School-Based Immunization

RECORDING Form 1: Masterlist of Kinder

To be filled up by the Vacc

Region: _________________________ Name of School: _______________________________Grade Level: ________________ MCV:
Lot No: _____________
Province/City: ___________________ Division: _____________________ Section: ____________________ Batch No:___________

District/Municipality: _____________ Date: ______________

To be filled up by the School Nurse / Class Adviser To be filled up by the Vaccin

Date of previous Parent's Sick today?

Date of Birth MCV received Response Slip History of allergies (fever, etc)
No. Name (Surname, First Name, MI) Complete Address Age Sex (food, meds, previous
(MM/DD/YY) immunization)
Zero
dose MCV1 MCV2 Yes No Y N

1
2
3
4
5
6
7
8
9
10

______________________________ ______________________________ ______________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
a - No Consent (Consent not Return) f - Vaccine post too far away
b - Child received 2 or more doses g - Vaccine post did not have vaccine
c - Child was sick h - Religious Beliefs
d - Child was absent/away from home I - Fear of Vaccine
e - Unaware of the campaign/location of post j - Consent which parents indicate not to give vaccine
 p by the Vaccination Team

__________
_________

by the Vaccination Team

Reasons for
Vaccine Given Unvaccinated
(refer to the list
below) *record only
the codes
MCV1 MCV2

_____________________________
Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 1 Students

To be filled up by the Vacc

Region: _________________________ Name of School: _______________________________Section: ____________________ MCV
Lot No: _____________
Province/City: ___________________ Division: _____________________ Batch No:___________

District/Municipality: _____________ Date: ______________ Td

Lot No: _____________
Batch No: ___________

To be filled up by the School Nurse / Class Adviser To be filled up by the Va

Date of previous Parent's Sick today?

Date of Birth MCV received Response Slip History of allergies (fever, etc)
No. Name (Surname, First Name, MI) Complete Address Age Sex (food, meds, previous
(MM/DD/YY) immunization)
Zero
dose MCV1 MCV2 Yes No Y N

1
2
3
4
5
6
7
8
9
10
TOTAL

______________________________ ______________________________ ______________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
a - No Consent (Consent not Return) f - Vaccine post too far away
b - Child received 2 or more doses g - Vaccine post did not have vaccine
c - Child was sick h - Religious Beliefs
d - Child was absent/away from home I - Fear of Vaccine
e - Unaware of the campaign/location of post j - Consent which parents indicate not to give vaccine
p by the Vaccination Team

__________
_________

__________
__________

up by the Vaccination Team

Reasons for
Vaccine Given Unvaccinated
(refer to the list
below) *record only
the codes
MCV1 MCV2 Td

_____________________________
Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 2 Students

To be filled up by the Vacc

Region: _________________________ Name of School: _______________________________Grade Level: ________________ MCV
Lot No: _____________
Province/City: ___________________ Division: _____________________ Section: ____________________ Batch No:___________

District/Municipality: _____________ Date: ______________

To be filled up by the School Nurse / Class Adviser To be filled up by the Vaccin

Date of previous Parent's Sick today?

Date of Birth MCV received Response Slip History of allergies (fever, etc)
No. Name (Surname, First Name, MI) Complete Address Age Sex (food, meds, previous
(MM/DD/YY) immunization)
Zero
dose MCV1 MCV2 Yes No Y N

1
2
3
4
5
6
7
8
9
10

______________________________ ______________________________ ______________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
a - No Consent (Consent not Return) f - Vaccine post too far away
b - Child received 2 or more doses g - Vaccine post did not have vaccine
c - Child was sick h - Religious Beliefs
d - Child was absent/away from home I - Fear of Vaccine
e - Unaware of the campaign/location of post j - Consent which parents indicate not to give vaccine
 p by the Vaccination Team

__________
_________

by the Vaccination Team

Reasons for
Vaccine Given Unvaccinated
(refer to the list
below) *record only
the codes
MCV1 MCV2

_____________________________
Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 4: Masterlist of Grade 3 Students

To be filled up by the Vacc

Region: _________________________ Name of School: _______________________________Grade Level: ________________ MCV
Lot No: _____________
Province/City: ___________________ Division: _____________________ Section: ____________________ Batch No:___________

District/Municipality: _____________ Date: ______________

To be filled up by the School Nurse / Class Adviser To be filled up by the Vaccin

Date of previous Parent's Sick today?

Date of Birth MCV received Response Slip History of allergies (fever, etc)
No. Name (Surname, First Name, MI) Complete Address Age Sex (food, meds, previous
(MM/DD/YY) immunization)
Zero
dose MCV1 MCV2 Yes No Y N

1
2
3
4
5
6
7
8
9
10

______________________________ ______________________________ ______________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
a - No Consent (Consent not Return) f - Vaccine post too far away
b - Child received 2 or more doses g - Vaccine post did not have vaccine
c - Child was sick h - Religious Beliefs
d - Child was absent/away from home I - Fear of Vaccine
e - Unaware of the campaign/location of post j - Consent which parents indicate not to give vaccine
 p by the Vaccination Team

__________
_________

by the Vaccination Team

Reasons for
Vaccine Given Unvaccinated
(refer to the list
below) *record only
the codes
MCV1 MCV2

_____________________________
Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 5: Masterlist of Grade 4 Students

Region: _________________________ Name of School: _______________________ Section: ________________

Province/City: ___________________ Division: ___________________________

District/Municipality: _____________ Date: ______________________

To be filled up by the School Nurse / Class Adviser

Date of previous MCV Had received Parent's Sick toda

Dengue History of allergies
Date of Birth received Response Slip (fever, et
No. Name (Surname, First Name, MI) Complete Address Age Sex Vaccine? (food, meds, previous
(MM/DD/YY) immunization)

Zero
dose MCV1 MCV2 Y N Yes No Y

1
2
3
4
5
6
7
8
9
10

______________________________ ______________________________ ____________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator
a - No Consent (Consent not Return) f - Vaccine post too far away
b - Child received 2 or more doses g - Vaccine post did not have vaccine
c - Child was sick h - Religious Beliefs
d - Child was absent/away from home I - Fear of Vaccine
e - Unaware of the campaign/location of post j - Consent which parents indicate not to give vaccine
 To be filled up by the Vaccination Team
HPV
Lot No: _____________
Batch No:___________

MCV
Lot No: _____________
Batch No:___________

To be filled up by the Vaccination Team

Date of HPV Vaccine Given Reasons for

today? (For Female 9-14 y/o Unvaccinated
ver, etc) Date of MR
Students Only) (refer to the list
vaccine given
below) *record only the
codes

N 1st dose 2nd dose

_______ _____________________________
nator 2 Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 6: Masterlist of Grade 5 Students

Region: IV-A Name of School: VICENTE P. VILLANUEVA MEMORIAL Grade Level: 5

Province/City: DASMARINAS CAVITE Division:DASMARINAS Section: EXODUS

District/Municipality: _DASMARINAS_ Date: AUG.23,2019

To be filled up by the School Nurse / Class Adviser To be filled u

Had received
Date of previous Parent's
Dengue
Date of Birth MCV received Response Slip History of allergies
No. Name (Surname, First Name, MI) Complete Address Age Sex Vaccine? (food, meds, previous
(MM/DD/YY) immunization)
Zero
dose MCV1 MCV2 Y N Yes No

1 PONCE,IERA S SAMPALOC 1 10/18/2009 10 F

2 GORUMUCHU , J ANDRIX P SAMPALOC 1,DASMARINAS CIT 2/26/2009 10 M
3 LERIT, KARLA MAE M SAMPALOC 1,DASMARINAS CIT 6/2/2009 10 F
4 ALEDIA, VINCE F SAN AGUSTIN I DASMARINAS CI 9/6/2009 10 M
5 NAWAF ROC B SAMPALOC 1 DASMARINAS CIT 3/26/2008 11 M
6
7
8
9
10

______________________________ ______________________________ ______________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
a - No Consent (Consent not Return) f - Vaccine post too far away
b - Child received 2 or more doses g - Vaccine post did not have vaccine
c - Child was sick h - Religious Beliefs
d - Child was absent/away from home I - Fear of Vaccine
e - Unaware of the campaign/location of post j - Consent which parents indicate not to give vaccine
 To be filled up by the Vaccination Team
MCV
Lot No: _____________
Batch No:___________

be filled up by the Vaccination Team

Sick today? Vaccine Given Reasons for

(fever, etc) Unvaccinated
(refer to the list
below) *record only
the codes
Y N MCV1 MCV2

_____________________________
Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 7: Masterlist of Grade 6

Region: _ IV-A CALABARZON Name of School: ___________ VPVMS Grade Level: SIX

Province/ CAVITE Division: DASMARINAS Section: ____ VIRGO

District/M DASMARINAS Date: __23 AUGUST 2019____________

To be filled up by the School Nurse / Class Adviser To be fi

Had received
Date of previous Parent's
Dengue
Date of Birth MCV received Response Slip History of allergies
No. Name (Surname, First Name, MI) Complete Address Age Sex Vaccine? (food, meds, previous
(MM/DD/YY) immunization)
Zero
dose MCV1 MCV2 Y N Yes No

1 Hernandez'Rhon Howard M. Sampaloc I,Dasma,City 11/15/2007 11 M

11/22/2007
2 Ygay,Wilmar A. Sampaloc I,Dasma,City 11 M
11/8/2008
3 Batallones,Samantha Nicole H. Sampaloc I,Dasma,City 11 F
4 Oberez, Edcel Gloraine A. Sampaloc I,Dasma,City 7/5/2008 11 F
5
6
7
8
9
10

______________________________ ______________________________ ______________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
a - No Consent (Consent not Return) f - Vaccine post too far away
b - Child received 2 or more doses g - Vaccine post did not have vaccine
c - Child was sick h - Religious Beliefs
d - Child was absent/away from home I - Fear of Vaccine
e - Unaware of the campaign/location of post j - Consent which parents indicate not to give vaccine
 To be filled up by the Vaccination Team
MCV
Lot No: _____________
Batch No:___________

be filled up by the Vaccination Team

Sick today? Vaccine Given Reasons for

(fever, etc) Unvaccinated
(refer to the list
below) *record only
the codes
Y N MCV1 MCV2

_____________________________
Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 8: Masterlist of Grade 7 Students

Regio IV-A CALABAZON Name of School: ___________ VPVMS

Provi CAVITE Division: ____ DASMA Section: ____ VIRGO

Distr DASMARINAS Date: ______________

To be filled up by the School Nurse / Class Adviser To be

Had received History of allergies Sick today?

Date of previous Parent's
Dengue (food, meds,
Date of Birth MCV received Response Slip (fever, etc)
No. Name (Surname, First Name, MI) Complete Address Age Sex Vaccine? previous
(MM/DD/YY) immunization
MR/Td)
Zero
dose MCV1 MCV2 Y N Yes No Y N

1 Hernandez,Rhon Howard M. Sampaloc 1,dasmarinas Ciy

2
3
4
5
6
7
8
9
10

______________________________ ______________________________ ______________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signat

a - No Consent (Consent not Return) f - Vaccine post too far away

b - Child received 2 or more doses g - Vaccine post did not have vaccine
c - Child was sick h - Religious Beliefs
d - Child was absent/away from home I - Fear of Vaccine
e - Unaware of the campaign/location of post j - Consent which parents indicate not to give vaccine
 To be filled up by the Vaccination Team
MCV
Lot No: _____________
Batch No:___________

Td
Lot No: _____________
Batch No: ___________

o be filled up by the Vaccination Team

Last Reasons for

Menstrual Potentially Vaccine Given Unvaccinated
Period (for Pregnant (refer to the list
FEMALES (Y/N) below) *record only
only) the codes
MR Td
(R arm) (L arm)

_____________________ _____________________________
Signature of Vaccinator 2 Name and Signature of Recorder
Region: _________________________________________

Province/City/Municipality: __________________________

Kinder

Province/City/Municipality
Total No. of
Enrolled Students Total No. of Enrolled
Total No. of Students with (0) or
Enrolled Students with 2 doses of (1) MCV dose
MCV Received

Region 4A
0 0 0
Batangas Total
0 0 0

Batangas (Municipalities)

Batangas City

Lipa City

Tanauan City

Cities Batangas 0 0 0

Cavite Total 0 0 0

Cavite (Municipalities)

Bacoor

Cavite City

Imus 1

Imus 2

Imus 3

Dasmariñas 1

Dasmariñas 2

Gen. Trias
Tagaytay

Trece Martires

Cities Cavite 0 0 0

Laguna Total 0 0 0

Laguna (Municipalities)

Biñan 1

Biñan 2

Cabuyao 1

Cabuyao 2

Calamba

San Pablo

San Pedro 1

San Pedro 2

Sta. Rosa 1

Sta. Rosa 2

Cities Laguna 0 0 0

Quezon Total 0 0 0

Quezon (Municipalities)

Lucena

Tayabas

Cities Quezon 0 0 0

Rizal Total 0 0 0

Rizal (Municipalities)

Antipolo City
 Grade 1 Grade 2

Total No. of Total No. of Total No. of

Total No. of Enrolled Students Enrolled Students Total No. of Enrolled Enrolled Students
Enrolled Students with 2 doses of with (0) or (1) Students with 2 doses of
MCV Received MCV dose MCV Received

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
de 2 Grade 3

Total No. of Total No. of Total No. of

Enrolled Students Total No. of Enrolled Enrolled Students Enrolled Students
with (0) or (1) Students with 2 doses of with (0) or (1) Total No. of Enrolled
MCV dose MCV Received MCV dose Students

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
 Grade 4

M F

Total No. of Enrolled Total No. of Total No. of Enrolled Total No. of Enrolled
Students with 2 Enrolled Students Total No. of Students with 2 Students with (0) or
doses of MCV with (0) or (1) Enrolled Students doses of MCV
Received MCV dose Received (1) MCV dose

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
 Target Population

Grade 5 Grade 6

Total No. of Total No. of

Total No. of Enrolled Total No. of
Total No. of Enrolled Enrolled Students Enrolled Students
Students with (0) or Enrolled
Students with 2 doses of with 2 doses of
(1) MCV dose Students
MCV Received MCV Received

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
 CONSOLIDATED FO

Grade 6 Grade 7

Total No. of
Total No. of Enrolled Total No. of Enrolled
Total No. of Enrolled Enrolled Students
Students with (0) or Students with (0) or
Students with 2 doses of
(1) MCV dose (1) MCV dose
MCV Received

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0
0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0
CONSOLIDATED FORM

Total Kinder, Grade 2 to Grade 6 Total Grade 1 and Gra

Total No. of Enrolled Total No. of Enrolled

Total No. of Enrolled Students Total No. of Enrolled
with 2 doses of Students with (0) or (1)
Students Students
MCV Received MCV dose

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0
0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0
Total Grade 1 and Grade 7 Total Kinder to Grade 7

Total No. of Enrolled Total No. of Enrolled Total No. of Enrolled

Total No. of Enrolled Students
Students with 2 doses of Students with (0) or (1) with 2 doses of
Students
MCV Received MCV dose MCV Received

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0
0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0
 Total No

to Grade 7 Grade 4

Total No. of Enrolled Kinder Grade 1 Grade 2 Grade 3

Students with (0) or (1) M
MCV dose

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
 Total No. of Enrolled Students with Consent

Grade 4

Total Kinder, Grade 2 to

Grade 5 Grade 6 Grade 7 Grade 6
F

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
 Kinder Grade 1

Total Grade 1 and Grade 7 Total Kinder to Grade 7

Enrolled Students

MCV MCV Td

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
 Vaccine Given

Grade 4
Grade 2 Grade 3 Grade 5
M F

MCV MCV MCV MCV HPV 1 HPV 2 MCV

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 0 0 0 0 0
Grade 6 Grade 7

Total MCV (Kinder, Total MCV (Grade 1

Grade 2 to Grade 6) and Grade 7)

MCV MCV Td

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
 Previous Dengue Vaccine RECEIVED and G
Measles Campaign 2019

Total Td (Grade 1 and Total HPV 1 Total HPV 2

Grade 7)

Grade 4 Grade 5

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0
 Vaccine RECEIVED and GIVEN MCV this
Measles Campaign 2019

Grade 6 Grade 7

0 0

0 0

0 0

0 0
0 0

0 0

0 0

0 0

0 0

0 0
School-based Immunization: Reasons for Unvaccinated

Child Child was

No Consent (Consent not received 2 Child was absent/
PROVINCE/ City away
Return) or more sick from home
doses

Region 4A - - - -
Batangas Total -
Batangas (Municipalities)
Batangas City
Lipa City
Tanauan City
Cities Batangas -
Cavite Total -
Cavite (Municipalities)
Bacoor
Cavite City
Imus 1
Imus 2
Imus 3
Dasmariñas 1
Dasmariñas 2
Gen. Trias
Tagaytay
Trece Martires
Cities Cavite -
Laguna Total -
Laguna (Municipalities)
Biñan 1
Biñan 2
Cabuyao 1
Cabuyao 2
Calamba
San Pablo
San Pedro 1
San Pedro 2
Sta. Rosa 1
Sta. Rosa 2
Cities Laguna -
Quezon Total -
Quezon (Municipalities)
Lucena
Tayabas
Cities Quezon -
Rizal Total -
Rizal (Municipalities)
Antipolo City
 Unaware of Vaccine Vaccine Consent which
the campaign/ post post did Religious Fear of parents
too not have beliefs vaccine indicate
location of far away not to
post vaccine give vaccine

- - - - - -