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  • CEIR Registration Form Front

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    jhon villafuerte
    61 views2 pages
    The document appears to be a form for registering individuals in the COVID-19 Electronic Immunization Registry (CEIR). It requests information such as name, contact details, demographic information, occupation, and whether the individual interacts with COVID patients. The form must be filled in capital letters and requires fields marked with an asterisk. It collects information to identify priority groups for COVID-19 vaccination.

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    The document appears to be a form for registering individuals in the COVID-19 Electronic Immunization Registry (CEIR). It requests information such as name, contact details, demographic information, occupation, and whether the individual interacts with COVID patients. The form must be filled in capital letters and requires fields marked with an asterisk. It collects information to identify priority groups for COVID-19 vaccination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    61 views2 pages

    CEIR Registration Form Front

    Uploaded by

    jhon villafuerte
    The document appears to be a form for registering individuals in the COVID-19 Electronic Immunization Registry (CEIR). It requests information such as name, contact details, demographic information, occupation, and whether the individual interacts with COVID patients. The form must be filled in capital letters and requires fields marked with an asterisk. It collects information to identify priority groups for COVID-19 vaccination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    COVID-19 Electronic Immunization Registry (CEIR)

    Note: PLEASE USE CAPITAL LETTERS TO FILL IN THIS FORM ASTERISK(*) are required field

    Category*: [ ] Health Care Worker [ ] Senior Citizen [ ] Indigent [ ] Uniform Personnel [ ] Essential Worker [ ] Others

    Category ID*:[ ] PRC Number [ ] OSCA Number [ ] Facility ID Number [ ] Other ID

    Category ID No.*:
    Philhealth ID*:
    PWD ID:
    Last Name* First Name* Middle Name* Suffix*

    Contact No*.
    Current Residence: (Unit/Building/House No., Street Name)*

    Current Residence Region:


    Current Residence Province*:
    Current Residence Municipality/City*:
    Current Residence Barangay*:

    Sex*: [ ] Male [ ] Female Birthdate (mm/dd/yyyy)*: / /

    Civil Status*: [ ] Single [ ] Married [ ] Widow/Widower [ ] Separated/Annulled [ ] Living w/ Patner

    Employment
    *: Status [ ] Government Employed [ ] Private Employed [ ] Self Employed [ ] Private Practitioner [ ] Other

    Directly in interaction with COVID patient* [ ] Yes [ ] No

    Profession* [ ] Dental Hygienist [ ] Dental Technologist [ ] Dentist [ ] Medical Technologist [ ] Midwife [ ] Nurse

    [ ] Nutritionist Dietician [ ] Occupational Therapist [ ] Occupational Therapist [ ] Optometrist

    [ ] Pharmacist [ ] Physical Theraphist [ ] Physician [ ] Radiologic Technologist [ ] Respiratory Therapist

    [ ] X ray Technologist [ ] Barangay Health Worker [ ] Maintenance Staff [ ] Administrative Staff [ ] Other

    COVID-19 Electronic Immunization Registry (CEIR)


    Note: PLEASE USE CAPITAL LETTERS TO FILL IN THIS FORM ASTERISK(*) are required field

    Category*: [ ] Health Care Worker [ ] Senior Citizen [ ] Indigent [ ] Uniform Personnel [ ] Essential Worker [ ] Others

    Category ID*:[ ] PRC Number [ ] OSCA Number [ ] Facility ID Number [ ] Other ID

    Category ID No.*:
    Philhealth ID*:
    PWD ID:
    Last Name* First Name* Middle Name* Suffix*

    Contact No*.
    Current Residence: (Unit/Building/House No., Street Name)*

    Current Residence Region:


    Current Residence Province*:
    Current Residence Municipality/City*:
    Current Residence Barangay*:

    Sex*: [ ] Male [ ] Female Birthdate (mm/dd/yyyy)*: / /

    Civil Status*: [ ] Single [ ] Married [ ] Widow/Widower [ ] Separated/Annulled [ ] Living w/ Patner

    Employment
    *: Status [ ] Government Employed [ ] Private Employed [ ] Self Employed [ ] Private Practitioner [ ] Other

    Directly in interaction with COVID patient* [ ] Yes [ ] No

    Profession* [ ] Dental Hygienist [ ] Dental Technologist [ ] Dentist [ ] Medical Technologist [ ] Midwife [ ] Nurse

    [ ] Nutritionist Dietician [ ] Occupational Therapist [ ] Occupational Therapist [ ] Optometrist

    [ ] Pharmacist [ ] Physical Theraphist [ ] Physician [ ] Radiologic Technologist [ ] Respiratory Therapist

    [ ] X ray Technologist [ ] Barangay Health Worker [ ] Maintenance Staff [ ] Administrative Staff [ ] Other
    Leoven M. Regalado
    MHO Calabanga

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