School-Based Immuni

MASTERLIST OF LEARNERS

Region: I Name of School: MALIMPEC ELEMENTARY SCHOOL

Province/City: PANGASINAN Section: VI-MARUNONG

District/Municipality: MALASIQUI Date:__________________________

To be filled up by the School Nurse/ Class Adviser

Date of previous MCV
Name (1) Dare of Birth received
No. Complete Address (2) Age Sex
(Surname, First Name, MI) MM/DD/YY
Zero
Dose MCV 1
1 BAYANGAT,JYAN, SALUNATIN MALIMPEC, MALASIQUI, PANGASINAN 05-26-2008 10 M
2 DE GUZMAN,JOMAR, LLACAR MALIMPEC, MALASIQUI, PANGASINAN 02-16-2008 10 M
3 DELA CRUZ,CARL ARNOLD, ROSOS MALIMPEC, MALASIQUI, PANGASINAN 09-16-2008 9 M
4 LEBITANIA,JUSTINE CARL, DOMANTAY MALIMPEC, MALASIQUI, PANGASINAN 10-18-2008 9 M
5 MARTINEZ,ROGER, JR BALBERAN MALIMPEC, MALASIQUI, PANGASINAN 02-05-2008 10 M
6 MENDOZA,ARVIN JAY, QUEÑANO MALIMPEC, MALASIQUI, PANGASINAN 10-05-2008 9 M
7 PEREZ,JOHN PATRICK, JIMENEZ MALIMPEC, MALASIQUI, PANGASINAN 02-07-2008 10 M
8 PIOQUID,JUZFER, POTES MALIMPEC, MALASIQUI, PANGASINAN 11-29-2007 10 M
9 QUEZON,RYAN, PIDO MALIMPEC, MALASIQUI, PANGASINAN 01-11-2008 10 M
10 QUINAGON,MYLES, UMALLA MALIMPEC, MALASIQUI, PANGASINAN 04-16-2008 10 M
11 QUINTERO,LEMUEL, LANERA MALIMPEC, MALASIQUI, PANGASINAN 12-10-2007 10 M
12 RAMOS,DWANE MARC, MALOGAN MALIMPEC, MALASIQUI, PANGASINAN 03-17-2008 10 M
13 VILLEGAS,JACOB, CARPIZ MALIMPEC, MALASIQUI, PANGASINAN 11-29-2008 9 M
14 BAYANGAT,HANNIKA, OMAGTANG MALIMPEC, MALASIQUI, PANGASINAN 05-03-2008 10 F
15 BAYANGAT,JOY ANN, DINOLA MALIMPEC, MALASIQUI, PANGASINAN 05-19-2008 10 F
16 CONMIGO,GEMMA, CAMORONGAN MALIMPEC, MALASIQUI, PANGASINAN 08-02-2007 10 F
17 CONMIGO,NIKKA, ANCHETA MALIMPEC, MALASIQUI, PANGASINAN 03-11-2008 10 F
18 CAYAGO,KRISHA ANN, LOMIBAO MALIMPEC, MALASIQUI, PANGASINAN 08-12-2008 9 F
19 EVANGELISTA,ERICH ANGEL, CASIPIT MALIMPEC, MALASIQUI, PANGASINAN 11-29-2007 10 F
20 GABRIEL,EDZIEL JOY, CULA MALIMPEC, MALASIQUI, PANGASINAN 11-12-2007 10 F
21 MANDAPAT,DIANA MAE, POQUIZ MALIMPEC, MALASIQUI, PANGASINAN 02-22-2008 10 F
22 RAMOS,NICOLE, QUEÑANO BAKITIW, MALASIQUI, PANGASINAN 05-11-2006 12 F
23 RANGES,SHANE, CASIPIT MALIMPEC, MALASIQUI, PANGASINAN 11-17-2008 9 F
Name and Signature of Supervisor Name and Signature of Vaccinator 1
 School-Based Immunization
MASTERLIST OF LEARNERS GRADE VI
To be filled up by the Vaccination Team
MR
Lot No: _______________________
Batch No: _____________________
Td
Lot No: _______________________
Batch No.______________________
Total no. of Grade 1 students:_______________
Total no. of MR vaccine given:_______________
Total no. of Td vaccine given:_______________
Total no. of children vaccinated:_____________
Total no. of deferred: ______________________
Total no. of refusal: _______________________

To be filled up by the Vaccination Team

te of previous MCV Parents' Sick today?
received Response Slip History of allergies ( fever, etc) Vaccine Given
(food, meds, previous Refusal
immunization)
Y N Y N MCV1 MCV2 Td
MCV2 (L arm)
Name of and Signature of Vaccinator 2 Name and Signature of Recorder
To be filled up by the Vaccination Team

Reasons
 School-Based Immunization
RECORDING Form 2: Masterlist of Grade 7 Students

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

MR
Province/City: _________________________ Section: _______________________ Lot No: _______________________
Batch No: _____________________
District/Municipality: ___________________ Date:__________________________
Td
Lot No: _______________________
Batch No.______________________
Total no. of Grade 7 students:_______________
Total no. of MR vaccine given:______________
Total no. of Td vaccine given:_______________
Total no. of children vaccinated:_____________
Total no. of deferred: ______________________
Total no. of refusal: _______________________
Total no. of female with
sexual contact in the past 4 wks.: ____________

To be filled up by the School Nurse/ Class Adviser To be filled up by the Vaccination Team
Parents' Sick today?
Response History of allergies Vaccine Given
( fever)
Slip (food, meds, Last Menstrual
Dare of Birth Potentially
No. Name (1) Complete Address (2) Age Sex previous Period (for Deferred Refusal Reasons for Refusal
MM/DD/YY
Y N immunization Y N FEMALES only) Pregnant (Y/N)
MR/Td) MR Td
(R arm) (L arm)

10

11

12

13

14

15

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name of and Signature of Vaccinator 2 Name and Signature of Recorder
 School-Based Immunization
RECORDING Form: Masterlist of Grade 4 FEMALE Students (9-
Region: I Name of School: MALIMPEC ELEMENTARY SCHOOL

Province/City: PANGASINAN Section: VI-MARUNONG

District/Municipality: MALASIQUI Date:__________________________

To be filled up by the School Nurse/ Class Adviser

Parents' Response
Name (1) (Surname, First Date of Birth Slip
No. Complete Address (2) Age Sex
Name, MI) MM/DD/YY
Y N

1 ABALOS, JEROME P. BUTAO MALASIQUI, PANGASINAN 08/17/2010 9 M

2 ANCHETA, LIMUEL G. BAKITIW MALASIQUI, PANGASINAN 12/29/2009 9 M

3 ANTALAN, JHYRO I. MALIMPEC MALASIQUI, PANGASINAN 03/14/2011 8 M

4 BAYANGAT, JERRICK A. MALIMPEC MALASIQUI, PANGASINAN 8/4/2011 8 M

5 BENITEZ, ALVIN JOHN C. MALIMPEC MALASIQUI, PANGASINAN 09/13/2010 8 M

6 BUGARIN, ASLIE E. MALIMPEC MALASIQUI, PANGASINAN 05/23/2011 8 M

7 CAPITLE, JASPHER P. MALIMPEC MALASIQUI, PANGASINAN 12/1/2011 8 M

8 CAYAGO, JEHRO G. MALIMPEC MALASIQUI, PANGASINAN 11/22/2010 8 M

9 CONMIGO, MHELCHUR A. MALIMPEC MALASIQUI, PANGASINAN 6/1/2011 8 M

10 DE GUZMAN, JOHN MICHAEL M. MALIMPEC MALASIQUI, PANGASINAN 8/4/2011 8 M

11 MACARANAS, DENVER C. MALIMPEC MALASIQUI, PANGASINAN 12/16/2010 8 M

12 PLEÑAGO, PERLITO CARL III, E MALIMPEC MALASIQUI, PANGASINAN 9/23/2011 8 M

13 QUEÑANO, NHIKKO JHON G. MALIMPEC MALASIQUI, PANGASINAN 6/13/2009 8 M

14 ABALOS, LOVE LEE P. BUTAO MALASIQUI, PANGASINAN 6/24/2011 8 F

15 BUGARIN,PRECIOUS DIVINE C. MALIMPEC MALASIQUI, PANGASINAN 4/1/2011 8 F
16 CARLOS, ROSEMARY S. BUTAO MALASIQUI, PANGASINAN 6/13/2011 F
17 DILOY, RHAILE ZYRINE M. BUTAO MALASIQUI, PANGASINAN 8/24/2011 9 F
18 FERNANDEZ, CHLOE G. MALIMPEC MALASIQUI, PANGASINAN 3/21/2011 F
19 IGLESIAS, VERONICA P. MALIMPEC MALASIQUI, PANGASINAN 11/25/2009 8 F
20 MADELO, XYRENE D. MALIMPEC MALASIQUI, PANGASINAN 11/30/2010 8 F
21 MASIGLAT, VIVIAN C. MALIMPEC MALASIQUI, PANGASINAN 12/13/2010 8 F
22 POQUIZ, CRIANZEL L. MALIMPEC MALASIQUI, PANGASINAN 12/3/2010 9 F
23 RAFANAN, RHIANNE JANE R. MALIMPEC MALASIQUI, PANGASINAN 12/9/2010 8 F
24 RAMOS, DANICA M. MALIMPEC MALASIQUI, PANGASINAN 1/10/2011 8 F
25 RANGES, KRISTAL JOY A. MALIMPEC MALASIQUI, PANGASINAN 8 F
26 RODEO, APRILYN K. MALIMPEC MALASIQUI, PANGASINAN F

Name and Signature of Supervisor Name and Signature of Vaccinator 1

(1st Dose)
ased Immunization
f Grade 4 FEMALE Students (9-13 yrs. old)
To be filled up by the Vaccination Team
HPV Total no. of Grade 4 eligible:___________________
Lot No: __________ Total no. of 1st dose of HPV vaccine given:_______
Batch No: ________ Total no. of 2nd dose of HPV vaccine given:______
Total no. of children vaccinated:________________
Total no. of deferred: _________________________
Total no. of refusal: __________________________

To be filled up by the Vaccination Team

Sick today? Date of HPV Vaccine Given
( fever) Remarks
History of allergies (food,
meds, previous immunization) Y N 1st dose 2nd dose
Name of and Signature of Vaccinator 2 Name and Signature of Recorder
(2nd Dose)

Region: _______________________________
Province/City: _________________________
District/Municipality: ___________________
School-Based Immunization
RECORDING Form 2: Masterlist of Grade 4 FEMALE Students (9-13 yrs. old)
Name of School: ________________________________________________________ To be filled up by the Vaccination Team
HPV Total no. of Grade 4 eligible:___________________
Section: _______________________ Lot No: __________ Total no. of 1st dose of HPV vaccine given:_______
Batch No: ________ Total no. of 2nd dose of HPV vaccine given:______
Date:__________________________ Total no. of children vaccinated:________________
Total no. of deferred: _________________________
Total no. of refusal: __________________________

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

10

11

12

13

14

15

Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name of and Signature of Vaccinator 2 Name and Signature of Recorder
(1st Dose) (2nd Dose)
BAYANGAT,JYAN, SALUNATIN 05-26-2008 MALIMPEC 10
DE GUZMAN,JOMAR, LLACAR 02-16-2008 MALIMPEC 10
DELA CRUZ,CARL ARNOLD, ROSOS 09-16-2008 MALIMPEC 9
LEBITANIA,JUSTINE CARL, DOMANTAY 10-18-2008 MALIMPEC 9
MARTINEZ,ROGER, JR BALBERAN 02-05-2008 MALIMPEC 10
MENDOZA,ARVIN JAY, QUEÑANO 10-05-2008 MALIMPEC 9
PEREZ,JOHN PATRICK, JIMENEZ 02-07-2008 MALIMPEC 10
PIOQUID,JUZFER, POTES 11-29-2007 MALIMPEC 10
QUEZON,RYAN, PIDO 01-11-2008 MALIMPEC 10
QUINAGON,MYLES, UMALLA 04-16-2008 MALIMPEC 10
QUINTERO,LEMUEL, LANERA 12-10-2007 MALIMPEC 10
RAMOS,DWANE MARC, MALOGAN 03-17-2008 MALIMPEC 10
VILLEGAS,JACOB, CARPIZ 11-29-2008 MALIMPEC 9
BAYANGAT,HANNIKA, OMAGTANG 05-03-2008
BAYANGAT,JOY ANN, DINOLA 05-19-2008 LOQUEB NORTE 10
CONMIGO,GEMMA, CAMORONGA08-02-2007 MALIMPEC 10
CONMIGO,NIKKA, ANCHETA 03-11-2008 MALIMPEC 10
CAYAGO,KRISHA ANN, LOMIBAO 08-12-2008 MALIMPEC 10
EVANGELISTA,ERICH ANGEL, CASIP11-29-2007 MALIMPEC 9
GABRIEL,EDZIEL JOY, CULA 11-12-2007 MALIMPEC 10
MANDAPAT,DIANA MAE, POQUIZ 02-22-2008 MALIMPEC 10
RAMOS,NICOLE, QUEÑANO 05-11-2006 MALIMPEC 10
RANGES,SHANE, CASIPIT 11-17-2008 BAKITIW 12
MALIMPEC 9