Annex B: Recording Form 1 - Masterlist of Grade 1 Students
SCHOOL-BASED IMMUNIZATION
Recording Form 1: Masterlist of Grade 1 Students
Region: VIII____________________________
Name of School: ________________________________________________ MR: Td:
Barangay: _________________________District/Municipality _____________________________________________ Number of Vaccine Received (in vials): _______ Number of Vaccine Received (in vials): _______
City/Province: Tacloban City Date: ________________________________________________ Number of Vaccine Used (in vials): ___________ Number of Vaccine Used (in vials): ___________
Number of Vaccine Unused (in vials): _________ Number of Vaccine Unused (in vials): _________
To be filled out by Local Health Center / Vaccination Team To be filled out by Local Health Center / Vaccination Team
Date of MCV Consent Sick today? Vaccine Given
Name Date of Birth Slip History of (fever,etc.)
(Surname, First Name, M.I.) Complete Address Age Sex Allergies Deferral Refusal Reasons
MM/DD/YYYY Lot/ Lot/ Lot/
MCV 1 MCV 2 Y N Y N MR1 Batch MR2 Batch Td Batch
No. No. No.
10
____________________________________ ____________________________________ ____________________________________
____________________________________
Name & Signature of Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2 Name & Signature of Recorder
Annex C: Recording Form 2 - Masterlist of Grade 7 Students
SCHOOL-BASED IMMUNIZATION
Recording Form 2: Masterlist of Grade 7 Students
Region: VIII____________________________
Name of School: _______ V&G NATIONAL HIGH SCHOOL MR: Td:
Barangay: _________________________District/Municipality _____________________________________________ Number of Vaccine Received (in vials): _______ Number of Vaccine Received (in vials): _______
City/Province: Tacloban City Date: ________________________________________________ Number of Vaccine Used (in vials): ___________ Number of Vaccine Used (in vials): ___________
Number of Vaccine Unused (in vials): _________ Number of Vaccine Unused (in vials): _________
To be filled out by Local Health Center / Vaccination Team To be filled out by Local Health Center / Vaccination Team
Date of MCV Consent Sick today? Vaccine Given
Name Date of Birth Received Slip History of (fever,etc.)
(Surname, First Name, M.I.) Complete Address Age Sex Allergies Deferral Refusal Reasons
MM/DD/YYYY Lot/ Lot/ Lot/
MCV 1 MCV 2 Y N Y N MR1 Batch MR2 Batch Td Batch
No. No. No.
1
ACERO, REX CHRISTIAN
2
BASON, JOSHUA
3
CABUGO, JAMES KEN
4
CAPATE, JHON MIKEY
5
CELESPARA, PRINCE CHARLES
6
DAYANDAYAN, RAFFAELE SHONE
7
DECHOS, MAKEEN JED
8
ENECILLO, ALEJANDRO
9
ESCOREL, RHEIN
10
ESMENA, BEN ANGELO
11
GEREZ, JASPER
12
HABACON, JESSRAEL
13
JAINGUE, DENMARK
14 LABITA, PRINCE BRYAN
15 LAURENCIANO, VIC JHON
16 MALINAO, VINCINT
17 MIRASOL, MATT ANDREW
18 PERINO, JOHN NINO
19 SUSAYA, KHLARENZ
20 TUMANDAO, RABBI
21 ALGO, MARY ANN RIZA
22 BASON, JOEY ANN
23 BARREDO, ROBIJHEN
24 BARREDO, ANGEL
25 CASAS,ANGELINE
26 CLARIDAD, CRISTHAL PRINCESS
27 DAJES, MARJORIE
28 DUMAS, TAYLOR
29
30
____________________________________ ____________________________________ ____________________________________
____________________________________
Name & Signature of Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2 Name & Signature of Recorder
Annex D: Recording Form 3 - Masterlist of Grade 4 Female Students
SCHOOL-BASED IMMUNIZATION
Recording Form 3: Masterlist of Grade 4 Female Students
Region: VIII____________________________
Name of School: ________________________________________________ HPV
Barangay: _________________________ District/Municipality _____________________________________________ Number of Vaccine Received (in vials): _______
City/Province: Tacloban City Date: ________________________________________________ Number of Vaccine Used (in vials): ___________
Number of Vaccine Unused (in vials): _________
To be filled out by Local Health Center / Vaccination Team To be filled out by Local Health Center / Vaccination Team
Date of HPV Consent Sick today? Vaccine Given
Name Date of Birth Received Slip History of (fever,etc.)
(Surname, First Name, M.I.) Complete Address Age Sex Allergies Deferral Refusal Reasons
MM/DD/YYYY Lot/
HPV Batch Lot/
HPV 1 HPV 2 Y N Y N 1 HPV 2 Batch
No. No.
10
____________________________________ ____________________________________ ____________________________________
____________________________________
Name & Signature of Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2 Name & Signature of Recorder
