RECORDING Form 1: Masterlist of Grade 1 Students

Region: I Name of school: _____________________________

Province/City: Pangasinan I Section: ___ A
District/Municipality:

To be filled up by the School Nurse/Class Adviser

Date of previous Parents
Date of Birth Sex MCV received Response Slip
History of allergies
No. Name (1) Complete Address (2) Age (food,meds, previous
MM/DD/YY immunization)
M/F
MCV1 MCV2 Y N
1

10

11

12

13

14

15
 16

17

18

19

20

21

22

TOTAL

____________________________ _________________________________ __________________________

Name and Signature of Adviser Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccina

* Grade I pupils shall be immunized with MR (Measles or tigdas and Rubella or tigdas hangin) and Td (Tetanus & diptheria)

* Deped shall submit the masterlist of Grade I pupils as a basis for the number of vaccines to be purchased by the DOH

This form (Recording Form 1) shall be filled up by the class adviser

It shall be kept by the adviser and present it to the vaccination team on the day of immunization

Under the column DATE OF MCV RECEIVED, Grade I teachers should ask the parents to bring the
immunization card of their children and copy the dates indicated in the card:
MCV 1(Measles containing vaccine) - administered on the 9th month of age
MCV 2 -administered during one year of age
If there is no immunization record, ask the parents if they can remember the date when their
children were vaccinated with measles-containing vaccines. If they can remember, write the dates on the space.

If parents attest that their children were vaccinated but cannot remember the exact date, leave the space blank

* Children who previously received the two measles-containing vaccine will not be immunized any more
with MR (Measles&Rubella)
* If the child received one, she will be vaccinated once in the school
* If the child did not received any or parents cannot remember the dates of their vaccination, he/she will
be immunized twice in the school.
* The second dose of measles-containing vaccine is 28 days after the first dose.

The Td vaccine shall be administered regardless of history of immunization

The division is still waiting for the revised consent forms, we will disseminate it as soon as we received it.
 MR
Lot No: _____________
Batch No. ___________

Td
Lot No: _____________
Batch No. ___________
To be filled up by the Vaccination Team

Sick today?(fever) Vaccine given

Remarks
Y N MR (R arm) Td (L arm)
_____________________ _________________________________
nature of Vaccinator 2 Name and Signature of Recorder
Reporting Form 1: School Consolidation Report for Grade I

Region I
Province : PANGASINAN
Municipality/District: ____________________________
Name of School: __________________________
Division: PANGASINAN I

MR Vaccination Td Vaccination
Total Number Enrolled
Number Given MR No. of No. of Number Given Td No. of No. of
Students Refusal Students Refusal
Section Male Female Total Male Female Total % referred Male Female Total % referred
A
B

TOTAL

Submitted by: Noted by:

GRADE 1 CHAIRMAN School Head

Reporting form 1: School Consolidation Report for Grade I shall be accomplished by one school personnel
assigned by the principal. Only the enrolment (male,female, total) shall be accomplished

After accomplishing this form a copy shall be submitted to

a. Division office - soft copy or send to marisolmapula@yahoo.com
b. Rural health Units or Municipal Health Office - hard copy

Deadline of submission is on June 15, 2015

The division is still waiting for the revised consent forms, we will disseminate it as soon as we received it.

Because of lack of health personnel, please do not wait for them to submit this report to RHUs to avoid
delay in the purchase of vaccines and kindly do the submission in case they cannot reach all the schools. Thank you.
RECORDING Form 2: Masterlist of All Grade 4 Students (Both Males and Females)
HPV
Region: I Name of school: Lot No: _____________
Province/City: Pangasinan I Section: ___ A & B Batch No. ___________

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

History of Sick today? Date of HPV Vaccine

Sex Parents Response Slip
allergies (fever) Given
Date of Birth
No. Name (1) Complete Address (2) Age (food,meds, Remarks
MM/DD/YY previous
M/F immunization) 1st dose 2nd dose
Y N Y N
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
__________________________ _____________________________ _____________________________ _______________________________ ______________________________
Name and Signature of Adviser Name and Signature of Supervisor Name and Signature of vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
1st dose 2nd dose
Human Papilloma Vaccine (HPV) shall be administered to 9-13 year old females in Grade 4. This vaccine shall prevent the
development of cervical cancer.
Two doses of HPV shall be given, the second dose will be after 6 months.

* Deped shall submit the masterlist of Grade 4 pupils as a basis for the number of vaccines to be purchased by the DOH (2nd dose)

RECORDING Form 2: Masterlist of All Grade 4 Students (Both Males and Females) shall be accomplished by Grade 4 teachers
*Even though males shall not be given HPV , their names shall be included in Recording Form 2
* Females below 9 years or more that 13 years of age shall also be included in Recording Form 2.

* This form (Recording Form 2) shall be kept by Grade 4 advisers and present it to the vaccination team on the day of immunization

The division is still waiting for the revised consent forms, we will disseminate it as soon as we received it.
Reporting Form 2: School Consolidation Report for Grade 4 Students

Region I
Province : PANGASINAN
Municipality/District: ____________________________
Name of School: __________________________
Division: PANGASINAN I

Total No. of Given HPV vaccines

Total No. of Eligible No. of students No. of students
Section Total No. Enrolled Females
Females ( 9-13 y/o) 1st Dose % 2nd Dose % Total referred refusal
Enrolled

TOTAL

Submitted by: Noted by:

_______________________________ __________________________________
School Head
 Reporting form 2: School Consolidation Report for Grade 4 shall be accomplished by one school personnel
assigned by the principal.

This form shall be submitted to:

a. Division office - soft copy or send to marisolmapula@yahoo.com
b. Rural health Units - hard copy
Deadline of submission is on

Because of lack of health personnel, please do not wait for them to submit this report to RHUs to avoid
delay in the purchase of vaccines and kindly do the submission in case they cannot reach all the schools. Thank you.
RECORDING Form 3: Masterlist of Grade 7 Students MR
Lot No: _____________
Region: I Name of school: _____________________________ Batch No. ___________
Province/City: Pangasinan I Section: _______________________
District/Municipality: ___________________ 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
Sex Response today? History of Vaccine given
allergies
Date of Slip (fever) Last menstrual sexual contact
(food,meds,
No. Name (1) Complete Address (2) Birth Age previous period (for in the past 4 Remarks
MM/DD/YY FEMALES only) weeks (for MR Td
M/F immunization FEMALES only)
(R arm) arm)
MR/Td) (L
Y N Y N

TOTAL

_________________________ ____________________________ _____________________________ ____________________________ ____________________________

Name and Signature of Adviser Name and Signature of Supervisor Name and Signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder
The Grade 7 students shall be immunized with Td (Tetanus & dipetheria) vaccine and MR (Measles & Tetanus) under the School-Based Immunization
if they were given consent by their parents

* Deped shall submit the masterlist of Grade 7 students as a basis for the number of vaccines to be purchased by the DOH

This form (Recording Form 3) shall be filled up by the class adviser

It shall be kept by the adviser and present it to the vaccination team on the day of immunization

The division is still waiting for the revised consent forms, we will disseminate it as soon as we received it.
________
o. ___________

_____________
o. ___________
Reporting Form 3: School Consolidation Report for Grade 7

Region I
Province : PANGASINAN
Municipality: ___________________________
Name of School: __________________________
Division: PANGASINAN I

MR Vaccination Td Vaccination
Total Number Enrolled
Number Given MR No. of Number Given Td No. of
No. of No. of
Students Refusal Students Refusal
Section Male Female Total Male Female Total % referred Male Female Total % referred

TOTAL

Submitted by: Noted by:

_______________________________ __________________________________
School Head
Reporting form 3: School Consolidation Report for Grade 4 shall be accomplished by one school personnel
assigned by the principal.

This form shall be submitted to:

a. Division office - soft copy or send to marisolmapula@yahoo.com
b. Rural health Units - hard copy
Deadline of submission is on June 15, 2015

Because of lack of health personnel, please do not wait for them to submit this report to RHUs to avoid
delay in the purchase of vaccines and kindly do the submission in case they cannot reach all the schools. Thank you.