Republic of the Philippines

Region IX
Department of Health
Upper Calarian, Zamboanga City 7000
Province of Zamboanga del Norte
Siocon Rural Health Unit
Poblacion, Siocon, Zamboanga del Norte

NOTIFICATION LETTER

DATE: __________________

DIVISION: ________________________________________
SCHOOL: ________________________________________
ADDRESS: ________________________________________

Dear Parent/Guardian:
This school as a Public Elementary / Secondary School will provide School-Based Immunization (SBI) of Measles-
Rubella (MR) and Tetanus–Diphtheria (Td) vaccines to Grade 1 and Grade 7 students and Humanpapilloma Virus
(HPV) vaccine to Grade 4 female students in coordination with the Department of Health (DOH) and the Local Government
Unit (LGU).
This Notification is being issued to you as information of the activity that will be conducted for SY 2024 – 2025.
Should you have further questions / clarifications on this matter, please get in touch with the Principal / School Head.

Thank you very much.

Very truly yours,

____________________________
Name of School Head / Principal
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
ACKNOWLEDGEMENT AND CONSENT

I have read and understood the information regarding the intended immunization services to be given to my child.

Name of the Child Date of Birth (mm/dd/yyyy)

Surname: First Name: Middle Name: / /

Contact Information Age Sex

Contact Number: School:

PRE-VACCINATION CHECKLIST (FOR PARENT/GUARDIAN TO COMPLETE)

Your consent is required before your child can be immunized at school. Request clearance from your physician
if any of the following applies (kindly check () if any condition applies to your

● My child had a history of severe allergy to measles-containing or Td vaccines.

● My child has a severe illness:
● Primary immune – deficiency disease
● Suppressed immune response from medications
● Leukemia
● Lymphoma
● Other generalized malignancies
● None, my child is relatively healthy.

CONSENT FOR IMMUNIZATION

(Please check in the box provided)

● Yes, I will allow my child to be provided the immunization services as per DOH recommendation.
● Grade 1 (MR, Td)
● Grade 4 (HPV)
● Grade 7 (MR, Td)
● No, I will not allow my child to receive the immunization service because
____________________________________________________________________________________________________________________. I understa
that by opting out of the required immunizations, my child may be at a higher risk of contracting vaccine-preventable diseases. By signing this waiver, I
acknowledge that I have read and understood the information provided above. I voluntarily choose to exempt my child from the required school
immunizations.
__________________________________

Name and Signature of Parent / Guardian

 Republic of the Philippines
Region IX
Department of Health
Upper Calarian, Zamboanga City 7000
Province of Zamboanga del Norte
Siocon Rural Health Unit
Poblacion, Siocon, Zamboanga del Norte

LIHIM NG PAUNAWA

PETSA: __________________

DIBISYON: ________________________________________
PAARALAN: ________________________________________
ADDRESS: ________________________________________

Mahal na Magulang/Tagapatnubay,

Magbibigay ang Pampublikong Mababang Paaralan / Mataas na Paaralang ito ng pagbabakuna laban sa Tigdas-Rubella
(Measles-Rubella) at Tetano-Dipterya (Tetanus-Diphtheria) sa mga batang Grade 1 at Grade 7, at Humanpapilloma Virus
(HPV) vaccine sa mga babaeng Grade 4 sa koordinasyon ng Kagawaran ng Kalusugan (DOH) at ng Lokal na Pamahalaan
(LGU).

Ang abisong ito ay inilalabas sa inyo bilang impormasyon ng mga aktibidad na isasagawa para sa SY 2024 - 2025.
Kung mayroon kayong karagdagang mga tanong / kailangang linawin ukol sa bagay na ito, mangyaring makipag-ugnayan sa
Punong-guro / Pinuno ng Paaralan.

Maraming salamat po.

Taos-pusong sumasainyo,
______________________________________________
(Lagda at Pangalan ng Punong-guro/ Pinuno ng Paaralan)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _
PAGBIBIGAY NG PAHINTULOT
Ito ay pagpapatunay na nabasa at naunawaan ko ang impormasyon tungkol sa mga serbisyong pangkalusugan na nakalaang
ibigay sa aking anak.

Pangalan ng Bata Araw ng Kapanganakan (mm/dd/

Apelyido: Unang Pangalan: Gitnang Pangalan: / /

Impormasyon sa Pakikipag-ugnayan Edad Kasaria

Contact Number: Pangalan ng Paaralan:

PRE-VACCINATION CHECKLIST (Para sa magulang / tagapag-alaga na kumpletuhin)

Ang iyong pahintulot ay kinakailangan bago mabakunahan ang iyong anak sa paaralan. Humingi ng sertipikasyon galing sa inyong doktor kung ito

● Ang aking anak ay may kasaysayan ng matinding allergy sa bakunang laban sa tigdas o tetanus-diphtheria.
● Ang aking anak ay may malubhang sakit:
● Primary immune – deficiency disease
● Suppressed immune response from medications
● Leukemia
● Lymphoma
● Iba pang generalized malignancies
● Wala, ang aking anak ay malusog.

PAHINTULOT SA PAGBABAKUNA

(Pakilagyan ng ang kahon)

● Oo, papayagan kong mabigyan ng mga serbisyong pangkalusugan ang aking anak ayon sa rekomendasyon ng DOH.
● Grade 1 (MR, Td)
● Grade 4 (HPV)
● Grade 7 (MR, Td)
● Hindi, hindi ko pahihintulutan na makinabang ang aking anak sa mga serbisyong pangkalusugan
____________________________________________________________________________________________________________________.
Nauunawaan ko na sa pamamagitan ng hindi pagsasailalim sa kinakailangang pagbabakuna, maaaring mas mataas ang panganib ng aking anak na magka
mga karamdaman na maaaring maiwasan sa pamamagitan ng bakuna. Sa pamamagitan ng paglagda sa abisong ito, kinikilala ko na nabasa at naunawaan
mga impormasyong ibinigay sa itaas. Kusang-loob kong pinipili na huwag pabakunahan ang aking anak ng mga kinakailangang bakuna para sa paaralan.

______________________________________

Pangalan at Lagda ng Magulang/Tagapag-alaga

 Republic of the Philippines
Region IX
Department of Health
Upper Calarian, Zamboanga City 7000
Province of Zamboanga del Norte
Siocon Rural Health Unit
Poblacion, Siocon, Zamboanga del Norte

NOTIFICATION LETTER

DATE: __________________

DIVISION: ________________________________________
SCHOOL: ________________________________________
ADDRESS: ________________________________________

Dear Parent/Guardian:

This school as a Public Elementary / Secondary School will provide School-Based Immunization (SBI) of Human
Papillomavirus (HPV) Vaccine to Grade 4 Female students in coordination with the Department of Health (DOH) and the
Local Government Unit (LGU).

This Notification is being issued to you as information of the activity that will be conducted for SY 2024 – 2025.
Should you have further questions / clarifications on this matter, please get in touch with the Principal / School Head.

Thank you very much.

Very truly yours,

____________________________
Name of School Head / Principal
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _

ACKNOWLEDGEMENT AND CONSENT

I have read and understood the information regarding the intended immunization services to be given to my child.

Name of the Child Date of Birth (mm/dd/yyyy)

Surname: First Name: Middle Name: / /

Contact Information Age Sex

Contact Number: School:

PRE-VACCINATION CHECKLIST (FOR PARENT/GUARDIAN TO COMPLETE)

Your consent is required before your child can be immunized at school. Request clearance from your physician
if any of the following applies (kindly check () if any condition applie

● My child had a history of severe allergy to human papillomavirus (HPV) vaccine.

● My child has a severe illness:
● Primary immune – deficiency disease
● Suppressed immune response from medications
● Leukemia
● Lymphoma
● Other generalized malignancies
● None, my child is relatively healthy.

CONSENT FOR IMMUNIZATION

(Please check in the box provided)

● Yes, I will allow my child to be provided the immunization services as per DOH recommendation.
● Human Papillomavirus (HPV) Vaccine
● No, I will not allow my child to receive the immunization service because
____________________________________________________________________________________________________________________. I
understand that by opting out of the required immunizations, my child may be at a higher risk of contracting vaccine-preventable diseases. By signing
this waiver, I acknowledge that I have read and understood the information provided above. I voluntarily choose to exempt my child from the required
school immunizations.
__________________________________

Name and Signature of Parent / Guardian

 Republic of the Philippines
Region IX
Department of Health
Upper Calarian, Zamboanga City 7000
Province of Zamboanga del Norte
Siocon Rural Health Unit
Poblacion, Siocon, Zamboanga del Norte

LIHIM NG PAUNAWA

PETSA: __________________

DIBISYON: ________________________________________
PAARALAN: ________________________________________
ADDRESS: ________________________________________

Mahal na Magulang/Tagapatnubay,

Magbibigay ang Pampublikong Mababang Paaralan / Mataas na Paaralang ito ng pagbabakuna laban sa Human
Papillomavirus sa mga babaeng Grade 4 estudyante, sa koordinasyon ng Kagawaran ng Kalusugan (DOH) at ng Lokal na
Pamahalaan (LGU).

Ang abisong ito ay inilalabas sa inyo bilang impormasyon ng mga aktibidad na isasagawa para sa SY 2024 - 2025.
Kung mayroon kayong karagdagang mga tanong / kailangang linawin ukol sa bagay na ito, mangyaring makipag-ugnayan sa
Punong-guro / Pinuno ng Paaralan.

Maraming salamat po.

Taos-pusong sumasainyo,
______________________________________________
(Lagda at Pangalan ng Punong-guro/ Pinuno ng Paaralan)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
PAGBIBIGAY NG PAHINTULOT
Ito ay pagpapatunay na nabasa at naunawaan ko ang impormasyon tungkol sa mga serbisyong pangkalusugan na nakalaang
ibigay sa aking anak.

Pangalan ng Bata Araw ng Kapanganakan (mm/dd/yyy

Apelyido: Unang Pangalan: Gitnang Pangalan: / /

Impormasyon sa Pakikipag-ugnayan Edad Kasarian

Contact Number: Pangalan ng Paaralan:

PRE-VACCINATION CHECKLIST (Para sa magulang / tagapag-alaga na kumpletuhin)

Ang iyong pahintulot ay kinakailangan bago mabakunahan ang iyong anak sa paaralan. Humingi ng sertipikasyon galing sa inyong doktor kung ito

● Ang aking anak ay may kasaysayan ng matinding allergy sa bakunang laban sa human papillomavirus.
● Ang aking anak ay may malubhang sakit:
● Primary immune – deficiency disease
● Suppressed immune response from medications
● Leukemia
● Lymphoma
● Iba pang generalized malignancies
● Wala, ang aking anak ay malusog.

PAHINTULOT SA PAGBABAKUNA

(Pakilagyan ng ang kahon)

● Oo, papayagan kong mabigyan ng mga serbisyong pangkalusugan ang aking anak ayon sa rekomendasyon ng DOH.
● Human Papillomavirus (HPV) Vaccine
● Hindi, hindi ko pahihintulutan na makinabang ang aking anak sa mga serbisyong pangkalusugan dahil
____________________________________________________________________________________________________________________.
Nauunawaan ko na sa pamamagitan ng hindi pagsasailalim sa kinakailangang pagbabakuna, maaaring mas mataas ang panganib ng aking anak n
magkasakit ng mga karamdaman na maaaring maiwasan sa pamamagitan ng bakuna. Sa pamamagitan ng paglagda sa abisong ito, kinikilala ko na nabasa a
naunawaan ko ang mga impormasyong ibinigay sa itaas. Kusang-loob kong pinipili na huwag pabakunahan ang aking anak ng mga kinakailangang bakuna
para sa paaralan.

______________________________________

Pangalan at Lagda ng Magulang/Tagapag-alaga