Republic of the Philippines
Department of Education
REGION V
SCHOOLS DIVISION OF MASBATE PROVINCE
SAN PASCUAL NORTH DISTRICT
SEGUNDINA L. RIVERA ELEMENTARY SCHOOL
Ki- Belen, San Rafael, San Pascual, Masbate
Community-based Immunization Activity
RECORDING Form 1: MR-Td (6-7 Years Old)
Region: V
Province/ City: Masbate
District/ Municipality: San Pascual North
To be filled up by the Vaccination Team
No
.
Name(1) (Surname, First Name, MI) Complete
Address(2)
Date of
Birth
MM/DD/YY
Age SEX History of
Allergies(foods,meds,
previous
immunization)
Sick
today?
(fever)
Date of HPV Vaccine
Given
Deffered(D)/
Refused( R )
Vaccinated
Deffered(VD)
/Vaccinated
Refusal(VR)
Remarks
Y N MR Td
1 Alburo, Amstrong P. Sitio ki-belen, San Rafael,
San Pascual, Masbate
12/19/14 6 M
2 Arcillas,Reymar N. Sitio ki-belen, San Rafael,
San Pascual, Masbate
03/12/14 7 M
3 Banuelos, Gino R. Sitio ki-belen, San Rafael,
San Pascual, Masbate
03/13/15 6 M
4 Ferrer, Aljun P. Sitio ki-belen, San Rafael,
San Pascual, Masbate
06/09/14 7 M
5 Lacno, Raffy Boy S. Sitio ki-belen, San Rafael,
San Pascual, Masbate
10/19/14 7 M
6 Luberas, Lean Jay P. Sitio ki-belen, San Rafael,
San Pascual, Masbate
05/11/15 6 M
7 Maglente, Joey Boy l. Sitio ki-belen, San Rafael,
San Pascual, Masbate
08/22/15 6 M
8 Maglente, Jomar L. Sitio ki-belen, San Rafael,
San Pascual, Masbate
01/13/14 7 M
9 Navarro, Ronel B. Sitio ki-belen, San Rafael,
San Pascual, Masbate
04/07/14 7 M
10 Rabia, Johnly C. Sitio ki-belen, San Rafael,
San Pascual, Masbate
01/27/14 7 M
11 Roca, Jhemiel P. Sitio ki-belen, San Rafael,
San Pascual, Masbate
06/30/15 6 M
12 Batiancila, Angel D. Sitio ki-belen, San Rafael,
San Pascual, Masbate
11/19/14 7 F
13 Caboquin, Queni Rose S. Sitio ki-belen, San Rafael,
San Pascual, Masbate
10/02/14 7 F
14 Cabuquin, Princess Elaine L. Sitio ki-belen, San Rafael,
San Pascual, Masbate
08/21/15 6 F

SARAH B. MANGUBAT__ Name and Signature of Vaccinator 1: Name and Signature of Vaccinator 2:
Name and Signature of School Head Name and Signature of Recorder 1: Name and Signature of Recorder 2:
15 Castillo, Hannah C. Sitio ki-belen, San Rafael,
San Pascual, Masbate
07/16/14 7 F
16 Contapay Disiefril M. Sitio ki-belen, San Rafael,
San Pascual, Masbate
12/12/14 7 F
17 Contapay, Jolly Ann E. Sitio ki-belen, San Rafael,
San Pascual, Masbate
10/27/14 7 F
18 Enopequiz, Crisly M. Sitio ki-belen, San Rafael,
San Pascual, Masbate
01/06/14 7 F
19 Molejon, Renabel Angela H.
Sitio ki-belen, San Rafael,
San Pascual, Masbate 04/24/14 7 F
20 Saliente, Elysa G.
Sitio ki-belen, San Rafael,
San Pascual, Masbate 03/28/15 6 F
21 Villanueva, Princess Analiza B.
Sitio ki-belen, San Rafael,
San Pascual, Masbate 03/26/15 6 F

Republic of the Philippines
Department of Education
REGION V
SCHOOLS DIVISION OF MASBATE PROVINCE
SAN PASCUAL NORTH DISTRICT
SEGUNDINA L. RIVERA ELEMENTARY SCHOOL
Ki- Belen, San Rafael, San Pascual, Masbate
Community-based Immunization Activity
RECORDING Form 3: HPV Masterlist of FEMALE 9-14 years old
Region: V
Province/ City: Masbate
District/ Municipality: San Pascual North
To be filled up by the Vaccination Team
No
.
Name(1) (Surname, First Name, MI) Complete
Address(2)
Date of
Birth
MM/DD/YY
Age History of
Allergies(foods,meds,
previous
immunization)
Sick
today?
(fever)
Date of HPV Vaccine
Given
Deffered(D)/
Refused( R )
Vaccinated
Deffered(VD)
/Vaccinated
Refusal(VR)
Remarks
Y N 1ST
dose 2nd
dose
1 Andales, Maris L. Sitio ki-belen, San Rafael,
San Pascual, Masbate
12/25/08 13
2 Banuelos, Jennilyn R. Sitio ki-belen, San Rafael,
San Pascual, Masbate
01/21/10 11
3 Banuelos, Jessabel R. Sitio ki-belen, San Rafael,
San Pascual, Masbate
12/21/12 9
4 Brusas, Lucky Angel P. Santa Cruz, San Pascual,
Masbate
03/10/12 9
5 Caboquin, Richel- Ann S. Sitio ki-belen, San Rafael,
San Pascual, Masbate
04/03/11 10
6 Cañete, Jay Ann M. Sitio ki-belen, San Rafael,
San Pascual, Masbate
06/17/12 9
7 Cañete, Melanie M. Sitio ki-belen, San Rafael,
San Pascual, Masbate
07/29/12 9
8 Cañete, Merasol M. Sitio ki-belen, San Rafael,
San Pascual, Masbate
04/14/07 14
9 Contapay, Jenny Ann E. Sitio ki-belen, San Rafael,
San Pascual, Masbate
09/28/11 10
10 Cuyos, Shaene N. Sitio ki-belen, San Rafael,
San Pascual, Masbate
11/03/12 9
11 Ecarma, Baby Grace B. Sitio ki-belen, San Rafael,
San Pascual, Masbate
10/06/10 11
12 Entoy, Hazel Jane L. Sitio ki-belen, San Rafael,
San Pascual, Masbate
10/16/11 10
13 Entoy, Shaila Anale L. Sitio ki-belen, San Rafael,
San Pascual, Masbate
10/11/09 12

SARAH B. MANGUBAT__ Name and Signature of Vaccinator 1: Name and Signature of Vaccinator 2:
Name and Signature of School Head Name and Signature of Recorder 1: Name and Signature of Recorder 2:
14 Escala, Ronalyn B. Sitio ki-belen, San Rafael,
San Pascual, Masbate
12/21/12 9
15 Fernandez, Jocel E. Sitio ki-belen, San Rafael,
San Pascual, Masbate
07/24/07 14
16 Ferrer, Ricalyn D. Sitio ki-belen, San Rafael,
San Pascual, Masbate
08/13/08 13
17 Ferrer, Shella P. Sitio ki-belen, San Rafael,
San Pascual, Masbate
05/04/09 12
18 Jacob.Princess Patima A. Sitio ki-belen, San Rafael,
San Pascual, Masbate
11/03/10 11
19 Lacno, Crestina C. Sitio ki-belen, San Rafael,
San Pascual, Masbate
11/13/10 11
20 Lacno, Soffia S. Sitio ki-belen, San Rafael,
San Pascual, Masbate
02/28/12 9
21 Lim, Jemaica M. Sitio ki-belen, San Rafael,
San Pascual, Masbate
09/01/10 11
22 Maglinte, Marjorie Sitio ki-belen, San Rafael,
San Pascual, Masbate
05/05/09 12
23 Molejon, Rhiana V. Sitio ki-belen, San Rafael,
San Pascual, Masbate
03/13/11 10
24 Molejon, Rhiza Mae V. Sitio ki-belen, San Rafael,
San Pascual, Masbate
04/28/12 9
25 Pepito, Biaca Jane C. Sitio ki-belen, San Rafael,
San Pascual, Masbate
10/08/10 11
26 Polar, Jecel B. Sitio ki-belen, San Rafael,
San Pascual, Masbate
09/05/09 12
27 Polar, Liezel B. Sitio ki-belen, San Rafael,
San Pascual, Masbate
06/18/ 12 9
28 Rubio, Karen Jane R. Sitio ki-belen, San Rafael,
San Pascual, Masbate
11/11/11 10
29 Talisic, Richelle D. Sitio ki-belen, San Rafael,
San Pascual, Masbate
10/24/10 11
30 Villaluna, Jasmine M. Sitio ki-belen, San Rafael,
San Pascual, Masbate
11/10/11 10
31 Villaluna, Maria Mae M. Sitio ki-belen, San Rafael,
San Pascual, Masbate
05/06/10 11
32 Villanueva, Princess Ayah B. Sitio ki-belen, San Rafael,
San Pascual, Masbate
12/11/12 9