Enclosure No. 1 (ANNEX A.
Reporting Forms for 2021 Community-based MR Td Immunization)
Community-based Immunization Activity
RECORDING FORM 1: MR Td(6-7 Years Old)
Region:_______________
Province/City:__________________________
School:____________________________________
District/Municipality:________________________________
to be filled up by the Teacher/Adviser t
Date of Birth History of
No. Name(1) Surname, First Name , MI. Complete Address(2) MM/DD/YY Age Sex Allergies(food,me
ds,previous
immunization)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Name and Signature of Vaccinator 1
Name and Signature of Supervisor(Vaccination) Name and Signature of Recorder
Enclosure No. 1 (ANNEX A. Reporting Forms for 2021 Community-based MR Td Immunization)
Community-based Immunization Activity
RECORDING FORM 1: MR Td(6-7 Years Old)
Region:_______________
Province/City:__________________________
School:____________________________________
District/Municipality:________________________________
to be filled up by the Teacher/Adviser t
Date of Birth History of
No. Name(1) Surname, First Name , MI. Complete Address(2) MM/DD/YY Age Sex Allergies(food,me
ds,previous
immunization)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Name and Signature of Vaccinator 1
Name and Signature of Supervisor(Vaccination) Name and Signature of Recorder
s Old)
to be filled up by the Vaccination Team
Sick Vaccinated
Date of Vaccine Given Deferred(D Deferral(VD)/V
today( fever) )/Refused. Remarks
(R) accinated
Y N MR Td Refusal(VR)
Name and Signature of Vaccinator 2 Prepared By:____________________
Name and Signature of Recorder
s Old)
to be filled up by the Vaccination Team
Sick Vaccinated
Date of Vaccine Given Deferred(D Deferral(VD)/V
today( fever) )/Refused. Remarks
accinated
(R) Refusal(VR)
Y N MR Td
Name and Signature of Vaccinator 2 Prepared By:____________________
Name and Signature of Recorder
Enclosure No. 2 (ANNEX A. Reporting Forms for 2021 Community-based MR Td Immunization)
Community-based Immunization Activity
RECORDING FORM 2: MR Td(12-13 Years Old)
Region:_______________
Province/City:__________________________
School:____________________________________
District/Municipality:________________________________
to be filled up by the Teacher/Adviser t
Date of Birth History of
No. Name(1) Surname, First Name , MI. Complete Address(2) MM/DD/YY Age Sex Allergies(food,me
ds,previous
immunization)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Name and Signature of Vaccinator 1
Name and Signature of Supervisor(Vaccination) Name and Signature of Recorder
Enclosure No. 2 (ANNEX A. Reporting Forms for 2021 Community-based MR Td Immunization)
Community-based Immunization Activity
RECORDING FORM 2: MR Td(12-13 Years Old)
Region:_______________
Province/City:__________________________
School:____________________________________
District/Municipality:________________________________
to be filled up by the Teacher/Adviser t
Date of Birth History of
No. Name(1) Surname, First Name , MI. Complete Address(2) MM/DD/YY Age Sex Allergies(food,me
ds,previous
immunization)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Name and Signature of Vaccinator 1
Name and Signature of Supervisor(Vaccination) Name and Signature of Recorder
ears Old)
to be filled up by the Vaccination Team
Sick Vaccinated
Date of Vaccine Given Deferred(D Deferral(VD)/V
today( fever) )/Refused. Remarks
(R) accinated
Y N MR Td Refusal(VR)
Name and Signature of Vaccinator 2 Prepared By:____________________
Name and Signature of Recorder
ears Old)
to be filled up by the Vaccination Team
Sick Deferred(D Vaccinated
today( fever) Date of Vaccine Given )/Refused. Deferral(VD)/V Remarks
accinated
(R) Refusal(VR)
Y N MR Td
Name and Signature of Vaccinator 2 Prepared By:____________________
Name and Signature of Recorder
