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    School - BAsed Immunization Recording Form

    Uploaded by

    Ernest Jerome Malamion
    This document contains 3 forms used to record immunization data from school-based vaccination programs. Form 1 is a master list containing students' names, addresses, dates of birth, and fields to record vaccines administered. Form 2 is for female students ages 9-10 years old and contains similar fields focused on the HPV vaccine. Form 3 is another master list for grade 1 students to record the MR and Td vaccines. The final sections provide spaces to consolidate data on vaccination coverage rates by location.

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    © All Rights Reserved
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    School - BAsed Immunization Recording Form

    Uploaded by

    Ernest Jerome Malamion
    2K views14 pages
    This document contains 3 forms used to record immunization data from school-based vaccination programs. Form 1 is a master list containing students' names, addresses, dates of birth, and fields to record vaccines administered. Form 2 is for female students ages 9-10 years old and contains similar fields focused on the HPV vaccine. Form 3 is another master list for grade 1 students to record the MR and Td vaccines. The final sections provide spaces to consolidate data on vaccination coverage rates by location.

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    recording

    Original Title

    School- BAsed Immunization Recording Form

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    This document contains 3 forms used to record immunization data from school-based vaccination programs. Form 1 is a master list containing students' names, addresses, dates of birth, and fields to record vaccines administered. Form 2 is for female students ages 9-10 years old and contains similar fields focused on the HPV vaccine. Form 3 is another master list for grade 1 students to record the MR and Td vaccines. The final sections provide spaces to consolidate data on vaccination coverage rates by location.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    2K views14 pages

    School - BAsed Immunization Recording Form

    Uploaded by

    Ernest Jerome Malamion
    This document contains 3 forms used to record immunization data from school-based vaccination programs. Form 1 is a master list containing students' names, addresses, dates of birth, and fields to record vaccines administered. Form 2 is for female students ages 9-10 years old and contains similar fields focused on the HPV vaccine. Form 3 is another master list for grade 1 students to record the MR and Td vaccines. The final sections provide spaces to consolidate data on vaccination coverage rates by location.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 14

    School-Based Immunization

    Recording Form 1:Masterlist of Grade 1 Students


    Region:

    Name of School:

    Section:

    To be filled up by the Vaccination Tea

    Province:

    Division:

    MR

    District/Municipality:

    Date:

    Lot No.
    Batch No.
    Td
    Lot No.
    Batch No.

    Date of previous MCV

    Parent's

    received

    Response Slip

    To be fiilled up by the School Nurse/Class Adviser

    Sick today?
    History of

    (fever,etc)

    Vaccine Given

    allergies(food,meds,p
    Date of
    No.

    Name(Surname,First Name, MI)


    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12
    13
    14
    15

    Complete Adress

    Bith(mm/dd/yy)

    Zero
    Age

    Sex

    dose

    revious
    MCV1

    MVC2

    immunization)

    MCV1

    Name and Signature of Supervisor

    Name and Siganature of Vaccinator 1

    Name/Signature of Vaccinator 2

    be filled up by the Vaccination Team

    Vaccine Given

    MCV2 Td

    Refusal

    Reasons

    Name/Signature of Recorder

    Region:
    Province:
    District/Municipality:

    Name of School:
    Division:
    Date:

    School-Based Immunization
    Recording Form 2:Masterlist of Female Students(9-10 yrs. Old)

    Parent's
    To be fiilled up by the School Nurse/Class Adviser

    Response Slip

    Date of
    No.

    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12
    13
    14
    15

    Name(Surname,First Name, MI)

    Name and Signature of Supervisor

    Complete Adress

    Bith(mm/dd/yy) Age

    History of
    allergies(food,m

    To be filled up by the Vaccination Team


    HPV:
    Lot No.
    Batch No.

    Sick today?

    Date of HPV

    (fever,etc)

    Vaccine Given

    eds, previous
    Sex

    immunization)

    Name and Siganature of VaccinName/Signature of Vaccinator 2

    1st dose

    2nd Dose

    Name/Signature of Recorder

    Vaccination Team

    Deffered

    Refusal

    Name/Signature of Recorder

    Reasons

    School-Based Immunization
    Recording Form 3:Masterlist of Grade 1 Students
    Region:

    Name of School:

    Province:
    District/Municipality:

    Division:
    Date:

    To be filled up by the Vaccination Team


    MR
    Lot No.
    Batch No.
    Td
    Lot No.
    Batch No.

    Parent's
    To be fiilled up by the School Nurse/Class Adviser

    Response Slip

    Date of
    No. Name(Surname,First Name, MI)

    Complete Adress

    Bith(mm/dd/yy)

    History of
    allergies(food,meds

    Sick today?
    (fever,etc)

    Vaccine Given

    ,previous
    Age

    Sex

    immunization)

    MR(R arm) Td(L arm)

    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12
    13
    14
    15

    Name and Signature of Supervisor

    Name and Siganature of Vaccinator 1

    Name/Signature of Vaccinator 2

    Name/Signature of Recorder

    Deffered

    gnature of Recorder

    Refusal

    Reasons

    Total No.
    Province/
    of
    City/Mun schools
    icipality Covered

    Students
    Vaccinated with
    MCV
    No.

    Grade 1
    Students
    Vaccinated with Td
    No.

    Total no. of Deffered


    MCV

    Td

    Total Number of Reffusal


    %

    MCV

    Td

    Total
    Number
    of
    Enrolled

    Grade IV FEMALE Students(9-13 yrs. Old


    No. of Female Students Vaccinated
    1st dose
    HPV

    2nd dose
    HPV

    Total no. of deffered


    2st dose
    HPV

    2nd dose
    HPV

    Total No. of Reffusal


    %

    1st dose
    HPV

    2nd dose
    HPV

    Total No.
    of
    Students
    Enrolled

    Students
    vaccinated with
    MR
    no.

    Grade VII
    Students
    vaccinated with Td
    No.

    Total no. of deffered


    MR

    Td

    Total No. of Refusal


    %

    MR

    Td

    ANNEX C
    Recording Form for HPV Vaccination
    Region of RHU:

    Province/City:

    Municipality:

    Name of RHU:
    Name of Children(Surname, First Name, MI)

    Date Submitted:
    Complete Adress

    Date of Birth

    INSTRUCTION: completely fill-out Form and keep for the next vaccination cshedulschedule
    Note: Health workers must ensure that those who received the HPV 1st dose of HPV vaccine after 6 mons.

    Age in Years

    Date 1st dose given

    Date 2nd dose given

    Remarks

    Reporting Form 1

    Consolidated Accomplishment Report for HPV Vaccination

    Region: I

    Province: La Union

    Municipality/RHU: San Gabriel RHU & Birthing Clinic


    No. Given 1st
    Name of Province/City/RHU/BHS

    Bayabas Elementary School


    Lon-oy Elementary School
    Sisi Elementary School

    Prepared by:
    Joyce Anne D. Africano, RN
    Name and Designation

    dose

    8
    13
    14

    Date Submitted: 8/25/16


    Remarks

    No. Given
    %

    100
    100
    93.33

    2nd dose

    Approved by:
    Juan Alfonso R. Perez IV, MD-MBA
    Name and Designation

    1 absent

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