cdc-vaccine-administration-record.pdf — PaddleOCR-VL (Baidu)

Vaccine Administration Record for Adults

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	Mahamud Omar
Birthdate	5/31/1971 Chart number
PRACTICE NAME AND ADDRESS Small Rural Clinic 135 County Road D Small Town, CD 46902

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practice name and address Small Rural Clinic 135 County Road D Small Town, CD 46902

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)
Vaccine	Type of Vaccine1	Date vaccine given (mo/day/yr)	Funding Source (F,S,P)2	Route3 and Site3	Lot #	M/F	Date on VIS4	Date given4	Vaccinator5 (signature or initials and title)
Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3	Td	8/1/2002	P	IM/LA	U0376AA	A/P	6/10/1994	8/1/2002	JTA
	Td	9/1/2002	P	IM/LA	U0376AA	AVP	6/10/1994	9/1/2002	RVO
	Td	3/1/2003	P	IM/LA	U0376AA	AVP	6/10/1994	3/1/2003	TAA
	Tdap	3/1/2015	P	IM/LA	AC52BC02AA	GSK	2/24/2015	3/1/2015	JA

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	MMR	8/1/2002	P	Subcut/RA	0025L	MSD	6/13/2002	8/1/2002	JTA
Measles, Mumps, Rubella (MMR) Give Subcut.3	MMR	11/1/2002	P	Subcut/RA	0025L	MSD	6/13/2002	11/1/2002	TAA
Varicella (VAR) Give Subcut.3	VAR	8/1/2002	P	Subcut/LA	0799M	MSD	12/16/1998	8/1/2002	JTA
Varicella (VAR) Give Subcut.3	VAR	11/1/2002	P	Subcut/LA	0689M	MSD	12/16/1998	11/1/2002	TAA
Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7	MenACWY	7/12/2011	P	IM/RA	M28011	NOV	1/2/2008	7/12/2011	LTB
	Menveo	7/15/2016	P	IM/LA	M12115	NOV	3/31/16	7/15/2016	RVO

Meningococcal B (e.g., MenB) Give MenB IM.7	MenB	1/14/2016	P	IM/LA	J296203	PFR	8/14/2015	1/14/2016	RVO
	Trumenba	3/15/2016	P	IM/LA	J296203	PFR	8/14/2015	3/15/2016	RVO
	Trumenba	7/15/2016	P	IM/RA	J296203	PFR	8/14/2015	7/15/2016	RVO

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Tdap_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03

3/1/2015_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03

P_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03

IM/LA_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03

AC52B030AA_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03

GSK_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03

2/24/2015_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03

3/1/2015_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03

JA_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03

Hepatitis A6 HJ+HS$+HS$+HS% *LYH,03

Hepatitis B6 HJ+HS%+HS$+HS% *LYH,03

_Human papillomavirus +39+39+39 *LYH,03

MMR

VAR

7/12/2011

IM/RA

1/2/2008

7/12/2011

Menveo_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369*LYH0HQ$&:< ,07*LYH03696XEFXW7

7/15/2016_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369*LYH0HQ$&:< ,07*LYH03696XEFXW7

P_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369*LYH0HQ$&:< ,07*LYH03696XEFXW7

IM/LA_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369*LYH0HQ$&:< ,07*LYH03696XEFXW7

M12115_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369*LYH0HQ$&:< ,07*LYH03696XEFXW7

NOV_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369*LYH0HQ$&:< ,07*LYH03696XEFXW7

3/31/16_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369*LYH0HQ$&:< ,07*LYH03696XEFXW7

7/15/2016_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369*LYH0HQ$&:< ,07*LYH03696XEFXW7

RVO_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369*LYH0HQ$&:< ,07*LYH03696XEFXW7

RVO

Trumenba

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.

Abbreviation	Trade Name and Manufacturer
Tdap	Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
Td	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)

IMMUNIZATION ACTION COALITION Saint Paul, Minnesota · 651-647-9009 · www.immunize.org · www.vaccineinformation.org