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FLOW AND SUBMISSION OF REPORTS
To be
Levels of Schedule of
Type of report Responsible Person Submitted
Implementation Report
to
Recording Form 1: Masterlist
of Grade 1 Students
Recording Form 2: Masterlist Local Health Center /
School of Grade 4 Students RHU Daily
Vaccination Team
Recording Form 3: Masterlist
of Grade 4 Students
Consolidated
RHU Accomplishment report by RHU Midwife PHO/CHO Weekly
Schools per Municipalities
Regional NIP
RHO Bulletin report of Prov/City CO-NIP Weekly
Coordinator
Analysis report of Provincial / City NIP
PHO/CHO RHO Weekly
Municipalities Coordinator
CO Bulletin report of CHDs DPCB NIP PHSC U Weekly
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SCHOOL-BASED IMMUNIZATION
Recording Form 1: Masterlist of Grade 1 Students
Region: VIII Name of School: Sto. Niño Integrated School
Section: Tarza MR:
Number of Vaccine Received (in vials):___
Barangay: Sto. Niño District/Municipality: Gandara Number of Vaccine Used (in vials):_______
Number of Vaccine Unused (in vials):_____
City/Province: Gandara, Samar Date:
To be filled out by Local Health Center / Vaccination Team Sick
Date of Consent today?
Name Birth Slip History of (Fever,
Complete Address Age Sex
(Surname, First Name, MI) MM/DD/ Y N Allergies Y etc) N
YYYY
1 Abitona, Mark Renzel H. Sto. Niño Gandara, Samar 4/4/2018 6 M
2 Carig, Jeffrey Jr. S. Sto. Niño Gandara, Samar 11/6/2018 6 M
3 Diaz, Hayward C. Sto. Niño Gandara, Samar 11/29/2028 6 M
4 Dista, Arken Gedric D. San Agustin Gandara, Samar 1/7/2018 6 M
5 Espela, Kelvin Kyle O. Sto. Niño Gandara, Samar 11/7/2018 6 M
6 Legason, MarkJohn Sto. Niño Gandara, Samar 09/19/2018 5 M
7 Manahon,Ronilo Jr. C. Sto. Niño Gandara, Samar 11/9/2018 5 M
8 Ogcila, Joseph A. Casandig, Gandara, Samar 12/12/2017 6 M
9 Pedrano, John Liam M. Sto. Niño Gandara, Samar 12/11/2017 6 M
10 Piamonte, Bart P. Sto. Niño Gandara, Samar 03/13/2018 6 M
11 Someno, Lorens F. Sto. Niño Gandara, Samar 12/18/2017 8 M
12 Abalos, Ziah Faith D. Pizarro, Gandara, Samar 4/1/2018 6 F
13 Agoy-Agoy, Kylie A. Sto. Niño Gandara, Samar 04/20/2018 6 F
14 Arcala, Jannice Febey A. Sto. Niño Gandara, Samar 10/2/2018 6 F
15 Arraz, Magendara M. Sto. Niño Gandara, Samar 09/21/2018 5 F
16 Ayangco, Nickie J. Sto. Niño Gandara, Samar 10/3/2018 6 F
17 Del Pilar, Mary Hyacinth Sto. Niño Gandara, Samar 10/19/2018 6 F
18 Estrelles, Reyn Nicole L. Sto. Niño Gandara, Samar 06/25/2018 6 F
19 Isaran, Adah Zuriel Q. Sto. Niño Gandara, Samar 12/28/2017 6 F
20 Mañozo, Rhea C. Sto. Niño Gandara, Samar 12/18/2017 6 F
21 Paular, Catherine C. Sto. Niño Gandara, Samar 09/29/2017 6 F
22 Villarin, Rhomen B. Sto. Niño Gandara, Samar 06/19/2018 6 F
____________________________ ___________________________________ ______________________________________
Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2
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nts
Td:
ccine Received (in vials):_______Number of Vaccine Received (in vials):_______
ccine Used (in vials):_______ Number of Vaccine Used (in vials):_______
ccine Unused (in vials):_______ Number of Vaccine Unused (in vials):_______
Vaccine Given Deferr Refusa
Lot/ Lot/ Reasons
MR Batch Td Batch al l
No. No.
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SCHOOL-BASED IMMUNIZATION
Recording Form 2: Masterlist of Grade 7 Students
Region: ____VII___________________ Name of School: STO. NIŇO INTEGRATED SCHOOL Section:HESTIA
MR: Td:
Barangay: STO. NIŇO District/Municipality: GANDARA Number of Vaccine Received (in vials):______ Number of Vaccine Received (in vials):_______
Number of Vaccine Used (in vials):_______ Number of Vaccine Used (in vials):_______
City/Province: SAMAR Date: NOVEMBER 10, 2024 Number of Vaccine Unused (in vials):_______ Number of Vaccine Unused (in vials):_______
To be filled out by Local Health Center / Vaccination Team Sick
Date of Consent today?
Name Birth History of Vaccine Given Deferr Refusa
Complete Address Age Sex Slip (Fever, Lot/ Lot/ Reasons
(Surname, First Name, MI) MM/DD/ Y N Allergies Y etc) N MR Batch Td Batch al l
YYYY No. No.
1 ALERIA, ALIXON C. BARANGAY MACUGO GANDARA WESTERN SAMAR 9/1/2012 12 M
2 ARRAZ, JOHN ELMAR G. BARANGAY SIDMON GANDARA WESTERN SAMAR 6/10/2011 13 M
3 BUNDOCAN, EUGENE S. BARANGAY MACUGO GANDARA WESTERN SAMAR 10/25/2011 13 M
4 DIAZ, HOMMEL C. BARANGAY STO. NIŇO GANDARA WESTERN SAMAR 8/6/2011 13 M
5 DONADILLO, DANIEL L. BARANGAY STO. NIŇO GANDARA WESTERN SAMAR 10/23/2011 13 M
6 HILBOY, JOHN VINCENT M. BARANGAY SIDMON GANDARA WESTERN SAMAR 06/15/2012 12 M
7 SEVERO, DAVE F. BARANGAY MACUGO GANDARA WESTERN SAMAR 02/20/2011 13 M
8 ANGELIO, ERLYN R. BARANGAY SIDMON GANDARA WESTERN SAMAR 02/20/2010 14 F
9 CASALJAY, DONABELLE C. BARANGAY MACUGO GANDARA WESTERN SAMAR 04-04-2012 13 F
10 CASALJAY, JENNY MAE A. BARANGAY MACUGO GANDARA WESTERN SAMAR 01/13/2010 14 F
11 DIGNOS, NOUMEE R. BARANGAY SIDMON GANDARA WESTERN SAMAR 10/17/2011 13 F
12 PILOTON, PRINCESS RIZZA A. BARANGAY STO. NIŇO GANDARA WESTERN SAMAR 02/21/2012 12 F
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SCHOOL-BASED IMMUNIZATION
Recording Form 3: Masterlist of Grade 4 Female Students
Region: ____VIII_________________Name of School: _Sto. Niño IntegratedSection:
School__________________________
___S
HPV:
Barangay: ___Sto. Niño____________________
District/Municipality: _Ga Number of Vaccine Received (in vials):_______
Number of Vaccine Used (in vials):_______
City/Province: ___Samar________Date: ______________________ Number of Vaccine Unused (in vials):_______
To be filled out by Local Health Center / Vaccination Team ToDate
be filled Sick
Date of of out by Vaccination Team
Consent today?
Name Birth HPV History of Vaccine Given Deferr Refusa
Complete Address Age Sex HPV HPV Slip (Fever, HPV Lot/ Lot/
HPV Batch Reasons
(Surname, First Name, MI) MM/DD/ Received Y N Allergies Y etc) N Batch al l
YYYY 1 2 1 No. 2 No.
1 Brozas, Trishia Mae V. Sto. Niño, Gandara, Samar 8/4/2015 9 F
2 Cortez, Princess Eunice T. Sto. Niño, Gandara, Samar 08/14/2015 9 F
3 Dacanay, Ashley F. Sto. Niño, Gandara, Samar 4/1/2015 9 F
4 Docil, Christila May L. Pizarro, Gandara, Samar 07/21/2015 9 F
5 Lim, Princess Jewel L. Sto. Niño, Gandara, Samar 5/6/2015 9 F
6 Quibuyen, Shiloh Exosia G. Sto. Niño, Gandara, Samar 12/6/2015 9 F
7
8
9
10
______________________________ _____________________________ __________________________________ _________________________________
Name & Signature of
Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2 Name & Signature of Recorder
Supervisor
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School-Based Immunization
DAILY SUMMARY REPORTING Form: RHU Consolidated Accomplishment Form Report
Region: ____________________________
Date: ______________________________
Province/City: _________________________ Municipal/City: _________________________
Grade 1 Grade 4 Female Grade 7
Students Students Students Students
No. of female students
vaccinated vaccinated Total no. of deferred Total no. of refusal Total no. of deferred Total no. of refusal vaccinated vaccinated Total no. of deferred Total no. of refusal
vaccinated
Name of Schools Total no. w/ MR w/ Td w/ MR w/ Td
Total no. Total no. of
of
of students
students 1st 2nd 1st 2nd 1st 2nd
enrolled enrolled
enrolled dose dose dose dose dose dose
No. % No. % MR % Td % MR % Td % % % % % % % No. % No. % MR % Td % MR % Td %
of of of of of of
HPV HPV HPV HPV HPV HPV
Total
Grade 1: Grade 7: Grade 4 Female:
MR: MR: HPV:
Number of Vaccine Received (in vials):_______ Number of Vaccine Received (in vials):_______ Number of Vaccine Received (in vials):_______
Number of Vaccine Used(in vials):_______ Number of Vaccine Used(in vials):_______ Number of Vaccine Used(in vials):_______
Number of Vaccine Unused(in vials):_______ Number of Vaccine Unused(in vials):_______ Number of Vaccine Unused(in vials):_______
Td: Td:
Number of Vaccine Received (in vials):_______ Number of Vaccine Received (in vials):_______
Number of Vaccine Used(in vials):_______ Number of Vaccine Used(in vials):_______
Number of Vaccine Unused(in vials):_______ Number of Vaccine Unused(in vials):_______