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    School Based Immunization Forms

    Uploaded by

    Leslie Pulod

    Copyright:

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

    School Based Immunization Forms

    Uploaded by

    Leslie Pulod
    1 views4 pages

    Copyright

    © © All Rights Reserved

    Available Formats

    XLSX, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    1 views4 pages

    School Based Immunization Forms

    Uploaded by

    Leslie Pulod

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 4

    SCHOOL-BASED IMMUNIZATION

    Recording Form 1: Masterlist of Grade 1 Students

    Region: _______________ Name of School: ______________ Section: ___ MR: Td:


    Number of Vaccine Received (in vials):_______ Number of Vaccine Received (in vials):_______
    Barangay: _____________ District/Municipality: Number of Vaccine Used (in vials):_______ Number of Vaccine Used (in vials):_______
    Number of Vaccine Unused (in vials):_______ Number of Vaccine Unused (in vials):_______
    City/Province: __________ Date: ______________

    To be filled out by Local Health Center / Vaccination Team


    Date of Consent Sick today?
    Name Vaccine Given
    Birth Slip History of (Fever, etc)
    Complete Address Age Sex Deferral Refusal Reasons
    MM/DD/ Allergies
    (Surname, First Name, MI) Y N Y N MR Lot/Batch No. Td Lot/Batch No.
    YYYY
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10

    _________________ _______________________ _________________________________________


    Name & Signature of
    Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2
    SCHOOL-BASED IMMUNIZATION
    Recording Form 2: Masterlist of Grade 7 Students

    Region: __________________ Name of School: __________________ Section: __________


    MR: Td:
    Barangay: ________________ District/Municipality: ___ Number of Vaccine Received (in vials):_______ Number of Vaccine Received (in vials):_______
    Number of Vaccine Used (in vials):_______ Number of Vaccine Used (in vials):_______

    City/Province: _____________ Date: _________________ Number of Vaccine Unused (in vials):_______ Number of Vaccine Unused (in vials):_______

    To be filled out by Local Health Center / Vaccination Team


    Date of Sick today?
    Name Consent Slip Vaccine Given
    Birth History of (Fever, etc)
    Complete Address Age Sex
    Allergies
    Deferral Refusal Reasons
    MM/DD/ Lot/Batch Lot/Batch
    (Surname, First Name, MI) Y N Y N MR Td
    YYYY No. No.
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10

    _________________ __________________________ __________________________________


    Name & Signature of
    Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2
    SCHOOL-BASED IMMUNIZATION

    ### Recording Form 3: Masterlist of Grade 4 Female Students


    ###
    ###
    Region: ___________________Name of School: __________________ Section: _______
    ### HPV:
    ###
    Barangay: _________________District/Municipality: ___ Number of Vaccine Received (in vials):_______
    ### Number of Vaccine Used (in vials):_______
    ###
    City/Province: ______________Date: _________________ Number of Vaccine Unused (in vials):_______
    ###
    ###
    To be filled out by Local Health Center / Vaccination Team To be filled out by Vaccination Team
    Date of Date of HPV Consent Sick today?
    ### Name Vaccine Given
    Birth Received Slip History of (Fever, etc)
    Complete Address Age Sex Deferral Refusal Reasons
    MM/DD/ Allergies
    ###(Surname, First Name, MI) HPV 1 HPV 2 Y N Y N HPV 1 Lot/Batch No. HPV 2 Lot/Batch No.
    YYYY
    ### 1
    ### 2
    ### 3
    ### 4
    ### 5
    ### 6
    ### 7
    ### 8
    ### 9
    ###10

    ###
    ______________________________ _____________________________ __________________________________ _________________________________
    Name & Signature of
    ### Name & Signature of Recorder
    Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2

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