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Vaccination G7

This document is a School-Based Immunization Recording Form for Grade 7 students, capturing essential details such as student information, vaccination data, and consent. It includes sections for recording the number of vaccines received, used, and unused, as well as a space for health history and reasons for deferral or refusal. The form must be filled out by the local health center or vaccination team and includes signatures from supervisors and vaccinators.

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theresalaron12
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34 views2 pages

Vaccination G7

This document is a School-Based Immunization Recording Form for Grade 7 students, capturing essential details such as student information, vaccination data, and consent. It includes sections for recording the number of vaccines received, used, and unused, as well as a space for health history and reasons for deferral or refusal. The form must be filled out by the local health center or vaccination team and includes signatures from supervisors and vaccinators.

Uploaded by

theresalaron12
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 IMMUNIZATION

Recording Form 2: Masterlist of Grade 7 Students

Region: __________________________Name of School: _________________________ Section: _____


MR: Td:
Barangay: _______________________District/Municipality: ______ 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: __________________ Date: ______________________ 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
CONTACT
History of Vaccine Given Deferr Refusa
NUMBER OF Slip (Fever,
Complete Address Age Sex Reasons
(Surname, First Name, MI) MM/DD/ PARENT/GUARDI Allergies etc) Lot/ Lot/ al l
YYYY
AN Y N Y N MR Batch Td Batch
No. No.
1
2
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____________________________ __________________________________________ ______________________________________
Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signature of Vaccinator 2

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