SCHOOL -BASED IMMUNIZATION
Recording Form 3: Masterlist of Grade 4 Female Students
HPV:
Region: ______________________ Name of School: __________________________ Section: ______________ Number of Vaccine Received (in vials): ___________
Barangay: ____________________ District/Municipality: ______________________ Number of Vaccine Used (in vials): ___________
City/Province: ________________ Date: ______________________________ Number of Vaccine Unused (in vials): ___________
To be filled out by Local Health Center/Vaccination Team To be filled out by Vaccination Team
Sick today?
Name Date of HPV Received Consent Slip (Fever, etc) Vaccine Given
Date of Birth
Complete Address Age Sex History of Allergies Deferral Refusal Reasons
Lot/Batch Lot/Batch
(Surname, First Name, MI) MM/DD/YYYY HPV 1 HPV 2 Y N Y N HPV 1 no. HPV 2 no.
10
_______________________________ _________________________________ ________________________________ ______________________________
Name & Signature of Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2 Name & Signature of Recorder
REASONS FOR BEING UNVACCINATED
(Select all that apply for the HH)
Code Reasons Code Reasons
1 Parent was absent/ away from home 10 Lack of trust in the vaccinator
2 Fear of vaccine side effect 11 Child just recovered from illness or just discharged from the hospital, the parent/caregiver refused
3 Vaccine safety issues (dengue vaccine experience, past adverse experience, etc) 12 Unaware of the campaign
4 Child already has complete routine vaccination, extra vaccine dose not necessary, so parents refused 13 Vaccine team did not visit
5 Fear of COVID transimission 14 Child was a from a different area
6 Vaccine perceived to be not effect , of low-quality or on near-expiry 15 Child was acutely sick or not feeling well
7 Client is a newborn and parents believed that her/his child is too young to be given vaccination 16 Do not know/ declined to respond
8 Child was already vaccinated by provate MD, against advised by private MD's, thus parents/caregiver refused 17 Outright refusal
9 percullar personal belief or misconceptions of the parents or caregiver on vaccination; Against religious beliefs 18 Other (Specify) : ___________________________________________
