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doc14117 cdc-vaccine-administration-record.pdf
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Page 3
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1 · HEADER
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"type": "list_item",
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"text": "Record the route by which the vaccine was given as either intramuscular (IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), or oral (PO) and also the site where it was administered as either RA (right arm), LA (left arm), RT (right thigh), or LT (left thigh).",
"marker": "3."
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"text": "Record the publication date of each VIS as well as the date the VIS is given to the patient.",
"marker": "4."
},
{
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"text": "To meet the space constraints of this form and federal requirements for documentation, a healthcare setting may want to keep a reference list of vaccinators that includes their initials and titles.",
"marker": "5."
},
{
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"text": "For combination vaccines, fill in a row for each antigen in the combination.",
"marker": "6."
}
]
},
{
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"type": "table",
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{
"row": 1,
"col": 1,
"coverage": 0,
"text": "Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])"
},
{
"row": 2,
"col": 1,
"coverage": 0,
"text": "Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biologica…"
},
{
"row": 3,
"col": 1,
"coverage": 0,
"text": "Havrix (GSK); Vaqta (Merck)"
},
{
"row": 4,
"col": 0,
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},
{
"row": 4,
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},
{
"row": 5,
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},
{
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},
{
"row": 6,
"col": 0,
"coverage": 0,
"text": "HPV2"
},
{
"row": 6,
"col": 1,
"coverage": 0,
"text": "Cervarix (GSK)"
},
{
"row": 7,
"col": 0,
"coverage": 0,
"text": "HPV4, HPV5"
},
{
"row": 7,
"col": 1,
"coverage": 0,
"text": "Gardasil, Gardasil 9 (Merck)"
},
{
"row": 8,
"col": 0,
"coverage": 0,
"text": "MMR"
}
]
}
},
"children": [
{
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}
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}
},
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},
{
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{
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{
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{
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"text": "IMMUNIZATION ACTION COALITION Saint Paul, Minnesota · 651-647-9009 · www.immunize.org · www.vaccineinformation.org"
},
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"text": "Technical content reviewed by the Centers for Disease Control and Prevention\nSaint Paul, Minnesota · 651-647-9009 · www.immunize.org · www.vaccineinformation.org\nwww.immunize.org/catg.d/p2023.pdf · Item #P2023 (4/16)",
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}
Page 4
331 item(s)
JSON
footer (1)
footnote (1)
form_field (93)
header (3)
heading (1)
list (1)
list_item (5)
table (3)
table_cell (222)
text (1)
1 · HEADER
2 · HEADER
3 · HEADER
4 · FORM_FIELD
5 · TEXT
6 · TABLE
7
8
9 · TABLE
10
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307 · FORM_FIELD
308 · HEADING
309 · LIST
310
311
312
313
314
315 · TABLE
316
317
318
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324
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330 · FOOTNOTE
331 · FOOTER
Table integrity:
23 of 126 cells don't match the text layer at their coordinates.
r0c3 (0%): “Funding Source (F,S,P) ^{{2}}”
r0c7 (29%): “Vaccinator ^{{5}} (signature or initials and title)”
r1c0 (0%): “Lot #”
r1c1 (0%): “Mfr.”
Table integrity:
12 of 14 cells don't match the text layer at their coordinates.
r1c0 (0%): “IIV3 (inactivated influenza vaccine, trivalent); IIV4 (inac…”
r1c1 (0%): “Fluarix (GSK); Flublok (Protein Sciences Corp.); Afluria, F…”
r2c0 (0%): “LAIV (live attenuated influenza vaccine, quadrivalent)”
r2c1 (0%): “FluMist (MedImmune)”
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"text": "Immunization Action Coalition · Saint Paul, Minnesota · 651-647-9009 · www.immunize.org · www.vaccineinformation.org\nwww.immunize.org/catg.d/p2023.pdf · Item #P2023 – page 2 (4/16)",
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}
],
"excluded_furniture": {
"first": [],
"last": []
}
}