Annexes B-F - SBI Recording - Reporting Forms

FLOW AND SUBMISSION OF REPORTS
To be
Levels of Schedule of
Type of report Responsible Person Submitted
Implementation Report
to
Recording Form 1: Masterlist
of Grade 1 Students
School Recording Form 2: Masterlist Local Health Center / RHU Daily

of Grade 4 Students Vaccination Team
Recording Form 3: Masterlist

of Grade 4 Students
Consolidated
RHU Accomplishment report by RHU Midwife PHO/CHO Weekly
Schools per Municipalities
Regional NIP
RHO Bulletin report of Prov/City CO-NIP Weekly
Coordinator
Analysis report of Provincial / City NIP

PHO/CHO RHO Weekly
Municipalities Coordinator
CO Bulletin report of CHDs DPCB NIP PHSC U Weekly

SCHOOL-BASED IMMUNIZATI
Recording Form 1: Masterlist of Grade
Region: _______________________Name of School: ______________________Section: ____
Barangay: ____________________District/Municipality: ____
City/Province: ________________Date: ____________________
To be filled out by Local Health Center / Vaccination TeamDate of

Consent
Name Birth Slip
Complete Address Age Sex
(Surname, First Name, MI) MM/DD/ Y
1 YYYY
2
3
4
5
6
7
8
9
10
__________________________ ________________________________ _________________

Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signatur
BASED 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
Consent History today?
Vaccine Given Deferr Refus
Slip of (Fever, Lot/ Lot/ Reasons
N Yetc)N MR Batch Td Batch al al
Allergies No. No.
___________________________________
Name & Signature of Vaccinator 2
ed (in vials):_______
n vials):_______
d (in vials):_______
SCHOOL-BASED IMMUNIZATI
Recording Form 2: Masterlist of Grade
To be filled out by Local Health Center / Vaccination TeamDate of

Consent
Name Birth Slip
Complete Address Age Sex
(Surname, First Name, MI) MM/DD/ Y
1 YYYY
2
3
4
5
6
7
8
9
10
__________________________ ________________________________ _________________

Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signatur
BASED 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
Vaccine Given Deferr Refus
Slip of (Fever, Lot/ Lot/ Reasons
N Yetc)N MR Batch Td Batch al al
Allergies No. No.
___________________________________
Name & Signature of Vaccinator 2
ed (in vials):_______
n vials):_______
d (in vials):_______
SCHOOL-BASED IMMU
Recording Form 3: Masterlist of Gra
To be filled out by Local Health Center / Vaccination TeamDate of ToDate

be filled
of out b
Name Birth HPV
Complete Address Age Sex HPV
Received
(Surname, First Name, MI) MM/DD/
YYYY 1
1
2
3
4
5
6
7
8
9
10
______________________________ _____________________________ ______________________

Name & Signature of
Supervisor Name & Signature of Vaccinator 1 Name & Signature of V
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
HPV Vaccine Given Deferr Refus
HPV Slip of (Fever, HPV Batch
Lot/ HPV Batch
Lot/
Received Y N Allergies Yetc)N al al
2 1 No. 2 No.
_________________________________ _________________________________
Name & Signature of Vaccinator 2 Name & Signature of Recorder
Reasons
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):_______

Annexes B-F - SBI Recording - Reporting Forms

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Annexes B-F - SBI Recording - Reporting Forms

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FLOW AND SUBMISSION OF REPORTS

School Recording Form 2: Masterlist Local Health Center / RHU Daily

Recording Form 3: Masterlist

Analysis report of Provincial / City NIP

CO Bulletin report of CHDs DPCB NIP PHSC U Weekly

Region: _______________________Name of School: ______________________Section: ____

Barangay: ____________________District/Municipality: ____

City/Province: ________________Date: ____________________

To be filled out by Local Health Center / Vaccination TeamDate of

__________________________ ________________________________ _________________

Region: _______________________Name of School: ______________________Section: ____

Barangay: ____________________District/Municipality: ____

City/Province: ________________Date: ____________________

To be filled out by Local Health Center / Vaccination TeamDate of

__________________________ ________________________________ _________________

Region: _______________________Name of School: ______________________Section: ____

Barangay: ____________________District/Municipality: ____

City/Province: ________________Date: ____________________

To be filled out by Local Health Center / Vaccination TeamDate of ToDate

______________________________ _____________________________ ______________________

Grade 1 Grade 4 Female Grade 7

Grade 1: Grade 7: Grade 4 Female:

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Region: _____Name of School: Section:

Barangay: ________________District/Municipality:

City/Province: Date: ____

__________ _

Region: _____Name of School: Section:

Barangay: ________________District/Municipality:

City/Province: Date: ____

__________ _

Region: _____Name of School: Section:

Barangay: ________________District/Municipality:

City/Province: Date: ____

________________ _ ________