FLOW AND SUBMISSION OF REPORTS
To be
Levels of Schedule of
Type of report Responsible Person Submitted
Implementation Report
Recording Form 1: Masterlist of to
Grade 1 Students
Recording Form 2: Masterlist of Local Health Center /
School RHU Daily
Grade
Recording Form 3: Masterlist of Vaccination Team
4 Students
Grade 4 Students
Consolidated Accomplishment
RHU report by Schools per RHU Midwife PHO/CHO Weekly
Municipalities
Regional NIP
RHO Bulletin report of Prov/City CO-NIP Weekly
Coordinator
Provincial / City NIP
PHO/CHO Analysis report of Municipalities RHO Weekly
Coordinator
CO Bulletin report of CHDs DPCB NIP PHSC U Weekly
SCHOOL-BASED IMMUNIZATION
Recording Form 1: Masterlist of Grade 1 Students
Region: III Name of School:Bangcol Elementary School
Section: Magalang MR: Td:
Number of Vaccine Received (in vialsNumber of Vaccine Received (in vials):_______
Barangay: Bangcol, Sta. Cruz, Zambales
District/Municipality: Sta.Cruz Number of Vaccine Used (in vials):__Number of Vaccine Used (in vials):_______
Number of Vaccine Unused (in vials):Number of Vaccine Unused (in vials):_______
City/Province: Zambales Date: October 9, 2024
To be filled out by Local Health Center / Vaccination Team Sick
Date of Consen History today?
Name Birth Ag of Vaccine Given
Complete Address Sex t Slip (Fever, Lot/ Lot/ Deferra Refusal Reasons
(Surname, First Name, MI) MM/DD/ e Allergi Bat Batc l
Y N es Yetc) N MR Td
YYYY ch h
1 CODERA,JAIMESON EDNAR, M. Bangcol, Sta. Cruz, Zambales 03-03-2018 6 Male No. No.
2 CORPUZ,IVAN, - Bangcol, Sta. Cruz, Zambales 08-08-2018 6 Male
3 EGMAO,JHON MARCO, M. Bangcol, Sta. Cruz, Zambales 10-09-2018 5 Male
4 MAS,AERON JAY, L. Bangcol, Sta. Cruz, Zambales 01-27-2018 6 Male
5 MEJOS,MATTEO, R. Bangcol, Sta. Cruz, Zambales 01-20-2018 6 Male
6 MENDIGORIN,KURT ALLEN, E. Bangcol, Sta. Cruz, Zambales 12-23-2017 6 Male
7 MORALEJO,JHON ALLEN, C. Bangcol, Sta. Cruz, Zambales 01-08-2018 6 Male
8 VIRAY,MARK JHAY, L. Bangcol, Sta. Cruz, Zambales 11-04-2017 6 Male
9 DENITO,CHEANNE JOY, M. Bangcol, Sta. Cruz, Zambales 03-26-2018 6 Female
10 EBUENGA,JHEWEL CALLIE M. Bangcol, Sta. Cruz, Zambales 03-25-2018 6 Female
11 MANALO,JOANNA JANE, B. Bangcol, Sta. Cruz, Zambales 01-07-2018 6 Female
12 MENDIGORIN,SHENE, M. Bangcol, Sta. Cruz, Zambales 09-12-2018 6 Female
13 MEREDOR,JULLIANNA, B. Bangcol, Sta. Cruz, Zambales 01-15-2018 6 Female
14 MESIA,KIMBERLY, M. Bangcol, Sta. Cruz, Zambales 01-10-2018 6 Female
15 MILLAN, JOSELYN M. Almasin, Sta. Cruz, Zambales 01-10-2017 7 Female
16 OGANG,KRYSTAL IANNE, M. Bangcol, Sta. Cruz, Zambales 09-22-2018 6 Female
17 PIA ALEXANDRIA,TONGSON Bangcol, Sta. Cruz, Zambales 07-22-2015 6 Female
18 SATERA, EVALYN Bangcol, Sta. Cruz, Zambales 09-07-2018 9 Female
19 TAMBOR,CHARMAINE JOYCE Bangcol, Sta. Cruz, Zambales 11-20-2017 5 Female
20
______________________________ _____________________________ ____________________________
Name & Signature of Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2
SCHOOL-BASED IMMUNIZATION
Recording Form 2: Masterlist of Grade 7 Students
Region: __________________________Name of School: _________________________Section: _____
MR:
Barangay: _______________________District/Municipality: ______ Number of Vaccine Received (in vials):___
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 Sick
Date of Consent today?
Name Birth History of Vaccine Gi
Complete Address Age Sex Slip (Fever,
(Surname, First Name, MI) MM/DD/ Y N Allergies Y etc) N MR
YYYY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
____________________________ ___________________________________ ______________________________________
Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2
Td:
eceived (in vials):_______Number of Vaccine Received (in vials):_______
sed (in vials):_______ Number of Vaccine Used (in vials):_______
nused (in vials):_______ Number of Vaccine Unused (in vials):_______
Vaccine Given Deferr Refusa
Lot/ Lot/ Reasons
Batch Td Batch al l
No. No.
SCHOOL-BASED IMMUNIZATION
Recording Form 3: Masterlist of Grade 4 Female Students
Region: __________________________Name of School: _________________________Section: _____
Barangay: _______________________District/Municipality: ______
City/Province: __________________ Date: ______________________
To be filled out by Local Health Center / Vaccination Team ToDate
be filled
of out by Vaccination Team
Date of Consent
Name Birth HPV History of
Complete Address Age Sex HPV HPV Slip
(Surname, First Name, MI) MM/DD/ Received Y N Allergies
YYYY 1 2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
______________________________ _____________________________ __________________________________
Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2
ON
emale Students
HPV:
Number of Vaccine Received (in vials):_______
Number of Vaccine Used (in vials):_______
Number of Vaccine Unused (in vials):_______
on Team Sick
today?
Vaccine Given Deferr Refusa
(Fever, HPV Lot/ Lot/
HPV Batch Reasons
Y etc) N Batch al l
1 No. 2 No.
_________________________________
Name & Signature of Recorder
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):_______
