FLOW AND SUBMISSION OF REPORTS

To be
Levels of Schedule of
Type of report Responsible Person Submitted
Implementation Report
to
Recording Form 1: Masterlist
of Grade 1 Form
Recording Students
2: Masterlist Local Health Center /
School RHU Daily
of Grade 4 Form
Recording Students
3: Masterlist Vaccination Team
of Grade 4 Students
Consolidated
RHU Accomplishment report by RHU Midwife PHO/CHO Weekly
Schools per Municipalities

Regional NIP
RHO Bulletin report of Prov/City CO-NIP Weekly
Coordinator
Analysis report of Provincial / City NIP
PHO/CHO RHO Weekly
Municipalities Coordinator
CO Bulletin report of CHDs DPCB NIP PHSC U Weekly
 SCHOOL-BASED IMMUNIZATIO
Recording Form 1: Masterlist of Grade 1

Region: __________________________Name of School: _________________________Section: _____

Barangay: _______________________District/Municipality: ______

City/Province: __________________ Date: ______________________

To be filled out by Local Health Center / Vaccination Team

Date of Consent
Name Birth Slip
Complete Address Age Sex
(Surname, First Name, MI) MM/DD/
YYYY Y

1
2
3
4
5
6
7
8
9
10

____________________________ ___________________________________ ____________________

Name & Signature of
Name & Signature of Vaccinator 1 Name & Signature
Supervisor
ASED IMMUNIZATION
Masterlist of Grade 1 Students

MR: Td:
Number of Vaccine Received (in vials):_______Number of Vaccine Received (in vials):_______
Number of Vaccine Used (in vials):_______ Number of Vaccine Used (in vials):_______
Number of Vaccine Unused (in vials):_______ Number of Vaccine Unused (in vials):_______

Sick
Consent today?
Vaccine Given
Slip History of (Fever, Deferr Refusa
etc) Reasons
Allergies Lot/ Lot/ al l
N Y N MR Batch Td Batch
No. No.

______________________________________
Name & Signature of Vaccinator 2
in vials):_______
als):_______
vials):_______
 SCHOOL-BASED IMMUNIZATIO
Recording Form 2: Masterlist of Grade 7

Region: __________________________Name of School: _________________________Section: _____

Barangay: _______________________District/Municipality: ______

City/Province: __________________ Date: ______________________

To be filled out by Local Health Center / Vaccination Team

Consent
Date of
Slip
Name Birth
Complete Address Age Sex
(Surname, First Name, MI) MM/DD/
YYYY Y

1
2
3
4
5
6
7
8
9
10

____________________________ ___________________________________ ____________________

Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signature
ASED IMMUNIZATION
Masterlist of Grade 7 Students

MR: Td:
Number of Vaccine Received (in vials):_______Number of Vaccine Received (in vials):_______
Number of Vaccine Used (in vials):_______ Number of Vaccine Used (in vials):_______
Number of Vaccine Unused (in vials):_______ Number of Vaccine Unused (in vials):_______

Sick
Consent today?
Vaccine Given
Slip (Fever,
History of Deferr Refusa
etc) Reasons
Allergies Lot/ Lot/ al l
N Y N MR Batch Td Batch
No. No.

______________________________________

Name & Signature of Vaccinator 2

in vials):_______
als):_______
vials):_______
 SCHOOL-BASED IMMUN
Recording Form 3: Masterlist of Gra

Region: __________________________Name of School: _________________________Section: _____

Barangay: _______________________District/Municipality: ______

City/Province: __________________ Date: ______________________

To be filled out by Local Health Center / Vaccination Team ToDate

be filled
of out by V
Date of
Name Birth HPV
Complete Address Age Sex HPV
Received
(Surname, First Name, MI) MM/DD/
YYYY 1
1
2
3
4
5
6
7
8
9
10

______________________________ _____________________________ _______________________

Name & Signature of
Name & Signature of Vaccinator 1 Name & Signature of V
Supervisor
OL-BASED IMMUNIZATION
Masterlist of Grade 4 Female Students

HPV:
Number of Vaccine Received (in vials):_______
Number of Vaccine Used (in vials):_______
Number of Vaccine Unused (in vials):_______

ToDate
be filled Sick
of out by Vaccination Team
Consent today?
HPV History of Vaccine Given Deferr Refusa
HPV Slip (Fever, HPV Lot/ Lot/
HPV Batch
Received Y N Allergies Y etc) N Batch al l
2 1 No. 2 No.

__________________________________ _________________________________
Name & Signature of Vaccinator 2 Name & Signature of Recorder
Reasons
 School-Based Immunization
DAILY SUMMARY REPORTING Form: RHU Consolidated Accomplishment Form Report

Region: ____________________________
Date: ______________________________
Province/City: _________________________ Municipal/City: _________________________

Grade 1 Grade 4 Female Grade 7

Students Students Students Students
No. of female students
vaccinated vaccinated Total no. of deferred Total no. of refusal Total no. of deferred Total no. of refusal vaccinated vaccinated Total no. of deferred Total no. of refusal
vaccinated
Name of Schools Total no. w/ MR w/ Td w/ MR w/ Td
Total no. Total no. of
of
of students
students 1st 2nd 1st 2nd 1st 2nd
enrolled enrolled
enrolled dose dose dose dose dose dose
No. % No. % MR % Td % MR % Td % % % % % % % No. % No. % MR % Td % MR % Td %
of of of of of of
HPV HPV HPV HPV HPV HPV

Total

Grade 1: Grade 7: Grade 4 Female:

MR: MR: HPV:
Number of Vaccine Received (in vials):_______ Number of Vaccine Received (in vials):_______ Number of Vaccine Received (in vials):_______
Number of Vaccine Used(in vials):_______ Number of Vaccine Used(in vials):_______ Number of Vaccine Used(in vials):_______
Number of Vaccine Unused(in vials):_______ Number of Vaccine Unused(in vials):_______ Number of Vaccine Unused(in vials):_______

Td: Td:
Number of Vaccine Received (in vials):_______ Number of Vaccine Received (in vials):_______
Number of Vaccine Used(in vials):_______ Number of Vaccine Used(in vials):_______
Number of Vaccine Unused(in vials):_______ Number of Vaccine Unused(in vials):_______