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 Accomplishment
RHU report by Schools per RHU Midwife PHO/CHO Weekly
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
Recording Form 1: Maste

Region: ___MIMAROPA_________________Name of School: __LOOC CENTRAL ELEM. SCHOOL______

Barangay: ___POBLACION______________District/Municipality: __LOOC__

City/Province: __ROMBLON____________Date: ___OCTOBER 07, 2024____

To be filled out by Local Health Center / Vaccination Team

Name Date of Birth

Complete Address
(Surname, First Name, MI) MM/DD/YYYY

1 MEDINA, PRINCESS HAILLY T. LIMON SUR, LOOC, ROMBLON 07/28/2018

2 MELLONA, THEA M POBLACION, LOOC, ROMBLON 06/05/18
3 SOLIDUM, KAE ANDREA G. POBLACION, LOOC, ROMBLON 3/9/2018
4 DOCOG, DIANA MARIE D. POBLACION, LOOC, ROMBLON 04/13/2018
5 SANTIAGO, ZACH DASTAN T. POBLACION, LOOC, ROMBLON 12/2/2018

______________________________ __________________________________________
Name & Signature of
Name & Signature of Vaccinator 1
Supervisor
 SCHOOL-BASED IMMUNIZATION
ecording Form 1: Masterlist of Grade 1 Students

Section: _____ MR: Td:

Number of Vaccine Received (in via 7 Number of Vaccine Received (in
Number of Vaccine Used (in vials): 6 Number of Vaccine Used (in vials
Number of Vaccine Unused (in vials 1 Number of Vaccine Unused (in vi

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

6 F / none / 0.5ml 0123W037 0.5 ml 2333L029A

6.1 F / none / 0.5ml 0.5 ml
6.4 F / none / 0.5ml 0.5 ml
6.3 F / none / 0.5ml 0.5 ml
6.5 M / none / 0.5ml 0.5 ml

_____________ ______________________________________
cinator 1 Name & Signature of Vaccinator 2
of Vaccine Received (in vials): 7
of Vaccine Used (in vials):____ 5
of Vaccine Unused (in vials):__ 2

Reaso
Refusal
ns
 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):_______
ials):_______
n vials):_______
 SCHOOL-BASED IMM
Recording Form 3: Masterlist of G

Region: _MIMAROPA____________________
Name of School: _LOOC CENTRAL ELEM. SC
Section: _____

Barangay: _POBLACION________________District/Municipality: ___LO

City/Province: _ROMBLON______________Date:

To be filled out by Local Health Center / Vaccination Team

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

1
2
3
4
5
6
7
8
9
10

______________________________ _____________________________
Name & Signature of Supervisor Name & Signature of Vaccinator 1
CHOOL-BASED IMMUNIZATION
m 3: Masterlist of Grade 4 Female Students

HPV:
Number of Vaccine Received (in vi 30
Number of Vaccine Used (in vials): 25
Number of Vaccine Unused (in vial 5

To be filled out by Vaccination Team

Sick
Date of
Consent today?
HPV Vaccine Given
Slip History of (Fever, Deferr Refusa
Received
Allergies etc) al l
HPV HPV HPV Lot/ HPV Lot/
Y N Y N Batch Batch
1 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):_______