TETANUS-DIPHTHERIA INVENTORY

SCHOOL BASED IMMUNIZATION

No. of Available Td Eligible for Td Vaccination (with case of D/T) Target Enrolless Required Td vaccine Deficiency Td vaccine Action
No. of Neonatal
No. of Diphtheria (if vaccine available is not sufficient for the
Name of Municipality Tetanus Cases YES (if yes, proceed with NO (if no, do not proceed
Vials Doses Cases 2014-2016 Grade I Grade VII Total Vials Doses Vials Doses entire eligible municipality, prioritize the brgy
2014-2017 the next columns) with next columns)
with reported case)
1 Duhat 34 340 3 0 ü 356 223 579 58 579 24 239
2 Banaba 53 530 0 0 ü 0 0 -53 -530 The 24 vials can be given to Duhat and 26 for Saging
3 Saging 33 330 2 3 ü 380 209 589 59 589 26 259
4 0 0 0 0 0 0
5 0 0 0 0 0 0
6 0 0 0 0 0 0
7 0 0 0 0 0 0
8 0 0 0 0 0 0
9 0 0 0 0 0 0
10 0 0 0 0 0 0
11 0 0 0 0 0 0
12 0 0 0 0 0 0
13 0 0 0 0 0 0
14 0 0 0 0 0 0
15 0 0 0 0 0 0
16 0 0 0 0 0 0
17 0 0 0 0 0 0
18 0 0 0 0 0 0
19 0 0 0 0 0 0
20 0 0 0 0 0 0
21 0 0 0 0 0 0
22 0 0 0 0 0 0
23 0 0 0 0 0 0
24 0 0 0 0 0 0
25 0 0 0 0 0 0
26 0 0 0 0 0 0
27 0 0 0 0 0 0
28 0 0 0 0 0 0
29 0 0 0 0 0 0
30 0 0 0 0 0 0
31 0 0 0 0 0 0
32 0 0 0 0 0 0
33
34
35 0 0 0 0 0 0
TOTAL 120 1200 5 3 0 0 736 432 1168 117 1168 -3 -32
Reporting Form 1: Masterlist of Students (Grade I)
MASTERLIST FOR SCHOOL BASED IMMUNIZATION (GRADE I)
(Year: ________)
Region: ____________________ District/Municipality: ____________________________ MR Td
Province/City: _________________ Name of School: ____________________ Lot no:  Elig. w/stock Lot no:
Date: ________________________ Section: _______________ Batch no:  Elig. w/o stock Batch no:
 Non-Elig. w/ stock
Division: ________________________  Non-Elig. w/o
stock
To be filled up by the school To be filled up by the vaccination team
History of
Sick today?
Allergies
Date of previous Parents' (ex. Fever,
Date of Birth (meds, food, Vaccine Given
No. Name (1) Complete Address (2) Age Sex MCV received Response Slip
previous imzn
cough, cold DEFFERED REFUSAL REASONS
(MM/DD/YY) etc.)
of MMR/Td)
Zero Y N Y N Y N Y N MCV (R) Td (L)

10

11

12

13

14

15
TOTAL

Name and signature of Advisor Name and signature of Vaccinator 1 Name and Signature of Recorder
Reporting Form 2: Masterlist of Students (Grade VII)
MASTERLIST FOR SCHOOL BASED IMMUNIZATION (GRADE VII)
(Year: ________)
Region: ___________________ District/Municipality: ____________________________ MR Td
Province/City: _________________ Name of School: ____________________ Lot no:  Elig. w/stock Lot no:
Date: ________________________ Section: _______________ Batch no:  Elig. w/o stock Batch no:
 Non-Elig. w/stock
Division: ________________________  Non-Elig. w/o stock

To be filled up by the school To be filled up by the vaccination team

History of
Allergies
Blood Last History of sexual
Date of Parents' Active disorders (ex. Menstrual contact in the past 4 Sick today?
(meds, food, Vaccine Given
Birth Response Slip
previous imzn
Untreated TB Bleeding Period weeks ( for FEMALE (fever)
No. Name (1) Complete Address (2) Age Sex tendencies) only) DEFFERED REFUSAL REMARKS
(MM/DD of MMR/Td) (For
/YY) FEMALE
Y N Y N Y N Y N ONLY) Y N Y N MCV (R) Td (L)

10

11

12

13

14

15
TOTAL

Name and signature of Advisor Name and signature of Vaccinator 1 Name and Signature of Vaccinator 2 Name and Signature of Recorder