Before administering any vaccines, give the patient copies of all pertinent Vaccine Information Statements (VISs) and make sure he/she understands the risks and benefits of the vaccine(s). Always provide or update the patient's personal record card.
Patient name
Birthdate
Chart number
practice name and address
Vaccine
Type of Vaccine1
Date vaccine given (mo/day/yr)
Funding Source (F,S,P)2
Route3 and Site3
Vaccine
Vaccine Information Statement (VIS)
Vaccinator5 (signature or initials and title)
Lot #
Mfr.
Date on VIS4
Date given4
Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3
Hepatitis B6 (e.g., HepB, HepA-HepB) Give IM.3
Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
Measles, Mumps, Rubella (MMR) Give Subcut.3
Varicella (VAR) Give Subcut.3
Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
Meningococcal B (e.g., MenB) Give MenB IM.7
(mo/day/yr)
Type of Vaccine1_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date on VIS4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date given4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Vaccinator5 (signature or initials and title)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Type of Vaccine1_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date on VIS4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date given4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Vaccinator5 (signature or initials and title)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Diphtheria, Pertussis
Type of Vaccine1_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date on VIS4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date given4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Vaccinator5 (signature or initials and title)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Diphtheria, Pertussis
Type of Vaccine1_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date on VIS4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date given4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Vaccinator5 (signature or initials and title)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Type of Vaccine1_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date on VIS4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date given4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Vaccinator5 (signature or initials and title)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
(e.g., HepA, HepA-HepB)
Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
(e.g., HepA, HepA-HepB)
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3
(e.g., HepA, HepA-HepB)
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
(e.g., HepB, HepA-HepB)
Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
(e.g., HepB, HepA-HepB)
Hepatitis B6 (e.g., HepB, HepA-HepB) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Human papillomavirus
Hepatitis B6 (e.g., HepB, HepA-HepB) Give IM.3
(HPV2, HPV4, HPV9)
Varicella (VAR) Give Subcut.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
Measles, Mumps, Rubella
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
(MMR) Give Subcut.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
Measles, Mumps, Rubella (MMR) Give Subcut.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
(MMR) Give Subcut.3
Measles, Mumps, Rubella (MMR) Give Subcut.3
Varicella (VAR) Give Subcut.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
(VAR) Give Subcut.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
Meningococcal ACWY
Varicella (VAR) Give Subcut.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
(e.g., MenACWY [MCV4],
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
(e.g., MenB) Give MenB
Meningococcal B (e.g., MenB) Give MenB IM.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
Meningococcal B
Meningococcal B (e.g., MenB) Give MenB IM.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
• See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
Meningococcal B (e.g., MenB) Give MenB IM.7
See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines (e.g., travel vaccines).
How to Complete this Record
Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right).
Record the funding source of the vaccine given as either F (federal), S (state), or P (private).
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).
Record the publication date of each VIS as well as the date the VIS is given to the patient.
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.
For combination vaccines, fill in a row for each antigen in the combination.
Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
HepA
Havrix (GSK); Vaqta (Merck)
HepB
Engerix-B (GSK); Recombivax HB (Merck)
HepA-HepB
Twinrix (GSK)
HPV2
Cervarix (GSK)
HPV4, HPV5
Gardasil, Gardasil 9 (Merck)
MMR
MMRII (Merck)
VAR
Varivax (Merck)
MenACWY
Menactra (Sanofi Pasteur); Menveo (GSK)
MPSV4
Menomune (Sanofi Pasteur)
MenB
Bexsero (GSK); Trumenba (Pfizer)
Trade Name and Manufacturer
Tdap
Td
HepA
Havrix (GSK); Vaqta (Merck)
HepB
Engerix-B (GSK); Recombivax HB (Merck)
Twinrix (GSK)
HPV2
Cervarix (GSK)
Gardasil, Gardasil 9 (Merck)
MMR
MMRII (Merck)
VAR
Varivax (Merck)
Menactra (Sanofi Pasteur); Menveo (GSK)
MPSV4
Menomune (Sanofi Pasteur)
MenB
Bexsero (GSK); Trumenba (Pfizer)
IMMUNIZATION ACTION COALITION
Technical content reviewed by the Centers for Disease Control and Prevention
Saint Paul, Minnesota · 651-647-9009 · www.immunize.org · www.vaccineinformation.org
www.immunize.org/catg.d/p2023.pdf · Item #P2023 (4/16)