Compliance to DILG Mc No.

2O21-007, dated January 18, 2021, entitled:

“Interim Preparatory Guidelines in the Implementation of the
National Vaccination Program"

LGU:____________

Region: NATIONAL CAPITAL REGION

NATIONAL VACCINATION PROGRAM PREPAREDNESS CHECKLIST

I. INTRODUCTION

(ln this section, write an update on the status of COVID-19 cases within the region. You
may also add relevant accomplishments herein, such as the Program, Plans, and
Activities already implemented, and the significant results of said PPAs)

II. LGU RISK COMMUNICATION PLANS

Vaccine Communication Campaigns

Means of Verification (May
Number of IECs include issuance reference
Communication Campaigns
disseminated per category numbers or photographs
attached as annexes)
Publications and Media
Collaterals produced and
disseminated by the Presidential
Communications Operations
Office (PCOO)

Publications and Media

Collaterals produced and
disseminated by the Presidential
lnformation Agency (PIA)

Publications and Media

Collaterals produced and
disseminated by other
government news agencies

LGU-initiated IEC Campaigns

on Vaccination

III. CREATION OF A MASTER-LIST OF PRIORITY AND ELIGIBLE VACCINE

RECIPIENTS
 Primary Vaccine Priorities
Priority Eligible Groups Number of Eligible Community Percentage of
Population Population (%)

1st Priority: Frontline Health

Workers

2nd Priority: Indigent Senior

Citizens

3rd Priority: Remaining Senior

Citizens

4th Priority: Remaining

Indigent Population

5th Priority: Uniformed

Personnel/Government
Workers

Secondary Vaccine Priorities

Priority Eligible Groups Number of Eligible Community Percentage of
Population Population (%)

7th Priority: Other Government

Worker

8th Priority: Other Essential

Workers outside health

9th Priority: High-risk Socio-

demographic groups (PWDs,
PDLs, IPs)

10th Priority: OFWs and

Seafarers

11th Priority: Other Remaining

IV. IDENTIFICATION OF POSIBLE VACCINE CENTERS, AVAILABLE COLD CHAIN

STORAGE FACILITIES AND OTHER LOGISTICS REQUIREMENTS

Possible Vaccine Centers

 Location of Identified Total Land Available Currently Utilized or
Remarks
Site On-site not utilized

Available Cold Chain Storage Facilities

Temperature
Capability (How cold
Location of Identified Currently Utilized or
can said storage get Remarks
Site not utilized
and could it maintain
said temperature)

Available Means of Transporting Vaccines

Means of Transportation Units ln Working condition?

Remarks
Transportation Available (Y/N)

V. HUMAN RESOURCES AND PERSONNEL AVAILABLE FOR INOCULATION OF

VACCINES

Human Resources and Personnel Available (Medical)

 Ratio of Personnel to
Patient's
Designation Number of Available Personnel Served [Example:
1:100(i.e. 1
doctor to 100 patients)]

Doctors
Nurses
Barangay Health Workers
Other Medical Personnel

Human Resources and Personnel Available (Non-Medical)

Ratio of Personnel to
Patient's
Designation Number of Available Personnel Served [Example:
1:100(i.e. 1
doctor to 100 patients)]
Drivers
Security/Crowd Control
Monitoring Personnel
Others

VI. PARTICIPATION OF HEALTH OFFICES, PUBLIC INFORMATION OFFICES,

SANITATION OFFICES, AMONG OTHERS, TO COVID-19 VACCINATION
PROGRAM TRAININGS

Participation in COVID-19 Vaccination Program Trainings

Office Number of Courses List of Courses Attended
Completed
Provincial/City/Municipal
Health Office
Provincial/City/Municipal
Public Information Office
Provincial/City/Municipal
Sanitation Office
Other Offices
(Provincial/City/Municipal
Level)

VII. PREPARENESS AND MOBILIZATION

Check (✓) the applicable boxes

Name of With existing With existing With existing With existing With COVID-
Barangay and and and and 19
 Operational
Operational
Barangay
operational Protocols for
Health operational
Emergency the Vaccination
Emergency Quarantine
operations management Action Plan
Response Facility
Center of COVID-
Team
19 Infections
(BHERT)
✓ ✓ ✓ ✓ ✓
Barangay #1

VIII. ATTACHMENTS
(You may attach copies of LGU reports herein to reflect the data above. Attachments
may also include copies of Local Ordinances and other relevant issuances.)

Consolidated by:

[sign]
NAME
Position, Office

Endorsed by:

[sign]
NAME
Position, Office

Approved by:

[sign]
NAME
Position, Office