cdc-vaccine-administration-record.pdf — PaddleOCR-VL (Baidu) — page 4

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 Mahamud Omar Birthdate 5/31/1971 Chart number

LUWKGDWH &KDUW QXPEHU

PRACTICE NAME AND ADDRESS

Small Rural Clinic

135 County Road D

Small Town, CD 46902

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 #	Mfr.	Date on VIS4	Date given4	Vaccinator5 (signature or initials and title)
Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4)\nGive IIV3, IIV4, ccIIV3, and RIV3 IM.3\nGive LAIV4 NAS.3	Fluoval	10/2/2009	F	IM/RA	2F600411	GSK	8/11/09	10/2/09	PWS
	H1N1	12/7/2009	P	IM/RA	10092224P	NOV	10/2/09	12/7/09	DLW
	Afluoria	9/12/2010	P	IM/RA	06949111A	CSL	8/10/10	9/12/10	TAA
	Fluaval	10/1/2011	P	IM/LA	2F600411	GSK	8/10/11	10/1/11	JTA
	IV3	9/5/2012	P	IM/RA	M50907	CSL	7/2/12	9/5/12	KKC
	RIV3	12/2/2013	P	IM/RA	350603F	PSC	7/26/13	12/2/13	DCP
	IV4	10/5/2014	P	IM/RA	UI196AA	PMC	8/19/14	10/5/14	JTA
	IV4	11/2/2015	P	IM/LA	111773P	NOV	8/7/15	11/2/15	DCP




Pneumococcal conjugate (e.g., PCV13) Give PCV13 IM.3	PCV13	11/1/2012	P	IM/LA	7-5096-06A	WYE	4/16/10	11/1/12	CJP
Pneumococcal polysaccharide (e.g., PPSV23)\nGive PPSV23 IM or Subcut.3	PPSV23	9/10/2011	P	IM/LA	663012/1163X	MSD	10/6/09	9/10/11	DLW
	PPSV23	9/15/2015	P	/LA	663860/1626X	MSD	4/24/15	9/15/15	TAA
Zoster (HZV) Give Subcut.3
Hib Give IM.3	AcHIB	11/1/2011	P	IM/RA	D05561	PMC	2/4/14	11/1/14	MAT
Other

'DWHRQ9,6

Flulaval

H1N1

Afluria

Flulaval

IIV3

RIV3

PSC

12/2/13

IIV4

PMC

10/5/14

IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63

PPSV23

PPSV23_Pneumococcal polysac- charideHJ3369 *LYH3369,0RU 6XEFXW3

9/15/2015_Pneumococcal polysac- charideHJ3369 *LYH3369,0RU 6XEFXW3

P_Pneumococcal polysac- charideHJ3369 *LYH3369,0RU 6XEFXW3

IM/LA_Pneumococcal polysac- charideHJ3369 *LYH3369,0RU 6XEFXW3

663860/1626X_Pneumococcal polysac- charideHJ3369 *LYH3369,0RU 6XEFXW3

MSD_Pneumococcal polysac- charideHJ3369 *LYH3369,0RU 6XEFXW3

4/24/15_Pneumococcal polysac- charideHJ3369 *LYH3369,0RU 6XEFXW3

9/15/15_Pneumococcal polysac- charideHJ3369 *LYH3369,0RU 6XEFXW3

TAA_Pneumococcal polysac- charideHJ3369 *LYH3369,0RU 6XEFXW3

Hib*LYH,03

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.

Abbreviation	Trade 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, Fluid, Fluclevax, Fluvirin (Seqirus); FluLaval (GSK); Fluzone, Fluzone Intradermal, Fluzone High-Dose (Sanofi Pasteur)
LAIV (live attenuated influenza vaccine, quadrivalent)	FluMist (MedImmune)
PCV13	Prevnar 13 (Pfizer)
PPSV23	Pneumovax 23 (Merck)
HZV (shingles)	Zostavax (Merck)
Hib	ActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHib (Merck)