School Based Immunization

Recording Form 1: Masterlist of Grade 1 Students

Region:______________________________ Name of School:______________________ Section:______________________
Province/City:_________________________ Division: ___________________________
District/Municipality:__________________ Date: _____________________
To be filled up by the School Nurse/Class Adviser
No.

Name (1) (Surname, First Name, MI)

Complete Address (2)

Date of Birth MM/DD/YY

Age

Sex

To be fi
Date of Previous MCV received
Zero dose

MCV 1

MCV 2

Parents Response Slip

Y

History of allergies
(food, meds,
previous
immunization

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:

To be filled up by the Vaccination Team

Sick Today (fever,etc.)
Y

Vaccine Given
MCV1

MCV 2

Refusal
TD

Reasons

Reporting Form 2: Masterlist of Students

MASTERLIST OF ADOLESCENTS FOR IMMUNIZATION (GRADE 7)

ADOLESCENTS HEALTH AND DEVELOPMENT PROGRAM
(Year: ________)
Region: ______________________
District/Municipality: ____________________________
Province/City: _________________
Name of School: ____________________
Date: ________________________
Section: _______________
To be filled up by the school

No.

Name (1)

Complete Address (2)

To be filled up by the vaccination team

Date of Birth
(MM/DD/YY)

Parents' Response
Slip

Age

Sex
Y

History of Allergies Blood disorders

(meds, food, previous (ex. Bleeding
imzn of MMR/Td)
tendencies) Last Menstrual Period
(For FEMALE
ONLY)
Y

History of sexual
contact in the past 4
weeks ( for FEMALE
only)

Sick today?
(fever)

Vaccine Given

MR

(R
arm)

10

Total:
Note:

Alphabetical, separate male/female, 6 pages/section

____________________________________________

____________________________________________________

_________________________________________________

___________________________________________

Td

(L
arm)

Name and signature of Supervisor

Name and signature of Vaccinator 1

Name and Signature of Vaccinator 2

Name and Signature of Recorder

vaccination team

MR
Lot no:
Batch no:

Td
Lot no:
Batch No:

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: _______________

Name of
School

1
2
3
4
5
6
7

Total No. Enrolled

Male

Female

ct/Municipal Consolidated Accomplishment

IMMUNIZATON FOR ADOLESCENTS (GRADE 7)

ADOLESCENT HEALTH AND DEVELOPMENT PROGRAM
(Year: ________)

District: _______________

Region: ___________________
Province : _____________________

Enrolled
Total

Given MR
Male Female

Total

No.
Deferred

Given Td
Male

Female

Total

No.
Deferred

Refusal
No.

Reasons for Refusal

Reporting Form 4: School Consolidated Accomplishment

Region: _______________

Name of School: ___________________

Province/ City: _______________

Division: _____________________

Total Number enrolled

Given MR

Given Td

Number
Section

Total
Male

Grand Total

Female

Total

Male

Female

Number
Deferred

Number
Total
Male

Female

Number
Deferred

Refusal

Number

Reasons for Refusal

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
M

2
3
4
5
6
7
8
9
10
Submitted by:

Total

Total

Total

Number of Refusals

Reasons for Refusal

Reporting Form 6: Regional Consolidated Accomplishment

IMMUNIZATION FOR ADOLESCENTS (GRADE 7 )

ADOLESCENT HEALTH AND DEVELOPMENT PROGRAM
(Year: ___________)
Region: _________________________

Given MR Vaccines
City/Province

2
3
4
5
6
7
8
9
10

TOTAL

Submitted by:

No.
Deferred

Total Eligible
M

Given Td Vaccines

Total

Total

No. of Refusals

Reasons for Refusal

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.

Date

Name of Student

Age

Sex

Year Level

Name of school

Complete Address

Chief Complaint and Date of

onset

Findings & Diagnosis

mitted:_________________

by:____________________

Treatment/ Action Taken

Vaccine Given Lot no./ Expiry

date