School-Based Immunization

RECORDING Form 1: Masterlist of Grade 1 Students

To be filled up by the Vaccination Team
MR
Region: _______________________________ Name of School: _______________________________Section: _______________________ Lot No: _______________________
Batch No: _____________________
Province/City: _________________________ Division: _______________________
Td
District/Municipality: ___________________ Date:__________________________ Lot No: _______________________
Batch No.______________________

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

Date of previous MCV Parents' Sick today? Vaccine Given

received Response Slip History of allergies ( fever, etc)
No. Name (1 Complete Address (2) Dare of Birth Age Sex (food, meds, previous Refusal Reasons
(Surname, First Name, MI) MM/DD/YY MCV2 immunization)
Zero MCV 1 (9 Y N Y N MCV1 MCV2 Td
dose mos) (MMR/
MR)

10

11
Alphabetical, separate male and female, 6 pages per section
Region: _______________________________

Province/City: _________________________

District/Municipality: ___________________

To be filled up by the Sc

No. Name (1)

3
 4

10

11

12

13

14

15
Potentially pregnant means history of sexual contact in the past 4 we
Alphabetical, separate male and female, 6 pages per section

________________________________________________
Name and Signature of Supervisor
 School-
RECORDING Form 3: Ma
Name of School: ____________________________

Division: _______________________ Section: ____

Date:__________________________

be filled up by the School Nurse/ Class Adviser

Dare of Birth
Complete Address (2) Age Sex
MM/DD/YY
ntact in the past 4 weeks (for FEMALES only)
s per section

________________________________________________
Name and Signature of Vaccinator 1
School-Based Immunization
m 3: Masterlist of Grade 7 Students (MCV-Td)
______________________________________

ection: ___________________

To be filled

Parents' Sick toda

Response Slip Last ( fever
Menstrual
History of allergies Potentially
(food, meds, previous Period(for pregnant
immunization MR/Td) (Y / N)
Y N FEMALES Y
only)
________________________________________________
Name and Signature of Vaccinator 2
V-Td)
To be filled up by the Vacc
MR
Lot No: ______________
Batch No: ____________
Td
Lot No: ______________
Batch No._____________

To be filled up by the Vaccination Team

Sick today? Vaccine Given

( fever)

Deferred Refusal
N MR Td
(R arm) (L arm)
________________________________________________
Name and Signature of Recorder
To be filled up by the Vaccination Team

Lot No: _______________________

Batch No: _____________________

Lot No: _______________________

Batch No.______________________

Reasons for Refusal

Name and Signature of Guide
 School-Based Immunization
REPORTING Form: Regional/Provincial/City Consolidated Accomplishment Form Report
Region: ____________________________
Date: ______________________________
Province/City: _________________________

Grade I Grade VII Grade 4

Students Students
Students Students Students Total no. of
vaccinated w/ vaccinated w/ Td Total no. of deferred Total no. of refusal vaccinated w/ MR vaccinated w/ Td Total no. of deferred Total no. of refusal vaccinated w/ deferred Total no. of refusal
Total no. of MCV Total no. of HPV
Total no. of Total no. of
Province/ City/Municipal schools schools % Total no. of schools schools % Total no. of
covered No. with covered Total no. of
students MCV2 students enrolled students enrolled
enrolled (Female only)
No. % No. % MCV % Td % MCV % Td % No. % No. % MR % Td % MR % Td % No. % HPV % HPV %

Total

* All deferred students who submitted for vaccination shall be recorded in Recording Form1-3 and reported using Reporting Form 4
For the district/city/municipality, in column B, kindly indicate name of school

Submitted by Noted by:

 School-Based Immunization
RECORDING Form 1: Masterlist of Grade 4 Students

To be filled up by the Vaccination Team

Region: _________________________ Name of School: ___________ Section: _______________________ HPV

Lot No: _______________________
Province/City: ___________________ Division: _______________________ Batch No: _____________________

District/Municipality: _____________ Date:__________________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents' Sick today?
Response Slip ( fever, etc) Vaccine Given
History of
Dare of allergies
Name (1
Complete Address Birth (food, meds,
No. (Surname, First Name, MI) Age Sex Refusal Reasons
Females Only (2) MM/DD/Y previous
HPV 1st HPV 2nd
Y Y N immunizatio Y N dose dose
n)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Alphabetical, separate male and female, 6 pages per section
 FLOW AND SUBMISSION OF REPORTS

Levels of
Type of report Responsible Person To be Submitted to Schedule of Report
Implementation

Recording Form 1: Masterlist of Grade 1

Students
Recording Form 2: Masterlist of Grade 4
School Teacher/ School Nurse Midwife Weekly
Students
Recording Form 3: Masterlist of Grade 4
Students
Masterlist of Deferred/Refused RHU Midwife/Recorder PHN/Supervisor
School Consolidated Reporting Form RHU Midwife/Recorder PHN/Supervisor Daily at 3pm
RHU
Consolidated Accomplishment report by Weekly (Thursday at
PHN/Supervisor Provincial/City Adolescent Coordinator
Schools per Municipalities 4pm)
Consolidated Accomplishment report by Provincial/City Adolescent Weekly (Thursday at
PHO/CHO Regional Adolescent Coordinator
Municipalities Coordinator 5pm)
Consolidated Accomplishment report by Regional Adolescent Weekly (Thursday at
RHO National Adolescent Coordinator
Prov/City Coordinator 6pm)