Department of Health

Municipality of Goa
Rural Health Unit of Goa

CHIKITING LIGTAS 2023

SUPPLEMENTAL IMMUNIZATION ACTIVITY
REFUSAL FORM

Date: ___________________

Ang aking anak na si ____________________________________________, _____________, ____________,

( Pangalan ng anak na babakunahan) (Birthdate) (Edad at Gender)

ng Zone ____ Barangay____________ ay hindi ko pinapayagan na pabakunahan ng Oral Polio Vaccine (bOPV)

dahil _______________________________________________________________________________________

____________________________________________________________________________________________.

Pangalan at Lagda ng Magulang

(Signature of Parent Over Printed Name)

-----------------------------------------------------------------------------------------------------------------------------------------------------------
Department of Health
Municipality of Goa
Rural Health Unit of Goa

CHIKITING LIGTAS 2023

SUPPLEMENTAL IMMUNIZATION ACTIVITY
REFUSAL FORM

Date: ___________________

Ang aking anak na si ____________________________________________, _____________, ____________,

( Pangalan ng anak na babakunahan) (Birthdate) (Edad at Gender)

ng Zone _______ Barangay____________ ay hindi ko pinapayagan na pabakunahan ng Oral Polio Vaccine (bOPV)

dahil _______________________________________________________________________________________

____________________________________________________________________________________________.

Pangalan at Lagda ng Magulang

(Signature of Parent Over Printed Name)