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SCHOOL-BASED IMMUNIZATION
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Recording Form 1: Masterlist of Grade 1 Students
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Region: _____________________________Name of School: ______________________________Section: ______________MR:Td:
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Number of Vaccine Received (in vials):_______
Number of Vaccine Received (in vials):_______
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Barangay: _______________________District/Municipality: ______________________
Number of Vaccine Used (in vials):_______
Number of Vaccine Used (in vials):_______
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Number of Vaccine Unused (in vials):_______
Number of Vaccine Unused (in vials):_______
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City/Province: __________________Date: _________________________
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To be filled out by Local Health Center / Vaccination Team
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Name
(Surname, First Name, MI)		Complete AddressDate of Birth
MM/DD/YYYY 		AgeSexConsent SlipHistory of AllergiesSick today? (Fever, etc)Vaccine GivenDeferralRefusalReasons
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YNYNMRLot/Batch No.TdLot/Batch No.
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_________________________________________________________________________________________________________________
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Name & Signature of SupervisorName & Signature of Vaccinator 1 Name & Signature of Vaccinator 2
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