School-Based Immunization

RECORDING Form 1: Masterlist of Grade 1 Students

To be filled up by the Vaccination Team
MR
Region: _______________________________ Name of School: ________________________________ Section: _______________________ Lot No: _______________________
Batch No: _____________________
Province/City: _________________________ Division: _______________________
Td
District/Municipality: ___________________ Date:__________________________ Lot No: _______________________
Batch No.______________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents'
Date of previous MCV Sick today? Vaccine Given
received Response History of allergies ( fever, etc)
No. Name (1 Complete Address (2) Dare of Birth Age Sex Slip (food, meds, previous No. Reasons
(Surname, First Name, MI) MM/DD/YY Refused
Zero MCV 1 MCV2 immunization)
Y N Y N MCV1 MCV2 Td
dose

8
________________________________________________ ________________________________________________ ________________________________________________
9 ________________________________________________ Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
Name and Signature of Supervisor

10

11

12

13

14

15
 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 4 FEMALE Students (9-13 yrs. old)

To be filled up by the Vaccination Team

Region: _______________________________ Name of School: _________________ Section: _______________________ HPV
Lot No: ___________
Province/City: _________________________ Division: _______________________ Batch No: _________

District/Municipality: ___________________ Date:__________________________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents' Sick today? Date of HPV Vaccine
Date of Birth Age Response Slip History of allergies ( fever) Given
No. Name (1) (Surname, First Name, MI) Complete Address (2) Sex Deferred Refusal Reason for Refusal
MM/DD/YY (food, meds,
Y N Y N 1st dose 2nd dose
previous immunization)

10

11

12

13

14

15
 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 7 Students
Region: IV-MIMAROPA Name of School: MNHS-CALAWAG EXTENSION To be filled up by the Vaccination Team
MR
Province/City: OCCIDENTAL MINDORO Division: OCCIDENTAL MINDORO Section: RUBY Lot No: _______________________
Batch No: _____________________
District/Municipality:MAGSAYSAY Date:__________________________ Td
Lot No: _______________________
Batch No.______________________

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

Parents' Sick today?

Last Vaccine Given
Response Slip ( fever)
Menstrual
Dare of Birth History of allergies (food, meds, previous Period Potentially
No. Name (1) Complete Address (2)
MM/DD/YY Age Sex immunization MR/Td) (for pregnant Deferred Refusal Reasons for Refusal
(Y / N) MR Td
Y N Y N FEMALES
only) (R arm) (L arm)

1 AGUILAR, ANDREW JOHN Z LASTE, MAGSAYSAY, OCCIDENTAL MINDORO

2 AGUILAR, KENNETH DAVE T. LASTE, MAGSAYSAY, OCCIDENTAL MINDORO
3 AGUIRRE, REGIE R. SILAD,SIBALAT,MAGSAYSAY,OCCIDENTAL MINDORO
4 ALOJADO, RENIER B. SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO
5 AÑAR, ROMMEL CALAWAG,MAGSAYSAY,OCCIDENTAL MINDORO
6 ANDRES, HENDRE S. BURIRAOAN,GAPASAN,MAGSAYSAY,OCC. MDO.
7 ANGELES, ELMO L NICOLAS,MAGSAYSAY,OCCIDENTAL MINDORO
8 BALAJADIA, RAYMOND T. CALAWAG,MAGSAYSAY,OCCIDENTAL MINDORO
9 BARRIOS, JHON REY Z. SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO
10 BERNADAS, MARCK LAWRENCE R TADLOK, ALIBOG, MAGSAYSAY,OCCIDENTAL MINDORO
11 BRABONGA, VINSON SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO
12 CACAYURIN, SHERWIN CAWIT,POBLACION,MAGSAYSAY,OCCIDENTAL MDO.
13 CAJELO, MARVEN TADLOK, ALIBOG, MAGSAYSAY,OCCIDENTAL MINDORO
14 CARACTA, JOHN HARVEY SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO
15 DALUNOS, MARJON O SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO

________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 7 Students
Region: IV-MIMAROPA Name of School: MNHS-CALAWAG EXTENSION
Province/City: OCCIDENTAL MINDORO Division: OCCIDENTAL MINDORO
District/Municipality:MAGSAYSAY Date:__________________________
To be filled up by the School Nurse/ Class Adviser
To be filled up by the Vaccination Team
MR
Section: RUBY Lot No: _______________________
Batch No: _____________________
Td
Lot No: _______________________
Batch No.______________________
To be filled up by the Vaccination Team

Parents' Sick
Respons History of today? Last Vaccine
e Slip allergies Given
( fever) Menstrual Poten
No. Complete Address (2) Date of Birth Age Sex (food, meds, Period tially Deferred Refusal Reasons for Refusal
Name (1) MM/DD/YY previous (for pregn Td
immunization FEMALES ant MR
Y N MR/Td) Y N only) (Y / N) (R (L
arm)
arm)
1 AGUILAR, ANDREW JOHN Z LASTE, MAGSAYSAY, OCCIDENTAL MINDORO M
2 AGUILAR, KENNETH DAVE T. LASTE, MAGSAYSAY, OCCIDENTAL MINDORO 10/9/2001 16 M
3 AGUIRRE, REGIE R. SILAD,SIBALAT,MAGSAYSAY,OCCIDENTAL MINDORO 8/22/2005 13 M
4 ALOJADO, RENIER B. SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 12/19/2005 12 M
5 AÑAR, ROMMEL CALAWAG,MAGSAYSAY,OCCIDENTAL MINDORO 9/27/2006 11 M
6 ANDRES, HENDRE S. BURIRAOAN,GAPASAN,MAGSAYSAY,OCC. MDO. 7/4/2005 13 M
7 ANGELES, ELMO L NICOLAS,MAGSAYSAY,OCCIDENTAL MINDORO 1/20/2005 13 M
8 BALAJADIA, RAYMOND T. CALAWAG,MAGSAYSAY,OCCIDENTAL MINDORO 2/4/2005 13 M
9 BARRIOS, JHON REY Z. SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 5/20/2006 12 M
10 BERNADAS, MARCK LAWRENCE TADLOK, ALIBOG, MAGSAYSAY,OCCIDENTAL MINDORO 10/27/2005 12 M
11 BRABONGA, VINSON SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 9/14/2006 11 M
12 CACAYURIN, SHERWIN CAWIT,POBLACION,MAGSAYSAY,OCCIDENTAL MDO. 6/22/2005 13 M
13 CAJELO, MARVEN TADLOK, ALIBOG, MAGSAYSAY,OCCIDENTAL MINDORO 10/6/2004 13 M
14 CARACTA, JOHN HARVEY SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 7/11/2006 12 M
15 DALUNOS, MARJON O SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 8/15/2004 14 M

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 7 Students

Region: IV-MIMAROPA Name of School: MNHS-CALAWAG EXTENSION To be filled up by the Vaccination Team
MR
Province/City: OCCIDENTAL MINDORO Division: OCCIDENTAL MINDORO Section: RUBY Lot No: _______________________
Batch No: _____________________
District/Municipality:MAGSAYSAY Date:__________________________ Td
Lot No: _______________________
Batch No.______________________
To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team

Parents' Sick
Response today? Last Vaccine Given
Slip ( fever) Menstrual
Date of Birth History of allergies Period Potentially
No. Name (1) Complete Address (2) Age Sex (food, meds, previous pregnant Deferred Refusal Reasons for Refusal
MM/DD/YY immunization MR/Td) (for (Y / N)
FEMALES
only) MR Td
Y N Y N
(R arm) (L arm)

16 DELA CRUZ, HASE JR BULALO,LASTE,MAGSAYSAY,OCCIDENTAL MINDORO M

17 DELA CRUZ, VON ERIC R BULALO,LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 2/20/2006 12 M

18 DELA FUENTE, JAMESON SIBALAT,MAGSAYSAY,OCCIDENTAL MINDORO 6/15/2003 15 M

19 DELOS SANTOS, JUSTIN T LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 4/17/2003 15 M

20 DELOS SANTOS, KEVIN R TADLOK,ALIBOG,MAGSAYSAY,OCCIDENTAL MINDORO M

21 ESPAÑOLA, RENIEL A SIBALAT,MAGSAYSAY,OCCIDENTAL MINDORO 4/12/2004 14 M

22 INSIGNE, MARK IVAN LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 2/16/2006 12 M

23 LUALHATI, JUNJUN KASUYAN,NICOLAS,MAGSAYSAY,OCCIDENTAL MDO. 2/1/2006 12 M

24 MAGBUDHI, BERNALD KASUYAN,NICOLAS,MAGSAYSAY,OCCIDENTAL MDO. 9/4/2004 13 M

25 OROZA, RICKY BUKAL,NICOLAS,MAGSAYSAY,OCCIDENTAL MINDORO 6/5/2004 14 M

26 PORTACIO, JIMAR CALAWAG,MAGSAYSAY,OCCIDENTAL MINDORO 5/22/2006 12 M

27 ROLDAN, RICHARD BURIRAOAN,GAPASAN,MAGSAYSAY,OCC. MDO. 12/2/2005 12 M

28 SABINO, BRYAN CALAWAG,MAGSAYSAY,OCCIDENTAL MINDORO 2/4/2006 12 M

29 SALAZAR, JERICO BURIRAOAN,GAPASAN,MAGSAYSAY,OCC. MDO. M

30 SALIMBAY, CHIEN REC SIBALAT,MAGSAYSAY,OCCIDENTAL MINDORO 5/17/2006 12 M

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 7 Students

Region: IV-MIMAROPA Name of School: MNHS-CALAWAG EXTENSION To be filled up by the Vaccination Team
MR
Province/City: OCCIDENTAL MINDORO Division: OCCIDENTAL MINDORO Section: RUBY Lot No: _______________________
Batch No: _____________________
District/Municipality:MAGSAYSAY Date:__________________________ Td
Lot No: _______________________
Batch No.______________________
To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team

Parents' Sick Last

Respons History of allergies today? Menstru Potenti Vaccine Given
e Slip (food, meds, ( fever) al Period
No. Complete Address (2) Date of Birth Age Sex previous ally Deferred Refusal Reasons for Refusal
Name (1) MM/DD/YY immunization (for pregna
MR/Td) FEMALE (Ynt
/ N) MR Td
Y N Y N S only) (R
arm) (L arm)
31 SAN JOSE, CEE JAY NICOLAS,MAGSAYSAY,OCCIDENTAL MINDORO 1/4/2005 13 M
32 SERNA, PAULO CABAG,POBLACION,MAGSAYSAY,OCCIDENTAL MDO. 8/28/2001 17 M
33 SIM, ROLAND SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 1/1/2006 12 M
34 TAGUMPAY, PAUL JORDAN LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 5/19/2005 13 M
35 TAÑEDO, MICO LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 8/2/2005 13 M
36 TAÑEDO, RAYMART LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 4/18/2005 13 M
37 URBINA, RONNIE BUKAL, NICOLAS,MAGSAYSAY,OCCIDENTAL MINDORO 9/12/2004 13 M
38 VILLAFLORES, REYNALD BUKAL, NICOLAS,MAGSAYSAY,OCCIDENTAL MINDORO 7/13/2005 13 M
39 ZABANAL JR., JONATHAN SILAD,SIBALAT,MAGSAYSAY,OCCIDENTAL MINDORO 3/28/2006 12 M
40 ACERON, CATHLEAH LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 2/8/2005 13 F
41 ARIOLA, JONNAFE BURIRAOAN,GAPASAN,MAGSAYSAY,OCC. MDO. 1/25/2006 12 F
42 BAGALAY, ERLYN CABAG,POBLACION,MAGSAYSAY,OCCIDENTAL MDO. 6/27/2006 12 F
43 BAYANAY, JESSA DC. LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 1/30/2005 13 F
44 CASIDSID, JESICA P SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 6/23/2005 13 F
45 CONTRERAS, ROSELYN CALAWAG,MAGSAYSAY,OCCIDENTAL MINDORO 12/29/2005 12 F

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 7 Students

Region: IV-MIMAROPA Name of School: MNHS-CALAWAG EXTENSION To be filled up by the Vaccination Team
MR
Province/City: OCCIDENTAL MINDORO Division: OCCIDENTAL MINDORO Section: RUBY Lot No: _______________________
Batch No: _____________________
District/Municipality:MAGSAYSAY Date:__________________________ Td
Lot No: _______________________
Batch No.______________________
To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team

Parents Sick
' History of allergies today? Vaccine Given
Respon
se Slip (food, meds, ( fever) Last Menstrual Potentiall
Date of Birth Period
No. Name (1) Complete Address (2) Age Sex previous y Deferred Refusal Reasons for Refusal
MM/DD/YY immunization (for FEMALES pregnant
only)
MR/Td) (Y / N)
Td
Y N Y N MR
(R arm)
(L arm)
46 DE SAN JOSE, CEE JANE NICOLAS,MAGSAYSAY,OCCIDENTAL MINDORO 11/29/2005 12 F
47 DELA CRUZ, CYREL NICOLE CALAWAG,MAGSAYSAY,OCCIDENTAL MINDORO 8/14/2006 12 F
48 DELA CRUZ, MONICA C BULALO,LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 1/9/2005 13 F
49 DELOS ANGELES, KRISTALA P SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 10/1/2005 12 F
50 DEYTA, RECA JANE BURIRAOAN,GAPASAN,MAGSAYSAY,OCC. MDO. 3/31/2006 12 F
51 DUCOS, WINDY BURIRAOAN,GAPASAN,MAGSAYSAY,OCC. MDO. 9/26/2005 12 F
52 ENCIA, JENNELYN KASUYAN,NICOLAS,MAGSAYSAY,OCCIDENTAL MDO. 12/24/2005 12 F
53 ERANDIO, SHIELA BUKAL,NICOLAS,MAGSAYSAY,OCCIDENTAL MINDORO 5/6/2006 12 F
54 ESPAÑOLA, SHARILLE SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 3/28/2006 12 F
55 GABINETE, JOVELYN TADLOK, ALIBOG, MAGSAYSAY,OCCIDENTAL MINDORO 6/9/2005 13 F
56 HARAYO, RITCHEL BULALO,LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 1/6/2005 13 F
57 JACINTO, AILEEN JOY NICOLAS,MAGSAYSAY,OCCIDENTAL MINDORO 2/13/2006 12 F
58 MANZANO, MARY GRACE KASUYAN,NICOLAS,MAGSAYSAY,OCCIDENTAL MDO. 2/10/2004 14 F
59 MAXIMO, TASHIA TADLOK, ALIBOG, MAGSAYSAY,OCCIDENTAL MINDORO 5/6/2006 12 F
60 MERCADER, MARIA CATHERINE SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 3/24/2005 13 F

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
 School-Based Immunization
RECORDING Form 3: Masterlist of Grade 7 Students

Region: IV-MIMAROPA Name of School: MNHS-CALAWAG EXTENSION To be filled up by the Vaccination Team
MR
Province/City: OCCIDENTAL MINDORO Division: OCCIDENTAL MINDORO Section: RUBY Lot No: _______________________
Batch No: _____________________
District/Municipality:MAGSAYSAY Date:__________________________ Td
Lot No: _______________________
Batch No.______________________
To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents'
Sick Vaccine
History of today? Last
Respon allergies ( fever) Menstrual Potenti Given
se Slip (food,
No. Name (1) Complete Address (2) Date of Birth Age Sex Period ally Reasons for Refusal
MM/DD/YY meds, (for pregna
Deferred Refusal
previous
immunizati FEMALES nt MR Td
Y N on MR/Td) Y N only) (Y / N) (R
arm) (L
arm)

61 MIRANDA,KRIZHALENE JANE TADLOK, ALIBOG, MAGSAYSAY,OCCIDENTAL MINDORO 10/19/2004 13 F

62 ORACION, MICAELA TADLOK, ALIBOG, MAGSAYSAY,OCCIDENTAL MINDORO 9/16/2005 12 F
63 PELARDO, MARIVIC BULALO,LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 12/27/2003 14 F
64 PERIANO, MERIAM BULALO,LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 2/9/2006 12 F
65 QUIJANO, JONNA MAY TADLOK, ALIBOG, MAGSAYSAY,OCCIDENTAL MINDORO 9/14/2006 11 F
66 SERNA, CRISTINE E SILAD,SIBALAT,MAGSAYSAY,OCCIDENTAL MINDORO 1/30/2006 12 F
67 SILVERIO, CHARLYN BURIRAOAN,GAPASAN,MAGSAYSAY,OCCIDENTAL MDO. 8/29/2005 13 F
68 TEJOSO, CRISTINE ANNE LASTE,MAGSAYSAY,OCCIDENTAL MINDORO 10/4/2005 12 F
69 TUAZON, ALLANA MARIE CALAWAG,MAGSAYSAY,OCCIDENTAL MINDORO 7/17/2006 12 F
70 VALDEZ, CHRISTINE MAE SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 5/24/2005 13 F
71 VILLARAM, JANINE SIBALAT, MAGSAYSAY, OCCIDENTAL MINDORO 8/6/2006 12 F

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2