Vaccine Administration Record for Adults (continued)
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___
PAGE 2 OF 2
Patient name
Patient name
Birthdate ___ Chart number ___
Birthdate
Chart number
PRACTICE NAME AND ADDRESS
practice name and address
VaccineType of Vaccine1Date vaccine given (mo/day/yr)Funding Source (F,S,P)2Route3 and Site3VaccineVaccine Information Statement (VIS)Vaccinator5 (signature or initials and title)
Lot #Mfr.Date on VIS4Date given4
Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4)
Give IIV3, IIV4, ccIIV3, and RIV3 IM.3
Give LAIV4 NAS.3
Pneumococcal conjugate (e.g., PCV13) Give PCV13 IM.3
Pneumococcal polysaccharide (e.g., PPSV23) Give PPSV23 IM or Subcut.3
Zoster (HZV) Give Subcut.3
Hib Give IM.3
Other
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
e.g., PCV13) Give PCV13 IM.3
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Pneumococcal polysac
charide (e.g., PPSV23
Zoster (HZV) Give Subcut.3
Hib Give IM.3
Other
Other
Other
Other
See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, MenACWY, and MenB 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.
AbbreviationTrade Name and Manufacturer
IIV3 (inactivated influenza vaccine, trivalent); IIV4 (inactivated influenza vaccine, quadrivalent); ccIIV3 (cell culture-based inactivated influenza vaccine, trivalent); RIV3 (inactivated recombinant influenza vaccine, trivalent)Fluarix (GSK); Flublok (Protein Sciences Corp.); Afluria, Fluad, Flucelvax, Fluvirin (Seqirus); FluLaval (GSK); Fluzone, Fluzone Intradermal, Fluzone High-Dose (Sanofi Pasteur)
LAIV (live attenuated influenza vaccine, quadrivalent)FluMist (MedImmune)
PCV13Prevnar 13 (Pfizer)
PPSV23Pneumovax 23 (Merck)
HZV (shingles)Zostavax (Merck)
HibActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHib (Merck)
Abbreviation
Trade Name and Manufacturer
(inactivated recombinant
FluMist (MedImmune)
rivalent]
PCV13
Prevnar 13 (Pfizer)
PPSV23
Pneumovax 23 (Merck)
HZV (shingles)
Zostavax (Merck)
Hib
(Merck)
Immunization Action Coalition · Saint Paul, Minnesota · 651-647-9009 · www.immunize.org · www.vaccineinformation.org
www.immunize.org/catg.d/p2023.pdf Item #P2023-page 2 (4/16)