School-Based Immunization

RECORDING Form 1: Masterlist of Grade 1 Students

To be filled up by the Vacc

Region: _________________________ Name of School: _______________________________Section: ____________________ MR
Lot No: _____________
Province/City: ___________________ Division: _____________________ Batch No:___________

District/Municipality: _____________ Date: ______________ Td

Lot No: _____________
Batch No: ___________

To be filled up by the School Nurse / Class Adviser To be filled up by t

Date of previous Parent's Sick today?

Date of Birth MCV received Response Slip History of allergies (fever, etc)
No. Name (Surname, First Name, MI) Complete Address Age Sex (food, meds, previous
(MM/DD/YY) immunization)
Zero
dose MCV1 MCV2 Yes No Y N

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Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
p by the Vaccination Team

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_________

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__________

filled up by the Vaccination Team

Vaccine Given
Refusal Reasons

MCV1 MCV2 Td
_____________________________
Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 4 FEMALE Students (9-13yrs. old)

Region: _________________________ Name of School: _______________________ Section: ________________ To be filled up by the V

HPV
Province/City: ___________________ Division: ___________________________ Lot No: ____________
Batch No:___________
District/Municipality: _____________ Date: ______________________

To be filled up by the School Nurse / Class Adviser To be filled up by the Vaccinatio

Parent's Sick today?

History of allergies Date of HPV Vaccine Given
Date of Birth Response Slip (fever, etc)
No. Name (Surname, First Name, MI) Complete Address Age Sex (food, meds, previous
(MM/DD/YY) immunization)

Yes No Y N 1st dose 2nd dose

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Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2

_____________________________ _____________________________
Name and Signature of Recorder Name and Signature of Recorder
by the Vaccination Team

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ccination Team

Deferred Refusal Reasons for Refusal

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

To be filled up by the Vaccination Team

Region: IV-A CALABARZON Name of School: ROSARIO NATIONAL HIGH SCHOOL MR
Lot No: _____________
Province/City: BATANGAS Division: BATANGAS Section: GRADE 7- SAMPAGUITA Batch No:___________

District/Municipality: ROSARIO WEST Date: OCTOBER 19, 2018 Td

Lot No: _____________
Batch No: ___________

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

Parent's History of allergies Sick today? Last

(food, meds, Menstrual Potentially Vaccine Given
Date of Birth Response Slip (fever, etc)
No. Name (Surname, First Name, MI) Complete Address Age Sex previous Period (for Pregnant Deferred Refusal Reasons for Refusal
(MM/DD/YY) immunization FEMALES (Y/N)
MR/Td) only)
MR Td
Yes No Y N
(R arm) (L arm)

1 BATANES,CESAR RYAN L. MARILAG, ROSARIO, BATANGAS 08-06-2006 11 M

2 BLASE,RONALDO JR L. NAMUNGA, ROSARIO, BATANGAS 09-20-2004 13 M
3 FABITO,MARK LAWRENCE F. SAN ROQUE, ROSARIO, BATANGAS 07-03-2006 11 M
4 FAMINIAL,EARL ANDREW F. NAMUNGA, ROSARIO, BATANGAS 03-17-2006 12 M
5 GREGORIO,RONJAE CALVIN M. STA. CRUZ, ROSARIO, BATANGAS 05-20-2006 12 M
6 HERRERA,PATRICK P. ITLUGAN, ROSARIO, BATANGAS 11-04-2006 11 M
7 ILAGAN,JAMES TRISTAN STA. CRUZ, ROSARIO, BATANGAS 11-15-2005 12 M
8 LAJARA,CHRIS ANDREW L. NAMUNGA, ROSARIO, BATANGAS 10-04-2006 11 M
9 LAJARA,KIERTH JIMMUEL T. NAMUNGA, ROSARIO, BATANGAS 04-20-2006 12 M
10 LEONOR, BENEDICT C. QUILIB, ROSARIO, BATANGAS 2/7/2006 12 M
11 MAGALING,KARLO C. NAMUCO, ROSARIO, BATANGAS 11-19-2005 12 M
12 MAGLAQUE,BEE JAY D. PINAGKAWITAN, LIPA CITY, BATANGAS 01-10-2006 12 M
13 MAGSINO,RONUEL C. MARILAG, ROSARIO, BATANGAS 10-31-2006 11 M
14 MANALO,JASPER LOUIS D. 06-16-2006 11 M
15 MOJICA,RENZ WILSON G. BAGONG POOK, ROSARIO, BATANGAS 12-12-2004 13 M

______________________________ ______________________________ ______________________________ _____________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 7 Students

To be filled up by the Vaccination Team

Region: IV-A CALABARZON Name of School: ROSARIO NATIONAL HIGH SCHOOL MR
Lot No: _____________
Province/City: BATANGAS Division: BATANGAS Section: GRADE 7- SAMPAGUITA Batch No:___________

District/Municipality: ROSARIO WEST Date: OCTOBER 19, 2018 Td

Lot No: _____________
Batch No: ___________

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

Parent's History of allergies Sick today? Last

Response Slip (food, meds, (fever, etc) Menstrual Potentially Vaccine Given
Date of Birth
No. Name (Surname, First Name, MI) Complete Address (MM/DD/YY) Age Sex previous Period (for Pregnant Deferred Refusal Reasons for Refusal
immunization FEMALES (Y/N)
MR/Td) only)

Yes No Y N MR Td
(R arm) (L arm)

1 MORAL,JEDRICK D. QUILO-QUILO NORTH, PADRE GARCIA, BATS. 11-22-2005 12 M

2 PAREDES,CHRISTIAN A. SAN ROQUE, ROSARIO, BATANGAS 11-19-2005 12 M
3 PLATA,VHON ASHREI B. TIMBUGAN, ROSARIO, BATANGAS 08-31-2006 11 M
4 ROMBAWA,ALJHUN P. BAGONG POOK, ROSARIO, BATANGAS 09-13-2005 12 M
5 ROSALES,KIRBY F. STA. CRUZ, ROSARIO, BATANGAS 11-24-2005 12 M
6 SADULLO,VEE-JAY R. NAMUNGA, ROSARIO, BATANGAS 04-03-2005 13 M
7 SAMBILI,LORENZ ANGELO T. QUILIB, ROSARIO BATANGAS 07-11-2005 12 M
8 ALFANTA,JENNIFER M. MARILAG, ROSARIO, BATANGAS 01-06-2006 12 F
9 ALFON,APRILYN B. POBLACION, ROSARIO, BATANGAS 04-24-2004 14 F
10 CAPISTRANO,ANGEL ANNE M. BAGONG POOK, ROSARIO, BATANGAS 02-25-2006 12 F
11 CARANDANG,GWEN L. NAMUNGA, ROSARIO, BATANGAS 09-15-2006 11 F
12 CASTILLO,CRIZZA MAE L. SAN ROQUE, ROSARIO, BATANGAS 10-16-2006 11 F
13 CRUZAT,SHEENA MAE V. STA. CRUZ, ROSARIO, BATANGAS 03-03-2006 12 F
14 DE VERA,HAZEL ANN M. NAMUNGA, ROSARIO, BATANGAS 06-20-2006 11 F
15 DELLORO,CATHLYN JOY S. SAN ROQUE, ROSARIO, BATANGAS 09-04-2006 11 F

______________________________ ______________________________ ______________________________ _____________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 7 Students

To be filled up by the Vaccination Team

Region: IV-A CALABARZON Name of School: ROSARIO NATIONAL HIGH SCHOOL MR
Lot No: _____________
Province/City: BATANGAS Division: BATANGAS Section: GRADE 7- SAMPAGUITA Batch No:___________

District/Municipality: ROSARIO WEST Date: OCTOBER 19, 2018 Td

Lot No: _____________
Batch No: ___________

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

Parent's History of allergies Sick today? Last

(food, meds, Vaccine Given
Date of Birth Response Slip (fever, etc) Menstrual Potentially
No. Name (Surname, First Name, MI) Complete Address Age Sex previous Period (for Pregnant Deferred Refusal Reasons for Refusal
(MM/DD/YY)
immunization FEMALES (Y/N)
MR/Td) only)

Yes No Y N MR Td
(R arm) (L arm)

1 EBITE,MELODY M. NAMUCO, ROSARIO, BATANGAS 10-19-2006 11 F

2 GONZALES,AVA SOPHIA M. NAMUNGA, ROSARIO, BATANGAS 04-13-2006 12 F
3 GONZALES,JHANELE G. QUILIB, ROSARIO, BATANGAS 03-08-2005 13 F
4 GUIRRE,DIANALYN M. BAGONG POOK, ROSARIO, BATANGAS 05-08-2006 12 F
5 JOVEN,MAUREEN ANNE G. NAMUNGA, ROSARIO, BATANGAS 05-20-2006 12 F
6 LAJARA,REIANN VALERIE L. NAMUNGA, ROSARIO, BATANGAS 08-26-2006 11 F
7 LARDIZABAL,REYNALYN C. NAMUCO, ROSARIO, BATANGAS 11-09-2005 12 F
8 LINDOG,ANGELA A. MARILAG, ROSARIO, BATANGAS 12-06-2005 12 F
9 MAGLASANG,ANN JHENEL O. BAGONG POOK, ROSARIO, BATANGAS 09-18-2006 11 F
10 MAGNAYE,VANNESA B. QUILIB, ROSARIO, BATANGAS 01-07-2006 12 F
11 MANALO,CASSANDRA MAE L. NAMUNGA, ROSARIO, BATANGAS 03-23-2006 12 F
12 MAPOY,STEPHANIE A. QUILIB, ROSARIO, BATANGAS 09-20-2004 13 F
13 MASONGSONG,KRISTINE JOY O. QUILIB, ROSARIO, BATANGAS 09-07-2005 12 F
14 MENDOZA,ALINAH JEN A. QUILIB, ROSARIO, BATANGAS 01-12-2006 12 F
15 RODELAS,CIARRA MAE R. QUILIB, ROSARIO, BATANGAS 09-11-2005 12 F

______________________________ ______________________________ ______________________________ _____________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 7 Students

To be filled up by the Vaccination Team

Region: IV-A CALABARZON Name of School: ROSARIO NATIONAL HIGH SCHOOL MR
Lot No: _____________
Province/City: BATANGAS Division: BATANGAS Section: GRADE 7- SAMPAGUITA Batch No:___________

District/Municipality: ROSARIO WEST Date: OCTOBER 19, 2018 Td

Lot No: _____________
Batch No: ___________

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

Parent's History of allergies Sick today? Last

(food, meds, Vaccine Given
Date of Birth Response Slip (fever, etc) Menstrual Potentially
No. Name (Surname, First Name, MI) Complete Address Age Sex previous Period (for Pregnant Deferred Refusal Reasons for Refusal
(MM/DD/YY)
immunization FEMALES (Y/N)
MR/Td) only)

Yes No Y N MR Td
(R arm) (L arm)

1 RODRIGUEZ,JENELLE S. SAN ROQUE, ROSARIO, BATANGAS 08-05-2006 11 F

2 ROSALES,VENISE B. STA. CRUZ, ROSARIO, BATANGAS 09-27-2005 12 F
3 SALAYON,ERICA MIEL M. QUILIB, ROSARIO, BATANGAS 10-23-2005 12 F
4 SARMIENTO,ZHYRIEL R. SAN ROQUE, ROSARIO, BATANGAS 07-29-2005 12 F
5 SOLIS,MARGIELYN C. SAN ROQUE, ROSARIO, BATANGAS 08-21-2006 11 F
6 SORIBA,HANNAH B. QUILIB, ROSARIO, BATANGAS 04-25-2006 12 F
7 HARINA, KYLA C. BAGONG POOK, ROSARIO, BATANGAS 6/20/2003 15 F
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______________________________ ______________________________ ______________________________ _____________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder