Roxas City Government PRE-VACCINATION PROFILE FORM
This Pre-Vaccination Profile Form is intended ONLY for Roxas City Residents (18 years old and above) and Frontline Health Care Workers residing outside Roxas City but works in Roxas City Private/Public Hospitals, RHUs, TTMFs, Contact Tracers and other NGAs as basis for the inclusion in the COVID-19 Roxas City Vaccinees in the DOH Vaccine Information Management System - Immunization Registry (VIMS-IR). This survey questionnaire ( https://tinyurl.com/RoxasCityVax ) is intended only for those who wants to registered their Vaccination Profile.  If you already filled up such form manually or enlisted in the VIMS-IR in your respective Organization, RHUs, Barangays or Municipality and you don't have any changes specially with your willingness to be vaccinated, please disregard to fill up this Online Form but if you have any changes specially with Willingness to get vaccinated you may fill up  through this form https://tinyurl.com/RoxasCityVaxUpdate . For more information about Roxas City COVID-19 Vaccination Implementation you may text or call Roxas City Health Office E-Consulta at 09219768315 / 09167946472 from 8am-5am, Friday to Saturday or visit their Facebook Account at https://www.facebook.com/rxseconsulta.

Thank You!

ROXAS CITY HEALTH OFFICE
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Data Privacy Notice & Consent
Prevaccination Profile Form for Roxas City COVID 19 Electronic Immunization Registry (CEIR) is a form developed by City Health Office of Roxas City Government for the purpose of gathering information; profiling of health status and processing thereof for the generation of the masterlist for vaccination among the identified list of the priority population; and are eligible to receive the COVID-19 vaccine in the City of Roxas to the DOH Vaccine Information Management System - Immunization Registry (VIMS-IR) Official Platform in order to reduce the morbidity and mortality due to COVID-19, in accordance with the Republic Act No. 10173, otherwise known as the Data Privacy Act of 2012.  This form had been executed strictly in accordance with the provisions indicated in the DOH Department Memorandum: Interim Guidelines on Master Listing for the COVID-19 Vaccine Information Management System - Immunization Registry (VIMS-IR). The personal information of the data subjects will be handled appropriately and securely; and will remain adherent to the general data privacy principles of transparency, legitimate purpose, and proportionality, in processing their personal information.  I am hereby agree, authorizing and giving consent to Roxas City Health Office to collect, process, retain, and dispose of my personal information in accordance with Department of Health policies on the implementation of Vaccine Information Management System and DIRECTS QR ID. *
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