Workshop 1 Recording-Reporting Form

Workshop 1: Recording
/ Reporting / and Other

Forms
Parents Response
Definition
ofSlip
Terms
Yes: if parents consented the provision of the health

services
No: if parents did not consented (reason stated)

History of Allergies (can be obtain from the consent
form)
Sick today: (child physically present but experiencing
moderate to high fever)
Zero dose / MCV1 / MCV2
Deferred
No consent form, drop-out, sick today

Refussal
e.g.Religious affiliation, parents refussal

Not Eligible: repeater with immunization card, completed
MCV2,
Absenteeism: not physically present on the day of the
vaccination
Drop-out: student was enrolled but has not been to school
Denominator for accomplishment: actual masterlisted
drop-out & not eligible
Grade 1 Recording Form

Name of Student

Address of
Student

Date of Birth of
Student, Age &
Sex
Parents Response:
Check Y if ok to give
vaccination
Check N if not consented
then fill in reason for
refusal
History of Allergies
(previous allergic reaction to food, meds or
previous immunization)
REMARKS: with precaution
DEFERRED: if with severe allergic reaction
to any of the above refer to MHO
Sick Today?
Check Y if with moderate to high
grade fever or any severe illness during
the time of vaccination then refer to
MHO
Check N if with no illness

Date of Previous MCV (based on
Immunization Card)
ZERO DOSE: was not able to receive any
routine dose or no proof of immunization
MCV 1: only 1 routine dose of MCV
MCV 2: 2 routine doses received as
confirmed by the immunization card
Date Vaccine Given (is the date of SBI) for

AUGUST
MCV 1: Write the date on MCV 1 column if this is the
first time that the student will receive an MCV
(ensure that the student will receive a second dose 1
month after)
MCV 2: Write the date on MCV 2 column if the
student has previously received 1 routine dose of
MCV
Td: Write the date on the Td column for the Td
DEFERRED
Check DEFERRED and state on
the Reasons/Remarks column
the reason for DEFERRAL
REFUSAL
Check REFUSAL and state on
the reason for REFUSAL
Grade
1
Recording
Form
At the bottom of the Recording
Form:
Name
and
Signature
of
Teacher
In-charge
of
the
Masterlisting
Name
and
Signature
of
Vaccination Team Supervisor
Name and Signature of the

Vaccinators in the Team
Name and Signature of the

Recorder of the Vaccination
Team

Name of Student

Address of
Student

Date of Birth of
Student, Age &
Sex
Parents Response:
Check Y if ok to give
vaccination
Check N if not consented
then fill in reason for
refusal
History of Allergies
(previous allergic reaction to food, meds or
previous immunization)
REMARKS: with precaution
DEFERRED: if with severe allergic reaction
to any of the above refer to MHO
Sick Today?
Check Y if with moderate to high
grade fever or any severe illness during
the time of vaccination then refer to
MHO
Check N if with no illness
LAST MENSTRUAL PERIOD

(for female Grade 7 students)
Indicate DATE of the LAST MENSTRUAL
PERIOD, determine whether regular or
irregular
POTENTIALLY PREGNANT
(for female Grade 7 students)
Check Y if history of LMP is possibly
delayed, student experiencing probable signs
and symptoms of pregnancy, or if with
positive signs of pregnancy; refer to MHO
Check N if not pregnant
VACCINE GIVEN
Indicate DATE of MR
and Td receipt
DEFERRED
Check DEFERRED and state on
the reason for DEFERRAL
REFUSAL
Check REFUSAL and state on
the reason for REFUSAL
Sample Case Scenario

Case # 1
Marrianna L. Santos
Grade 1 student of Brgy. A Elem. School
Birthday: September 3, 2009
Address: Brgy Allegre, San Rafael.
With signed consent
Was not able to receive previous dose
No allergies
If you are the Teacher in-charge, how are

you going to record this information?
SANTOS, MARRIANNA L.
Brgy. Alegre, San Rafael
09/03/20
09

Case # 1
Date: August 1, 2016.
As the health worker, plan on how you are

going to immunize Marrianna.
none
08/01/201
6
08/01/201
6
Schedule for
2nd dose 1
month after

Case # 2
Jeffrey T. de Castro
Birthday: March 9, 2010
Address: Brgy Allegre, San Rafael
With parental consent for immunization
No history of any allergies
1 dose of measles at 9mos old (January 9,

2011)

09/03/20
09
DE CASTRO, JEFFREY T.
03/09/20
09

Case # 2

going to immunize Jeffrey.
none
none
01/09/201
1
08/01/201
08/01/201
6
6
08/01/201
6 08/01/201
6
Schedule for
2nd dose 1
month after

Case # 3
Michael L. Villaflor
Birthday: May 7, 2010
Address: Brgy Allegre, San Rafael
With parental consent
Previous doses of MCV: Measles on

February 23, 2011 and MMR on May 14,
2011

09/03/20
09
03/09/20
09
VILLAFLOR, MICHAEL L.
05/07/20
11

Case # 3
Date: August 1, 2016

going to immunize Michael.
none
none
none
08/01/201
08/01/201
6
6
08/01/201
6 08/01/201
6
01/09/201
1
02/23/201
1 05/14/201
1
08/01/201
6
Schedule for
2nd dose 1
month after
Not eligible
for MR
vaccination

Case # 4
Ella F. Delfin
Birthday: September 16, 2011
Address: Brgy Binuhatan, San Rafael.
Refuse to sign consent because of religious belief
No preious MCV dose
Severe allergy to previous medication
If you are the Teacher in-charge, how are you

going to record this information?
09/03/20
09
03/09/20
09
05/07/20
11
DELFIN, ELLA F.
Brgy. Binuhatan, San

Rafael
09/16/20
11

Case # 4
As the health worker of the barangay and

member of the vaccination team, plan on
how you are going to immunize Ella and
decide on how you are going to handle
the situation.
none
none
none
none
Schedule for
2nd dose 1
month after
08/01/201
08/01/201
6
6
08/01/201
6 08/01/201
6
01/09/201
1
02/23/201
1 05/14/201
1
Not eligible
for MR
vaccination
08/01/201
6
Religious
belief

Case # 5
Miguel P. Cruz
Birthday: December 11, 2010
Address:
Brgy Binuhatan, San Rafael.
His
mother works as the midwife of the baranggay.
With parental consent
1 dose of MCV only: September 16, 2011
If you are the Teacher in-charge, how are you

going to record this information?
09/03/20
09
03/09/20
09
05/07/20
11
M
M
DELFIN, ELLA F.

Rafael
Rafael
09/16/20
11
12/11/20
10
CRUS, MIGUEL P.

Case # 5
Sick during schedule vaccination
Temp was 390C with some runny nose
As the health worker of the barangay and

member of the vaccination team, plan on
how you are going to immunize Miguel
and decide on how you are going to
handle the situation.
none
none
none
none
08/01/201
08/01/201
6
6
08/01/201
6 08/01/201
6
01/09/201
1
02/23/201
1 05/14/201
1
antibioti
cs
09/16/201
1
Schedule for
2nd dose 1
month after
Not eligible
for MR
vaccination
08/01/201
08/01/201
6
6
Religious
belief
High grade
fever
Reporting Timeline
Additional Reports collected by Central
Office
1. Weekly No of Deferrals/Refusals &
Corresponding Reasons (Quantified)
to be reported together with Form6
For mop-ups, update the original master list, then

ensure that those deferrals/refusals who are
vaccinated during the mop-up are translated to the
number of children vaccinated
Reporting Timeline
Additional Reports collected by
Central Office
2. Provincial Summary of AEFI
Reports to be reported together
with Form6
Vaccination Card
School Accomplishment
Form
GENERAL
INFORMATION
Form
TOTAL NO. OF
STUDENTS
ENROLLED
Form
ACTUAL NO. OF
STUDENTS
VACCINATED WITH
MR & Td
Form
TOTAL NO. OF DEFERRED

STUDENTS FOR
VACCINATION
Form
TOTAL NO. OF REFUSALS

FOR VACCINATION
Form
SINGATORIES
Vaccination Team
Supervisor
Vaccinators
Recorder
Municipal Consolidated
Accomplishment Form
Reporting Timeline
Workshop 2:
Microplanning
Microplanning
Objectives: To formulate a municipal plan for the
conduct of the 2016 School-Based Immunization
Instructions:
This activity is for 1 hour only
Group together per municipality together with
your partners (DepEd and others identified).
Choose a Leader and a Secretary for this activity.
Formulate a municipal plan and mop-up plan
based on the template provided.
Discuss among yourselves on how are you going
to conduct the prescribed activities.
You may have additional activities as deemed
necessary.
Prepare for a short presentation of the plan
Microplanning
Municipal Planning for the Conduct of the 2016 School-Based
Immunization
Activities /
Strategies
Time
Frame
Performan
ce
Indicator
I. Pre-Implementation Phase
II. Implementation Phase
III. Post-Implementation Phase
Resource
Requireme
nts
Sourc
e of
Fund
Person
Responsib
le
Mop-up Planning
Objectives: Formulate plan for mop-up activities
Instructions:
1. Identify strategy best suited in your area for mop-up activities
2. Prioritized areas for mop-up (highly dense schools with low 2015
SBI coverage, proximity of the school, and/or schools with high
deferral/refusal rate)
3. Plan the conduct of mop-up based on the template provided
2016 AUGUST 2016
MON
WEEK1
WEEK2
WEEK3
WEEK4
WEEK5
TUE
WED
THU
FRI
SAT/SU
N

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Workshop 1: Recording

/ Reporting / and Other

Yes: if parents consented the provision of the health

No: if parents did not consented (reason stated)

No consent form, drop-out, sick today

e.g.Religious affiliation, parents refussal

Grade 1 Recording Form

Grade 1 Recording Form

Grade 1 Recording Form

Grade 1 Recording Form

Grade 1 Recording Form

Grade 1 Recording Form

Grade 1 Recording Form

Grade 1 Recording Form

Grade 1 Recording Form

Grade 1 Recording Form

Grade 1 Recording Form

Date Vaccine Given (is the date of SBI) for

Grade 1 Recording Form

Grade 1 Recording Form

Name and Signature of the

Name and Signature of the

Grade 7 Recording Form

Grade 7 Recording Form

Grade 7 Recording Form

Grade 7 Recording Form

Grade 7 Recording Form

Grade 7 Recording Form

Grade 7 Recording Form

Grade 7 Recording Form

Grade 7 Recording Form

Grade 7 Recording Form

LAST MENSTRUAL PERIOD

Grade 7 Recording Form

Grade 7 Recording Form

Grade 7 Recording Form

Grade 7 Recording Form

Sample Case Scenario

Grade 1 student of Brgy. A Elem. School

Birthday: September 3, 2009

Address: Brgy Allegre, San Rafael.

With signed consent

Was not able to receive previous dose

If you are the Teacher in-charge, how are

Grade 1 Recording Form

Brgy. Alegre, San Rafael

Sample Case Scenario

Date: August 1, 2016.

As the health worker, plan on how you are

Grade 1 Recording Form

Sample Case Scenario

Grade 1 student of Brgy. A Elem. School

Birthday: March 9, 2010

Address: Brgy Allegre, San Rafael

With parental consent for immunization

No history of any allergies

1 dose of measles at 9mos old (January 9,

If you are the Teacher in-charge, how are

Grade 1 Recording Form

Brgy. Alegre, San Rafael

Brgy. Alegre, San Rafael

Sample Case Scenario

Date: August 1, 2016.