This document contains records from a community-based immunization activity conducted in Masbate Province, Philippines. It includes lists of children ages 6-7 who received the MR-Td vaccine and females ages 9-14 who were scheduled to receive the HPV vaccine. For each child, it records their name, address, date of birth, age, sex, medical history, and date the vaccine was administered or reason for deferral. A total of 32 females are listed to receive the HPV vaccine across two doses. The activity was conducted by vaccinators and recorders from Segundina L. Rivera Elementary School.

1. 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

2. 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

3. 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

4. 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