Annex School-Based Immunization

C.1 RECORDING Form: Masterlist of Kinder Students (Measles Cont

Region: __________________________ Name of School: ______________________ Section: _______________________

Province/City: ____________________ Division: _______________________

District/Municipality: ______________ Date:__________________________

To be filled up by the School Nurse/ Class Adviser

Date of previous MCV received
Name (1) Date of Birth Age Sex
No. Complete Address (2)
(Surname, First Name, MI) MM/DD/YY MCV 1 MCV2
Zero dose (9 mos) (MMR/MR)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Alphabetical, separate male and female, 6 pages per section

Name & Signature of Supervisor Name & Signature of Vaccinator 1

mmunization
ents (Measles Containing Vaccine (MCV))

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

Parents' History of Sick today? Vaccine Given
Response Slip allergies ( fever, etc)
(food, meds, Refusal Reasons
previous
Y N immunization) Y N MCV1 MCV2

Name & Signature of Guide

 Annex School-Based Immunization
C.2
RECORDING Form: Masterlist of Grade 1 Students (M

Region: __________________________ Name of School: ______________________ Section: _______________________

Province/City: ____________________ Division: _______________________

District/Municipality: ______________ Date:__________________________

To be filled up by the School Nurse/ Class Adviser

Date of previous MCV received
Name (1) Date of Birth Age Sex
No. Complete Address (2)
(Surname, First Name, MI) MM/DD/YY MCV 1 MCV2
Zero dose
(9 mos) (MMR/MR)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Alphabetical, separate male and female, 6 pages per section

Name & Signature of Supervisor Name & Signature of Vaccinator 1 Name & Signature o
 munization
Grade 1 Students (MR & TD)

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

Parents' History of Sick today? Vaccine Given
Response Slip allergies ( fever, etc)
(food, meds, Refusal Reasons
previous
Y N immunization) Y N MCV1 MCV2 Td

Name & Signature of Vaccinator 2 Name & Signature of Guide

 Annex School-Based Immunization
C.3 RECORDING Form: Masterlist of Grade 2 Students (Measles Con

Region: __________________________ Name of School: ______________________ Section: _______________________

Province/City: ____________________ Division: _______________________

District/Municipality: ______________ Date:__________________________

To be filled up by the School Nurse/ Class Adviser

Date of previous MCV received
Name (1) Date of Birth Age Sex
No. Complete Address (2)
(Surname, First Name, MI) MM/DD/YY MCV 1 MCV2
Zero dose
(9 mos) (MMR/MR)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Alphabetical, separate male and female, 6 pages per section

Name & Signature of Supervisor Name & Signature of Vaccinator 1

mmunization
dents (Measles Containing Vaccine (MCV))

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

Parents' History of Sick today? Vaccine Given
Response Slip allergies ( fever, etc)
(food, meds, Refusal Reasons
previous
Y N immunization) Y N MCV1 MCV2

Name & Signature of Guide

 Annex School-Based Immunization
C.4
RECORDING Form: Masterlist of Grade 3 Students (Measles Con

Region: __________________________ Name of School: ______________________ Section: _______________________

Province/City: ____________________ Division: _______________________

District/Municipality: ______________ Date:__________________________

To be filled up by the School Nurse/ Class Adviser

Date of previous MCV received
Name (1) Date of Birth Age Sex
No. Complete Address (2)
(Surname, First Name, MI) MM/DD/YY MCV 1 MCV2
Zero dose
(9 mos) (MMR/MR)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Alphabetical, separate male and female, 6 pages per section

Name & Signature of Supervisor Name & Signature of Vaccinator 1

mmunization
dents (Measles Containing Vaccine (MCV))

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

Parents' History of Sick today? Vaccine Given
Response Slip allergies ( fever, etc)
(food, meds, Refusal Reasons
previous
Y N immunization) Y N MCV1 MCV2

Name & Signature of Guide

 Annex School-Based Immunization
C.5 RECORDING Form: Masterlist of Grade 4 Students (Measles Con

Region: __________________________ Name of School: ______________________ Section: _______________________

Province/City: ____________________ Division: _______________________

District/Municipality: ______________ Date:__________________________

To be filled up by the School Nurse/ Class Adviser

Date of previous MCV received
Name (1) Date of Birth Age Sex
No. Complete Address (2)
(Surname, First Name, MI) MM/DD/YY MCV 1 MCV2
Zero dose
(9 mos) (MMR/MR)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Alphabetical, separate male and female, 6 pages per section

Name & Signature of Supervisor Name & Signature of Vaccinator 1

mmunization
dents (Measles Containing Vaccine (MCV))

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

Parents' History of Sick today? Vaccine Given
Response Slip allergies ( fever, etc)
(food, meds, Refusal Reasons
previous
Y N immunization) Y N MCV1 MCV2

Name & Signature of Guide

 Annex School-Based Immunization
C.6
RECORDING Form: Masterlist of Grade 4 FEMALE Students (9-13 yrs. old) (Human Papilloma Virus - HPV)

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
Response History of
Slip allergies ( fever) Given
No. Name (1) (Surname, Date of Birth Age Sex
Complete Address (2) (food, meds, Deferred Refusal Reason for Refusal
First Name, MI) MM/DD/YY previous
Y N immunization) Y N 1st dose 2nd dose

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Alphabetical, separate male and female, 6 pages per section

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2
 Annex School-Based Immunization
C.7 RECORDING Form: Masterlist of Grade 5 Students (Measles Con

Region: __________________________ Name of School: ______________________ Section: _______________________

Province/City: ____________________ Division: _______________________

District/Municipality: ______________ Date:__________________________

To be filled up by the School Nurse/ Class Adviser

Date of previous MCV received
Name (1) Date of Birth Age Sex
No. Complete Address (2)
(Surname, First Name, MI) MM/DD/YY MCV 1 MCV2
Zero dose
(9 mos) (MMR/MR)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Alphabetical, separate male and female, 6 pages per section

Name & Signature of Supervisor Name & Signature of Vaccinator 1

mmunization
dents (Measles Containing Vaccine (MCV))

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

Parents' History of Sick today? Vaccine Given
Response Slip allergies ( fever, etc)
(food, meds, Refusal Reasons
previous
Y N immunization) Y N MCV1 MCV2

Name & Signature of Guide

 Annex School-Based Immunization
C.8 RECORDING Form: Masterlist of Grade 6 Students (Measles Con

Region: __________________________ Name of School: ______________________ Section: _______________________

Province/City: ____________________ Division: _______________________

District/Municipality: ______________ Date:__________________________

To be filled up by the School Nurse/ Class Adviser

Date of previous MCV received
Name (1) Date of Birth Age Sex
No. Complete Address (2)
(Surname, First Name, MI) MM/DD/YY MCV 1 MCV2
Zero dose
(9 mos) (MMR/MR)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Alphabetical, separate male and female, 6 pages per section

Name & Signature of Supervisor Name & Signature of Vaccinator 1

mmunization
dents (Measles Containing Vaccine (MCV))

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

Parents' History of Sick today? Vaccine Given
Response Slip allergies ( fever, etc)
(food, meds, Refusal Reasons
previous
Y N immunization) Y N MCV1 MCV2

Name & Signature of Guide

Annex C.9
School-Based Immunization
RECORDING Form: Masterlist of Grade 7 Students (MR & TD)

Region: ______________________________ Name of School: ________________________________________________________ To be filled up by the Vaccination Team

MR
Province/City: ________________________ Division: _______________________
Section: ___________________ Lot No: _______________________
Batch No: _____________________
District/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
Parents' Sick today?
Response Slip History of allergies ( fever) Vaccine Given
Name (1) Date of Birth Last Menstrual Potentially
No. (Surname, First Name, MI) Complete Address (2) MM/DD/YY Age Sex (food, meds, previous Period (for pregnant Deferred Refusal Reasons for Refusal
MR Td
Y N immunization MR/Td) FEMALES only) (Y / N) Y N (R arm) (L arm)

10

11

12

13

14

15
Potentially pregnant means history of sexual contact in the past 4 weeks (for FEMALES only)
Alphabetical, separate male and female, 6 pages per section

Name & Signature of Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2 Name & Signature of Guide