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| # | Category | Category_ID | Category_ID_Number | PhilHealth_ID | PWD ID | Last_Name | First_Name | Middle_Name | Suffix | Contact_No. | Current_Residence:_Unit/Building/House_Number,_Street_Name | Current_Residence:_Region | Current_Residence: Province | Current_Residence: Municipality/City | Current_Residence: Barangay | Sex | Birthdate_mm/dd/yyyy_ | Civil_Status | Employment_Status | Directly_in_interaction_with_COVID_patient | Profession | Name_of_Employer | Province/HUC/ICC_of_Employer | Address_of_Employer | Contact_number_of_employer | Pregnancy_status | Drug_Allergy? | Food_Allergy? | Insect_Allergy? | Latex_Allergy? | Mold_Allergy? | Pet_Allergy? | Pollen_Allergy? | With_Comorbidity? | Hypertension | Heart_Disease | Kidney_Disease | Diabetes_Mellitus | Bronchial_Asthma | Immunodeficiency_Status | Cancer | Others | Patient_was_diagnosed_with_COVID_19 | Date_of_first_positive_result_/_specimen_collection_mm/dd/yyyy_ | Classification_of_COVID_19 | Willing to_be_Vaccinated? | Consent | Reason for Refusal | Age more than 16 years old? | Has no allergies to PEG or polysorbate? | Has no severe allergic reaction after the 1st dose of the vaccine? | Has no allergy to food, egg, medicines, and no asthma? | If Yes, Specify what allergies | * If with allergy or asthma, will the vaccinator able to monitor the patient for 30 minutes? | Has no history of bleeding disorders or currently taking anti-coagulants? | Specify bleeding disorder or anticoagulants if there are any | * if with bleeding history, is a gauge 23 - 25 syringe available for injection? | Does not manifest any of the following symptoms: Fever/chills, Headache, Cough, Colds, Sore throat, Myalgia, Fatigue, Weakness, Loss of smell/taste, Diarrhea, Shortness of breath/ difficulty in breathing | * If manifesting any of the mentioned symptom/s, specify all that apply | Has no history of exposure to a confirmed or suspected COVID-19 case in the past 2 weeks? | If yes, TEST DONE/WHEN/RESULTS | Has not been previously treated for COVID-19 in the past 90 days? | Has not received any vaccine in the past 2 weeks? | Has not received convalescent plasma or monoclonal antibodies for COVID-19 in the past 90 days? | Not Pregnant? | * if pregnant, 2nd or 3rd Trimester? | Does not have any of the following: HIV, Cancer/ Malignancy, Underwent Transplant, Under Steroid Medication/ Treatment, Bed Ridden, terminal illness, less than 6 months prognosis | * If with mentioned condition/s, specify. | * If with mentioned condition, has presented medical clearance prior to vaccination day? | If yes, Name of Physician and License Number | Deferral | Date of Vaccination | Manufacturer Name | Batch Number | Lot Number | Vaccinator Name | Profession of Vaccinator | 1st Dose | 2nd Dose |
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