TETANUS-DIPHTHERIA INVENTORY

SCHOOL BASED IMMUNIZATION

No. of Available Td Eligible for Td Vaccination (with case of D/T) Target Enrolless Required Td vaccine Deficiency Td vaccine Action
No. of Neonatal
No. of Diphtheria (if vaccine available is not sufficient for the
Name of Municipality Tetanus Cases YES (if yes, proceed with NO (if no, do not proceed
Vials Doses Cases 2014-2016 Grade I Grade VII Total Vials Doses Vials Doses entire eligible municipality, prioritize the brgy
2014-2017 the next columns) with next columns) with reported case)
1 Duhat 34 340 3 0 ü 356 223 579 58 579 24 239
2 Banaba 53 530 0 0 ü 0 0 -53 -530 The 24 vials can be given to Duhat and 26 for Saging
3 Saging 33 330 2 3 ü 380 209 589 59 589 26 259
4 0 0 0 0 0 0
5 0 0 0 0 0 0
6 0 0 0 0 0 0
7 0 0 0 0 0 0
8 0 0 0 0 0 0
9 0 0 0 0 0 0
10 0 0 0 0 0 0
11 0 0 0 0 0 0
12 0 0 0 0 0 0
13 0 0 0 0 0 0
14 0 0 0 0 0 0
15 0 0 0 0 0 0
16 0 0 0 0 0 0
17 0 0 0 0 0 0
18 0 0 0 0 0 0
19 0 0 0 0 0 0
20 0 0 0 0 0 0
21 0 0 0 0 0 0
22 0 0 0 0 0 0
23 0 0 0 0 0 0
24 0 0 0 0 0 0
25 0 0 0 0 0 0
26 0 0 0 0 0 0
27 0 0 0 0 0 0
28 0 0 0 0 0 0
29 0 0 0 0 0 0
30 0 0 0 0 0 0
31 0 0 0 0 0 0
32 0 0 0 0 0 0
33
34
35 0 0 0 0 0 0
TOTAL 120 1200 5 3 0 0 736 432 1168 117 1168 -3 -32
Reporting Form 1: Masterlist of Students (Grade I)
MASTERLIST FOR SCHOOL BASED IMMUNIZATION (GRADE I)
(Year: ________)
Region: _____________________ District/Municipality: ____________________________ MR Td
Province/City: _________________ Name of School: ____________________ Lot no:  Elig. w/stock Lot no:
Date: ________________________ Section: _______________ Batch no:  Elig. w/o stock Batch no:
 Non-Elig. w/ stock
Division: ________________________  Non-Elig. w/o stock

To be filled up by the school To be filled up by the vaccination team

History of
Blood Sick today?
Allergies
Parents' disorders (ex. (ex. Fever,
Date of Birth (meds, food, Vaccine Given
No. Name (1) Complete Address (2) Age Sex Response Slip Bleeding cough, cold DEFFERED REFUSAL REASONS
(MM/DD/YY) previous imzn
tendencies) etc.)
of MMR/Td)
Y N Y N Y N Y N MCV (R) Td (L)

10

11

12

13

14

15
TOTAL

Name and signature of Advisor Name and signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
Reporting Form 2: Masterlist of Students (Grade VII)
MASTERLIST FOR SCHOOL BASED IMMUNIZATION (GRADE VII)
(Year: ________)
Region: ___________________ District/Municipality: ____________________________ MR Td
Province/City: _________________ Name of School: ____________________ Lot no:  Elig. w/stock Lot no:
Date: ________________________ Section: _______________ Batch no:  Elig. w/o stock Batch no:
 Non-Elig. w/stock
Division: ________________________  Non-Elig. w/o stock

To be filled up by the school To be filled up by the vaccination team

History of
Allergies
Blood Last History of sexual
Date of Parents' Active disorders (ex. Menstrual contact in the past 4 Sick today?
(meds, food, Vaccine Given
Birth Response Slip
previous imzn
Untreated TB Bleeding Period weeks ( for FEMALE (fever)
No. Name (1) Complete Address (2) Age Sex tendencies) only) DEFFERED REFUSAL REMARKS
(MM/DD of MMR/Td) (For
/YY) FEMALE
Y N Y N Y N Y N ONLY) Y N Y N MCV (R) Td (L)

10

11

12

13

14

15
TOTAL

Name and signature of Advisor Name and signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
Reporting Form 3: District/Municipal Consolidated Accomplishment

SCHOOL BASED IMMUNIZATION PROGRAM (MEASLES-RUBELLA)

NATIONAL IMMUNIZATION PROGRAM TD ELIG. CHECKLIST
(Year: ________)  Elig. w/ stock
 Elig. w/o stock
Name of Municipality/District: _______________ Region: ___________________  Non-Elig. w/stock
Target: _______________ Province : __________________  Non-Elig. w/o stock

GRADE I GRADE VII

Total No. Enrolled Given MR Given Td Refusal Total No. Enrolled Given MR Given Td Refusal
No. No.
Name of School
Deferred Reasons for Deferred Reasons for
Male Female Total Male Female Total % Male Female Total % No. Male Female Total Male Female Total % Male Female Total % No.
Refusal Refusal

10

11

12

13

14

15

16

17

18

19

20

TOTAL

Name and signature of Supervisor/PHN Name and signature of Municipal Health Officer
Reporting Form 4: Provincial/City Consolidated Accomplishment

SCHOOL BASED IMMUNIZATION PROGRAM (MEASLES-RUBELLA)

NATIONAL IMMUNIZATION PROGRAM
(Year: ________)

Name of Province/City: _______________ Region: ___________________

Target: _______________

GRADE I GRADE VII

TD Eligibility Checklist Total No. Enrolled Given MR Given Td Refusal Total No. Enrolled Given MR Given Td Refusal
No. No.
Name of Municipality
EL w/ EL w/o Non-EL w/ Non-EL Deferred Reasons for Deferred Reasons for
Male Female Total Male Female Total % Male Female Total % No. Male Female Total Male Female Total % Male Female Total % No.
stock stock stock w/o stock Refusal Refusal

10

11

12

13

14

15

16

17

18

19

20

TOTAL

Name and signature of NIP Provincial/City Manager Name and signature of Chief Technical Unit Name and signature of Provincial/City Health Officer
Reporting Form 5: Provincial/City Consolidated Accomplishment

SCHOOL BASED IMMUNIZATION PROGRAM (MEASLES-RUBELLA)

NATIONAL IMMUNIZATION PROGRAM
(Year: ________)

Name of Region: _______________

Target: _______________

GRADE I GRADE VII

No. of Municipalities with TD Eligibility Total No. Enrolled Given MR Given Td Refusal Total No. Enrolled Given MR Given Td Refusal
No. No.
Name of Province/City
EL w/ EL w/o Non-EL w/ Non-EL Deferred Reasons for Deferred Reasons for
Male Female Total Male Female Total % Male Female Total % No. Male Female Total Male Female Total % Male Female Total % No.
stock stock stock w/o stock Refusal Refusal

10

11

12

13

14

15

16

17

18

19

20

TOTAL

Name and signature of NIP Regional Manager Name and signature of Division Chief Name and signature of Director
Reporting Form 6: AEFI FORM
IMMUNIZATION FOR ADOLESCENTS
ADOLESCENT HEALTH AND DEVELOPMENT PROGRAM

Line List for the Adverse Events Following Immunization (AEFI)

Region: ____________________ Any AEFI among vaccinated adolescent should be reported using this form. Date submitted:_________________
This form should be completely accomplished by the teaam supervisor and submitted to the next higher administrative level at the end of the activity.

Province/ City: _______________________ Consolidated reports should be submitted to the regional/ central DOH one (1) week after the end of the activity. Prepared by:____________________
Ensure that every reportable AEFI case recorded here should has a corresponding filled- up case investigation form.
Municipality: ________________________

Chief Complaint and Date Vaccine Lot no./

Date Name of Student Age Sex Year Level Name of school Complete Address Findings & Diagnosis Treatment/ Action Taken
of onset Given Expiry date