School-Based Immunization

RECORDING Form 1: Masterlist of Students

Masterlist of Kinder 1 to Grade 7 (Except Grade 4)
Region: __________________________ Name of School: _____________________________________________ To be filled up by the Vaccination Team
MR
Province/City: ____________________ Division: __________________ Section: ________________________ Lot No: _________________________
Batch No: _________________________
City/Municipality: _________________ Date: ___________________ Td
Lot No: ___________________________
Batch No. _________________________
To be filled up by the School Nurse/Class Adviser To be filled up by the Vaccination Team
No. Name (1) Complete Address (2) Date of Birth Age Sex Date of previous MCV received Parents’ Response History of allergies Sick today? Last Menstrual Potentially Date of Vaccine Given Deferre Refusal Reasons for Refusal
Slip
MM/DD/YY (food, meds, previous (fever) Period pregnant d
immunization (for FEMALES (Y/N)
MCV/Td only)
Y N MCV MCV Td
1 2 (for Grade 1
Zero MCV 1 MCV 2 Y N and 7 only)
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 1
*MCV-Measles Containing Vaccine (Anti-measles Vaccine [AMV], Measles, Mumps, Rubella (MMR)
*Td-Tetanus-diptheria