ANNEX A.

Reporting for 2021 Community -based MR-Td Immunization

COMMUNITY -based Immunization Activity

RECORDING Form 1 : MR - Td (6 - 7 Years Old)
RegionII

Provin ISABELA

Distric SAN MARIANO

To be filled up by theVaccination Team

History of allergies Sick today? Date of Vaccine Vaccinated Deferral

Name Date of Birth ( fever, etc) given Deferred (D)
No. (Surname, First Name, MI) Complete Address MM/DD/YY Age Sex (foods,meds,previous
Refused ( R ) (VD) Vaccinated Remarks
Immunization) Refusal (VR)
Y N MR Td

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________________________________________________ ________________________________________________
________________________________________________
Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2

________________________________________________ _____________________________________________

Name and Signature of Recorder Name and Signature of Recorder

 Community -based Immunization Activity
RECORDING Form 2: MR - Td ( 12-13 Years Old)
Regio II

ProvinISABELA

Distri SAN MARIANO I

To be filled up by the Vaccination Team

Sick today?
( fever) Vaccine Given
Vaccinated
History of allergies Deferred (D) Deferral
Date of Birth
No. Name Complete Address MM/DD/YY Age Sex (food, meds, previous Refused (VD) Vaccinated Remarks
immunization MR/Td) MR Td (R) Refusal
Y N (VR)

AGLUGUB,XAVIER DANE, GARO BITABIAN, SAN MARIANO, ISABELA 11-05-2009 10 MALE

1 \

AGTANG,PATRICK JOHN, SALADINO BITABIAN, SAN MARIANO, ISABELA 05-25-2009 11 MALE

2

BAGAUISAN,SANDRELLE, SUBIA BITABIAN, SAN MARIANO, ISABELA 10-24-2008 12 MALE

3

BUMAGAT,RAINE STEUART, LIMBAUAN BITABIAN, SAN MARIANO, ISABELA 10-17-2009 11 MALE

4

GUITANG,JAYVEE MARK, CAGURANGAN BITABIAN, SAN MARIANO, ISABELA 02-23-2009 11 MALE

5

LAGUTAO,ALDREI, PADDIT BITABIAN, SAN MARIANO, ISABELA 07-17-2009 11 MALE

6

MALANA,RICO, VINARAO DIPUSU, SAN MARIANO, ISABELA 08-10-2008 12 MALE

7

MAYOR,JERALD, SALAGUINTO BITABIAN, SAN MARIANO, ISABELA 09-23-2008 12 MALE

8

MONTERICO,KEINS ZYRON, AGLUGUB BITABIAN, SAN MARIANO, ISABELA 02-23-2009 11 MALE

9

PAGULAYAN,GERALD, TURQUEZA BITABIAN, SAN MARIANO, ISABELA 09-17-2009 11 MALE

10

PASCUA,JAYPEE, CADIENTE BITABIAN, SAN MARIANO, ISABELA 11-28-2009 10 MALE

11

VALENCIA,JUNE ANTHENOR, PAMINTUAN BITABIAN, SAN MARIANO, ISABELA 06-21-2009 11 MALE

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VIZCARA,RANNIE, LAGGUI BITABIAN, SAN MARIANO, ISABELA 10-29-2009 11 MALE

13

VIZCARA,VHON ERRON, BAGAUISAN BITABIAN, SAN MARIANO, ISABELA 03-02-2009 11 MALE

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ACIDERA,HANNA LEA, SALAGUINTO BITABIAN, SAN MARIANO, ISABELA 08-08-2009 11 FEMALE

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 CABALDO,KATRINA, MARALLAG BITABIAN, SAN MARIANO, ISABELA 03-06-2006 14 FEMALE
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DANCEL,QUENSY, BALIUAG BITABIAN, SAN MARIANO, ISABELA 01-26-2009 11 FEMALE

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DE GOLLO,KYRIE ELAIZA, GANGAN BITABIAN, SAN MARIANO, ISABELA 10-09-2009 11 FEMALE

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GAMIAO,JANYLLA MAFANE, DELOS SANTOS BITABIAN, SAN MARIANO, ISABELA 05-25-2009 11 FEMALE
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RUBIO,NERIE JOY, BAGAUISAN BITABIAN, SAN MARIANO, ISABELA 11-18-2008 11 FEMALE

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SALAGUINTO,MARIANNE, JUAN BITABIAN, SAN MARIANO, ISABELA 11-18-2009 10 FEMALE

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TIZON,SHADDY RAIZALYN, ANDRES BITABIAN, SAN MARIANO, ISABELA 12-13-2008 11 FEMALE

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________________________________________________
Name and Signature
____MARYLEN of Supervisor
T. JACINTO______ Name and Signature of Vaccinator 1 ________________________________________________
Name and Signature of Vaccinator 2

________________________________________________ ________________________________________________
Name and Signature of Recorder \ Name and Signature of Recorder
 Community -based Immunization Activity
RECORDING Form 3: HPV Masterlist of Female 9-14 years old

RegionII

ProvinISABELA

Distri SAN MARIAO I

To be filled up by the Vaccination Team

Sick today? Date of HPV Vaccine Vaccinated
( fever) Given Deferred (D)
No. Name (1) (Surname, First Name, MI) Complete Address (2) Date of Birth Age Sex History of allergies Refused Deferral (VD) Remarks
MM/DD/YY (food, meds, (R) Vaccinated
Y N 1st dose 2nd dose Refusal (VR)
previous immunization)

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Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2

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Name and Signature of Recorder Name and Signature of Recorder