COVID-19 Vaccine Delivery Support (CDS) to Intensify and Scale-up Vaccine Deployment

in Various Regions
Form MOV_2.1 Attendance Sheet for Routine Immunization
MOV2.1_v1

Name of Activity: ___________________________________ Venue: _______________________ Region: ___________

Date: __________________ Barangay/Municipality/Province: ___________________________ GIDA? YES ⃝ NO ⃝

PRIVACY NOTICE: Relief International would like to thank you for your continued trust in providing us with your personal
information. Rest assured that your data shall only be used for VALIDATION purposes only. Your information shall only be subjected
to reproduction, correction, and/or deletion upon your personal request. For data privacy concerns, you may contact us at 0917-
707-3266.

VACCINATION
VULNERABLE PURPOSES ONLY*
SEX AGE RANGE
GROUPS *vaccine dose received during
VACCINE CARD/FAMILY the CDS2 engagement
NUMBER
0-12 13-24 25-59

PENTA1

Others
MCV2

OPV3
months months months
CWD IP Others M F
old old old
(0-1 y/o) (1-2 y/o) (2-5 y/o)

10

11

12

13

14

15

16

17

18

19

20

SUMMARY OF PARTICIPANTS

FOR RELIEF INTERNATIONAL STAFF ONLY

Name & Signature of PO/CM: ___________________ Verified by MEALO: _______________________ Page____ of _____