School Based Immunization

Recording Form 1: Masterlist of Grade 1 Students

To be filled up by
Region:______________________________ Name of School:______________________ Section:______________________

Province/City:_________________________ Division: ___________________________

District/Municipality:__________________ Date: _____________________

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

History of allergies
Date of Birth Date of Previous MCV received Parents Response Slip (food, meds, Sick Today (fever,etc.) Vaccine Given
No. Name (1) (Surname, First Name, MI) Complete Address (2) MM/DD/YY Age Sex previous
immunization
Zero dose MCV 1 MCV 2 Y N Y N MCV1 MCV 2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

_______________________________ ________________________________ _______________________________ __________________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
 To be filled up by the Vaccination Team
` MR
Lot no:
Batch no:
Td
Lot no:
Batch No:
p by the Vaccination Team

Vaccine Given
Refusal Reasons

TD
Reporting Form 2: Masterlist of Students
MASTERLIST OF ADOLESCENTS FOR IMMUNIZATION (GRADE 7)
ADOLESCENTS HEALTH AND DEVELOPMENT PROGRAM
(Year: ________)
MR
Region: ______________________ Lot no:
District/Municipality: ____________________________ Batch no:
Province/City: _________________
Name of School: ____________________ Td
Date: ________________________ Lot no:
Section: _______________ Batch No:

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

History of Blood History of sexual

Parents' Allergies (meds, disorders contact in the past Sick today?
Response Slip Last Menstrual
food, previous (ex. Bleeding 4 weeks ( for (fever) Vaccine Given
Date of Birth imzn of MMR/Td) tendencies) Period
No. Name (1) Complete Address (2) (MM/DD/YY)
Age Sex (For FEMALE
FEMALE only)

ONLY)
MR Td
Y N Y N Y N Y N Y N
(R arm) (L arm)

10

Total:
Note: Alphabetical, separate male/female, 6 pages/section

____________________________________________ ____________________________________________________ _________________________________________________ ___________________________________________

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 Guide
 Reporting Form 3: District/Municipal Consolidated Accomplishment

IMMUNIZATON FOR ADOLESCENTS (GRADE 7)

ADOLESCENT HEALTH AND DEVELOPMENT PROGRAM
(Year: ________)

Name of Municipality/District: _______________

Target: _______________

Total No. Enrolled

Name of
School
Male Female

7
/Municipal Consolidated Accomplishment

IMMUNIZATON FOR ADOLESCENTS (GRADE 7)

ADOLESCENT HEALTH AND DEVELOPMENT PROGRAM
(Year: ________)

District: _______________ Region: ___________________

Province : _____________________

. Enrolled Given MR Given Td Refusal

No. No.
Deferred Deferred
Total Male Female Total % Male Female Total % No. Reasons for Refusal
Reporting Form 4: School Consolidated Accomplishment

Region: _______________ Name of School: ___________________

Province/ City: _______________ Division: _____________________

Total Number enrolled Given MR Given Td Refusal

Number Number Number Number

Deferred Deferred
Section Total % Total % Number Reasons for Refusal
Male Female Total Male Female Male Female

Grand Total
Reporting Form 5: Division/Provincial Consolidated Accomplishment

IMMUNIZATION FOR ADOLESCENTS (GRADE 7)

ADOLESCENT HEALTH AND DEVELOPMENT PROGRAM
(Year: ________)
Region: ________________________

Province/City:______________________

Total Eligible Given MMR Vaccines Given Td Vaccines

Name of Municipality No. Deferred Number of Refusals Reasons for Refusal

M F Total M F Total % M F Total %

10

Submitted by:
Reporting Form 6: Regional Consolidated Accomplishment

IMMUNIZATION FOR ADOLESCENTS (GRADE 7 )

ADOLESCENT HEALTH AND DEVELOPMENT PROGRAM
(Year: ___________)

Region: _________________________

Given MR Vaccines Given Td Vaccines

No.
City/Province Total Eligible Deferred
No. of Refusals Reasons for Refusal
M F Total % M F Total %

10

TOTAL

Submitted by:
Reporting Form 7: AEFI FORM
IMMUNIZATION FOR ADOLESCENTS
ADOLESCENT HEALTH AND DEVELOPMENT PROGRAM

Line List for the Adverse Events Following Immunization (AEFI)

Region: ____________________ Date submitted:_________________

Province/ City: _______________________ Prepared by:____________________

Municipality: ________________________
Any AEFI among vaccinated adolescent should be reported using this form.
This form should be completely accomplished by the teaam supervisor and submitted to the next higher administrative level at the end of the activity.
Consolidated reports should be submitted to the regional/ central DOH one (1) week after the end of the activity.
Ensure that every reportable AEFI case recorded here should has a corresponding filled- up case investigation form.

Chief Complaint and Date of Vaccine Given Lot no./ Expiry

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