OTHERS: Senior Citizen, PWD, Solo Parent, Pregnant Women, Middle-Class
Bacolod City COVID-19 Vaccination Program
CoVaC Vaccination Information Form
Current Residence Region : Western Visayas
Current Residence Municipality/City: Bacolod City 431-1392 / 0910-123-1111
Contact Number:____________________
Barangay Banago
Current Residence Barangay:___________________________________________________________________________
PUROK WHATEVER
Current Residence Unit/Building/House Number/ Street Name:_____________________________________________
Category Category ID DE LA CRUZ
Last Name:_____________________________________
✓Health Care Worker JUAN
PRC ID Number_______________ First Name:____________________________________
Indigent VERGARA
OSCA ID Number______________ Middle Name:__________________________________
Uniformed personnel Facility ID Number:____________ Suffix: II III IV JR✓NA SR V
Essential Worker NA
PWD ID Number:____________
Others ✓Others_____________________
SSS 111-111-11 Sex: ✓Male Female
Pls. Fill up Philhealth Number*
✓PhilHealth ID Number: Civil Status: ✓ Single Married Widow/Widower
Kung wala gid: Check _____1211-111-111
______________________ Separated/Annulled Living with Partner
indigent
10-26-1992
Birthdate: mm/dd/yyyy:_________________________
Profession Employment Status Name of Employer Address of Employer
Dental Hygienist ✓Government Employed BARANGAY BANAGO
_______________________ FELIX AMANTE AVE,
______________________
Dental Technologist Private Employed _______________________ BRGY BANAGO
______________________
Dentist Self employed Contact Number of Employer ______________________
Medical Technologist Private practitioner 700-7718
____________________ ______________________
Midwife Others
Nurse
Province/HUC/ICC of Employer
Nutrition Dietitian
Occupational Therapist BACOLOD CITY
Optometrist
Pharmacist Pregnancy Status Yes ✓ No
Physical Therapist Types of Allergies
✓ Pollen Allergy
Comorbidity/Other Health Conditions
Physician Drug Allergy
Radiologic Technologist Food Allergy Others: ✓ Hypertension Cancer
Respiratory Therapist Insect Allergy _____________ Heart Disease Immunodeficiency
Xray Technologist ✓ Pet Allergy Diabetes Mellitus Status
✓Barangay Health Worker Latex Allergy Kidney Disease Others:
Maintenance Staff Mold Allergy Bronchial Asthma
Administrative Staff Directly in interaction with COVID patient Patient was diagnosed with COVID-19
Others: Yes ✓No Yes ✓No
Date of first positive result/ Classification of COVID-19 Provided Electronic Informed Consent?
specimen collection mm/dd/yyyy Asymptomatic Severe ✓ Yes
N/A Mild Critical No
Moderate Unknown
Interviewed by:
I hereby certify that all information supplied
are true and correct to my own knowledge and belief.
Signature: _______________________ Signature: _______________________
Name in Print:____________________ Name in Print:____________________
Date:____________________________ Contact Number:_________________
CoVaC Encoding Done by (Name/Signature/Date):
