIO
Recording Form 1: Masterlist of Grade 1

Region: _________________________ Name of School: _________________________Section: _____

Barangay: _______________________District/Municipality: ______

City/Province: __________________ Date: ______________________

To be filled out by Local Health Center / Vaccination Team

Date of Consent
Name Birth Slip
Complete Address Age Sex
(Surname, First Name, MI) MM/DD/ Y
YYYY
1
2
3
4
5
6
7
8
9
10

____________________________ ___________________________________ ____________________

Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signature
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ASED IMMUNIZATION
Masterlist of Grade 1 Students

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):_______

Consent today?
History of Vaccine Given Deferr Refusa
Slip (Fever, Lot/ Lot/ Reasons
N Allergies Y N MR Batch Td Batch al l
No. No.

______________________________________
Name & Signature of Vaccinator 2
e then select download.

(in vials):_______
ials):_______
n vials):_______
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SCHOOL-BASED IMMUNIZATION
Recording Form 2: Masterlist of Grade 7 Students

Region: VIII Name of School: Burauen National HS Section: Bolivar

MR: Td:
Barangay: Camansi Dist.1 District/Municipality: Burau Number of Vaccine Received (in vials):_______Number of Vaccine Received (in vials):_______
Number of Vaccine Used (in vials):_______ Number of Vaccine Used (in vials):_______
City/Province: Leyte Date: November 11,2024 Number of Vaccine Unused (in vials):_______ Number of Vaccine Unused (in vials):_______

To be filled out by Local Health Center / Vaccination Team Date of Consent today?
Name Birth History of Vaccine Given Deferr Refusa
Complete Address Age Sex Slip (Fever, Lot/ Lot/ Reasons
(Surname, First Name, MI) MM/DD/ Y N Allergies Y N MR Batch Td Batch al l
YYYY No. No.
1 Advincula, James C. Brgy. Sambel 3/2/2012 12 M √
2 Agustin, Denver A. Malitbog Dist.3 12/5/2002 14 M √ 4
3 Apostol,Andrew James M. Maghubas 11/13/2011 13 M √ 4
4 Bantula, Elvie D. Tabuanon 3/10/2011 13 M √ 4
5 Cabudoc, Justin Jay C. Malitbog Dist.3 6/9/2011 13 M √ 3
6 Cadion, Elthon Vanne B. Hugpa West 12/12/2011 13 M √ 4
7 Candela, Niῆo Carl B. Matin-ao 11/27/2011 13 M √
8 Coral, Albert C. Villa Rosas 12/9/2011 13 M √ 3
9 Dagala, Mark Gale Cagangon 05/22/2012 12 M √ 3
10 De Paz, Aljhon A. Cadahunan 2/9/2011 13 M √
11 Famor, Prince Gerome Sto. Niῆo St. 06/29/2012 12 M √
12 Juarez, Roger R. Takin 8/1/2012 12 M √ 3
13 Maceda, Jhayril D. Cagangon 04/23/2011 13 M √ 3
14 Mandreza, Oscar III L. San Juan St. 10/27/2011 13 M √ 4
15 Narca, Ralph L. Matin-ao 03/19/2010 14 M √ 4
16 Redoῆa, Elias R. Gamay 11/16/2010 14 M √ 4
17 Redubla, Elvin M. Pangdan 9/3/2011 13 M √
18 Refugido, Carlos Dwannie Catagbacan 3/7/2012 12 M √ 4
19 Rellesiva, Reyvin T. Arado 05/30/2010 14 M √ 4
20 Remandaban, Shaun JuerainPatong 01/31/2012 12 M √
21 Almarines, Ellaijha A. A Benitez St. Guinarona 07/22/2012 12 F √
22 Almo, Shiela Mae T. Malaihao 03/16/2012 12 F √ 3
23 Arabejo, Rhian Jane T. Arado 7/7/2012 12 F √
24 Barbosa, Atipal Gloria T. Villarosas 05/18/2012 12 F √ 3
25 Boco, Janche Nicole M. San Juan St. 2/8/2012 12 F √ 3
26 Brown, Zyra Lawrence C. San Jose St. 03/18/2012 12 F √
27 Canaber, Pauline May C. Matin-ao 07/15/2012 12 F √ 4
28 Capangpangan, Judy Ann L. Toloyao 12/22/2011 13 F √
29 Cerna, Lynrose R. San Joaquin St. 10/10/2011 13 F √ 4
30 Enabore, May Eurosayas A. San Joaquin St. 10/2/2012 12 F √
31 Lansita,Joeffrem D. Gamay 02/25/2012 12 F √ 4
32 Manasis, Ashley Jean V. Buri 11/29/2011 13 F √
33 Manidlanagan, Cassidy C. Camansi 08/24/2012 12 F √ 4
34 Mendoza, Michaella R. Buri 4/3/2012 12 F √
35 Partulan, Ynnah Mae P. San Miguel St. Dist.4 07/15/2011 13 F √ 3
36 Patiom, Erika P. Pangdan 07/15/2012 12 F √
37 Raga, Angelin< Catagbacan 08/15/2012 12 F √
38 Raga, Cielo There Transferred Out
39 Reforzado, Janine Kyle C. San Juan St. 01/20/2012 12 F √ 3
40 Villa, Delmarie Roxas 5/3/2012 12 F √ 3

____________________________ ___________________________________ _________________________________________

Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2
e then select download.

n vials):_______
als):_______
vials):_______
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SCHOOL-BASED IMMUN
Recording Form 3: Masterlist of Gra

Region: _________________________ Name of School: _________________________Section: _____

Barangay: _______________________District/Municipality: ______

City/Province: __________________ Date: ______________________

To be filled out by Local Health Center / Vaccination Team ToDate

be filled
of out by V
Date of
Name Birth HPV
Complete Address Age Sex HPV
Received
(Surname, First Name, MI) MM/DD/
YYYY 1
1
2
3
4
5
6
7
8
9
10

______________________________ _____________________________ _______________________

Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signature of V
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OOL-BASED IMMUNIZATION
Masterlist of Grade 4 Female Students

HPV:
Number of Vaccine Received (in vials):_______
Number of Vaccine Used (in vials):_______
Number of Vaccine Unused (in vials):_______

ToDate
be filled
of out by Vaccination Team
Consent today?
HPV History of Vaccine Given Deferr Refusa
HPV Slip (Fever, HPV Lot/ Lot/
HPV Batch
Received Y N Allergies Y N Batch al l
2 1 No. 2 No.

__________________________________ _________________________________
Name & Signature of Vaccinator 2 Name & Signature of Recorder
file then select download.

Reasons
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School-Based Immunization
DAILY SUMMARY REPORTING Form: RHU Consolidated Accomplishment Form Report

Region: ____________________________
Date: ______________________________
Province/City: _________________________ Municipal/City: _________________________

Grade 1 Grade 4 Female Grade 7

Students Students Students Students
No. of female students
vaccinated vaccinated Total no. of deferred Total no. of refusal Total no. of deferred Total no. of refusal vaccinated vaccinated Total no. of deferred Total no. of refusal
vaccinated
Name of Schools Total no. w/ MR w/ Td w/ MR w/ Td
Total no. Total no. of
of
of students
students 1st 2nd 1st 2nd 1st 2nd
enrolled enrolled
enrolled dose dose dose dose dose dose
No. % No. % MR % Td % MR % Td % % % % % % % No. % No. % MR % Td % MR % Td %
of of of of of of
HPV HPV HPV HPV HPV HPV

Total

Grade 1: Grade 7: Grade 4 Female:

MR: MR: HPV:
Number of Vaccine Received (in vials):_______ 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 Used(in vials):_______
Number of Vaccine Unused(in vials):_______ Number of Vaccine Unused(in vials):_______ Number of Vaccine Unused(in vials):_______

Td: 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):_______