School-Based Immunization

Recording Form 1: Masterlist of Grade 1 Students

Region:______________________________ Name of School:____________________________________________ Section:___________________ MR Td

Province/City:_________________________ Division:__________________________________________________ Lot No.:_______________ Lot No.:_______________
District/Municipality:____________________ Date:_____________________________________________________ Batch No.:_____________ Batch No.:_____________

Parents' sick today

Date of previous MCV
Response History of Allergies (food, Vaccine Given
Received
No. Name (Surname,
Complete Address
Date of Birth
Age Sex Slip meds, previous (fever, etc.) Refusal Reasons for Deferred/Refusal
First Name, MI) MM/DD/YY Zero immunizaion
MCV 1 MCV 2 Y N Y N MCV 1 MCV 2 Td
1 Dose
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name of Signature of Vaccinator 2 Name and Siganture of Recorder
 School-Based Immunization
Recording Form 2: Masterlist of Grade 4 Female Students(9-13 yrs. Old)

Region:______________________________ Name of School:____________________________________________ Section:___________________ HPV

Province/City:_________________________ Division:__________________________________________________ Lot No.:_______________
District/Municipality:____________________ Date:_____________________________________________________ Batch No.:_____________

Parents' History of Allergies Sick today? Date of HPV Given

No. date of Birth Response (food, meds, (fever) Reason for Deferred/
Name (Surname, First name, MI) Complete Address Age Sex Deferred Refusal
(MM/DD/YY) previous Refusal
Y N immunization) Y N 1st Dose 2nd dose

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name of Signature of Vaccinator 2 Name and Siganture of Recorder
 School-Based Immuniza
Recording Form 3: Masterlist of Gra

Region:______________________________ Name of School:____________________________________________

Province/City:_________________________ Division:__________________________________________________
District/Municipality:____________________ Date:____________________________________________________

Parents'
Name Date of Birth Response
Complete Address Age Sex
No. (Surname, First Name, MI) MM/DD/YY Slip
Y N
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22

Name and Signature of Supervisor Name and Signature of Vaccinator 1

 School-Based Immunization
Recording Form 3: Masterlist of Grade 7 Students

_________________________________ Section:___________________ MR
_________________________________ Lot No.:_______________
_________________________________ Batch No.:_____________

History of Allergies Sick Today Last Menstrual Potentially

(Food, meds, Vaccine Given
(Fever) Period (for Pegnant Deferred Refusal
previous
female only) (Y/N)
immunization) Y N MR Td

Name of Signature of Vaccinator 2 Name and Siganture of Recorder

 Td
Lot No.:_______________
Batch No.:_____________

Reason of Deferred/
Refusal

Siganture of Recorder