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

This document is a recording form summarizing immunization information for grade 7 students at New Era High School in Quezon City, National Capital Region, Philippines. It includes columns for student name, address, date of birth, gender, allergy history, last menstrual period, potential pregnancy, vaccine details, and reasons for deferral or refusal. The form is used to track which students received vaccinations and document any reasons why vaccinations were deferred or refused. It is signed by the school nurse, vaccinator, and division representative.

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Laarni Quindoyos Antonio
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355 views2 pages

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

This document is a recording form summarizing immunization information for grade 7 students at New Era High School in Quezon City, National Capital Region, Philippines. It includes columns for student name, address, date of birth, gender, allergy history, last menstrual period, potential pregnancy, vaccine details, and reasons for deferral or refusal. The form is used to track which students received vaccinations and document any reasons why vaccinations were deferred or refused. It is signed by the school nurse, vaccinator, and division representative.

Uploaded by

Laarni Quindoyos Antonio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Recording Form 3

School – Based Immunization


Masterlist of Grade 7 Students

Region: National Capital Region Name of School : New Era High School Section: ___________________________
Province/City: Quezon City Division: Quezon City
Municipality: _______________ Date: ______________________

Parent’s Sick today?

Deferred

Refused
Name Complete Address Date of Birth Gender History of allergies Last Menstrual Potentially Vaccine Information Reasons for Deferral/Refusal

(13)

(14)
Age Response Slip (fever, etc.)
(Surname, First Name, MI) (House No. St., City/Municipality) MM/DD/YY (M/F) (food, meds, previous Period ( for pregnant? (12) (15)
No. (6) (8)
immunization, MR/Td FEMALES only) (Y/N)
(7) (9) (10) Lot Batch Expiry
(1) (2) (3) (4) (5) Y N Y N
No. No. Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
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26
27
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30

_________________________________________ ______________________________________ _______________________________________ _______________________________________


Name and Signature of School Nurse/Class Advisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 1

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