1. Elementary School: ________________________
District: _______________________
Grade Level
Total No. of Enrolled
Learners
No. of learners having Initial Dosage Booster Dosage Total No. of
Unvaccinated
First
Dose
Second
Dose
No.
Unvaccinated
1st
Dose
(Number)
2nd
Dose
(Number)
Kinder
Grade 1
Grade II
Grade III
Grade IV
Grade V
Grade VI
Total
Secondary School: ________________________
District: _______________________
Grade Level
Total No. of Enrolled
Learners
No. of learners having Initial Dosage Booster Dosage Total No. of
Unvaccinated
First
Dose
Second
Dose
No.
Unvaccinated
1st
Dose
(Number)
2nd
Dose
(Number)
Grade VII
Grade VIII
Grade IX
Grade X
Grade XI
Grade XII
Total
Submitted by:
______________________________
