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Copy of Annexes B-F_ SBI Recording_Reporting Forms

The document contains various recording forms for school-based immunization, specifically for Grade 1, Grade 7, and Grade 4 female students. Each form requires information such as the student's name, date of birth, address, and vaccination details, including the number of vaccines received, used, and unused. Additionally, there are sections for consent slips and signatures from health personnel and vaccinators.

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joeyjones talibong
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2 views

Copy of Annexes B-F_ SBI Recording_Reporting Forms

The document contains various recording forms for school-based immunization, specifically for Grade 1, Grade 7, and Grade 4 female students. Each form requires information such as the student's name, date of birth, address, and vaccination details, including the number of vaccines received, used, and unused. Additionally, there are sections for consent slips and signatures from health personnel and vaccinators.

Uploaded by

joeyjones talibong
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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SCHOOL-BASED IMMUNIZATIO

Recording Form 1: Masterlist of Grade 1

Region: _________________________ Name of School: _________________________Section: _____

Barangay: _______________________District/Municipality: ______

City/Province: __________________ Date: ______________________

To be filled out by School Nurse/ School Health Personnel To be filled out by L


Date of Consent
Name Birth Slip
Complete Address Age Sex
(Surname, First Name, MI) MM/DD/ Y
YYYY
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ASED IMMUNIZATION
Masterlist of Grade 1 Students

MR: 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):_______

Sick
To be filled out by Local Health Center / Vaccination Team
Consent today?
History of (Fever, Vaccine Given Deferr Refusa
Slip Lot/ Lot/ Reasons
N Allergies Y etc)N MR Batch Td Batch al l
No. No.
(in vials):_______
ials):_______
n vials):_______

____________________________ __________________________________________
Name & Signature of
Supervisor Name & Signature of Vaccinator 1
_________________________________________
Name & Signature of Vaccinator 2
SCHOOL-BASED IMMUNIZATIO
Recording Form 2: Masterlist of Grade 7

Region: _________________________ Name of School: _________________________Section: _____

Barangay: _______________________District/Municipality: ______

City/Province: __________________ Date: ______________________

To be filled out by School Nurse/ School Health Personnel To be filled out by L


Date of Consent
Name Birth Slip
Complete Address Age Sex
(Surname, First Name, MI) MM/DD/ Y
YYYY
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ASED IMMUNIZATION
Masterlist of Grade 7 Students

MR: 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):_______

Sick
To be filled out by Local Health Center / Vaccination Team
Consent today?
History of (Fever, Vaccine Given Deferr Refusa
Slip Lot/ Lot/ Reasons
N Allergies Y etc)N MR Batch Td Batch al l
No. No.
(in vials):_______
ials):_______
n vials):_______

____________________________ __________________________________________
Name & Signature of
Supervisor Name & Signature of Vaccinator 1
_________________________________________
Name & Signature of Vaccinator 2
SCHOOL-BASED IMMUN
Recording Form 3: Masterlist of Gra

Region: _________________________ Name of School: _________________________Section: _____

Barangay: _______________________District/Municipality: ______

City/Province: __________________ Date: ______________________

To be filled out by School Nurse/ School Health Personnel ToDate


be filled
of out by V
Date of
Name Birth HPV
Complete Address Age Sex HPV
Received
(Surname, First Name, MI) MM/DD/
YYYY 1
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2
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OOL-BASED IMMUNIZATION
Masterlist of Grade 4 Female Students

HPV:
Number of Vaccine Received (in vials):_______
Number of Vaccine Used (in vials):_______
Number of Vaccine Unused (in vials):_______

ToDate
be filled Sick
of out by Vaccination Team
Consent today?
HPV History of Vaccine Given Deferr Refusa
HPV Slip (Fever, HPV Lot/ Lot/
HPV Batch
Received Y N Allergies Y etc)N Batch al l
2 1 No. 2 No.
Reasons

______________________________ _____________________________
Name & Signature of
Supervisor Name & Signature of Vaccinator 1
__________________________________
Name & Signature of Vaccinator 2
_________________________________
Name & Signature of Recorder

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